Family & Societal Nursing

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Using Family Theory to Guide Nursing Practice Sonja J. Meiers

C H A P T E R 7

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

1. Discuss ways in which family theories guide family nursing practice. 2. Consider differences in the ways that nurses’ personal experiences influence individual and family-

focused care in nursing practice. 3. Identify several different family theories that nurses can use to guide nursing practice. 4. Describe how nurses use knowledge of family coping, family development, family interaction, and

family integrity to set goals for nursing care and guide nursing actions.

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

● Calgary Family Intervention Model

● Family coping ● Family development ● Family Health Model ● Family Health Systems Model ● Family identity ● Family integrity

● Family Management Model ● Family nursing theory ● Family science ● Family theory ● Family therapy ● Illness Beliefs Model ● Stress

Introduction

Family theories, whether family science, family therapy, or family nursing theories, are useful in guiding nurses’ ideas about thinking family and practicing innovative family-focused care. Family theories help nurses move beyond what they know from personal experiences of their own families. Personal family experiences are powerful influences on perceptions, biases, and assumptions about family. Family theories can help nurses expand thinking and provide templates for more holistic assessment. In addition, use of family theories can encourage nurses to consider broader possibilities for family-focused nursing actions than are known from their personal family lives.

This chapter presents examples of how theoretical perspectives can be used to guide family-focused thinking and actions. Core elements of family science and family therapy theories are described and differentiated from family nursing theories. Finally this chapter

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Denham, Sharon, et al. Family Focused Nursing Care, F. A. Davis Company, 2015. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mnsu/detail.action?docID=1963709. Created from mnsu on 2022-05-22 16:42:01.

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demonstrates how existing family science, family therapy, and family nursing theories and models can guide family-focused nursing actions when considering the realms of family coping, development, interaction, and integrity.

Family Theories: What They Are and How They Help

The family, as a system, socially constructs its reality (Reiss, 1987). When families initially form and then later add members, they seldom fully plan the future or see future challenges. Risks and threats to the family system happen when unintended events occur in families. Life happens. Life events influence choices and decisions. Families evolve and develop boundaries that are open to influences from the outside, closed to such influences, or flexible (Olson & Gorall, 2003). This fluctuation can depend upon the situation, but also on family roles, goals, and purposes. Family boundaries also differ and may change over time. Atten- tion needs to be given to boundaries. Behaviors such as touching, hugging, and personal distance signal some information about these boundaries. A family might be predominately opened or closed, but stress can cause the family to take a contrary position until the stressor is decreased or suffering is lessened. For instance, a family may appear open to others, but this openness might be due to one member with an especially extroverted personality. If this person becomes critically ill, more introverted family members might be less welcoming. Nurses’ understandings about family systems have grown over time. An early family nursing theory contributed by Marilyn Friedman drew upon ideas of structural-functional systems and family development theories (Friedman, 1981). Friedman suggested that family is an open system that interacts with a variety of societal institutions (e.g., health care, education, religion). Her family assessment ideas are widely taught in nursing classes across the world.

Family Science

Family scientists and family nursing professionals base their ideas and recommendations for family care on observations of family life and member interactions. These theories are mainly concerned with the ways that families function, develop, and interact with environ- ments. Nurses are mostly concerned with what occurs around families’ health and illness experiences. Family theories developed by family scientists, when used by nurses, are gen- erally viewed as borrowed theories. Nurses use family science theories to understand com- plex family member interactions and the varied dynamics that influence health and illness (McEwin & Wills, 2011). Family science has enhanced discovery of approaches to family nursing care. Social science theories largely focus on the form or structure of families (e.g., nuclear, single parent, cohabiting), ways members interact to accomplish needed functions (e.g., parenting, socialization, economics), and developmental tasks (e.g., young versus mid- dle age or older families). Those ideas are often only loosely relevant to nursing practice. For example, a nurse assesses a family’s type and finds that it is a cohabiting family. This helps the nurse know who to include in parenting tasks if the mother is acutely ill. However, theories about family type and evidence about effectiveness of the cohabiting parents may not be especially useful at the time of a critical illness or to direct care.

The family satisfies certain core societal functions such as in the nurture and protection of children or the provision of stable economics. Another core function of families is fos- tering societal survival by producing new members to replace dying members and social- izing these new members to eventually enacting adult roles. Families also transmit shared norms and values from one generation to the next. To meet these functional needs, families are structured in ways that use differentiated roles such as parent, child, economic provider, and home organizer.

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Think about your own family. What roles does each person serve? What happens if a member does not fulfill an expected role? Think about a crisis or acute situation, when surgery or an intensive care stay in the hospital is required. What happens within the fam- ily? Who is filling usual roles? How might families differ in needs? Suppose a mother caring for an autistic child is unexpectedly hospitalized as a result of an automobile accident. What stressors might she and her family have? Can an individual crisis become a family crisis? Family science theories can be used to consider the complexity of what needs to be assessed and can guide nursing actions in organized and purposeful ways.

Family Therapy

Family therapy aims to understand relationships and interactions within family groups rather than merely considering needs of single individuals. Nurses need some knowledge from what is known about family therapy even though they are not involved in psychotherapy. Nurses need to know how to sensitively collaborate within the family to meet family expectations. Family therapy usually involves several family meetings and is focused on resolving problems within the family. Family-focused nursing differs from this type of intense family therapy. Nurses with family therapy backgrounds use family therapy theories to contribute knowledge for family-focused nursing (Wright & Leahy, 2013). Yet, family therapy theories cannot always adequately guide nursing actions when it comes to health and illness.

Usefulness of Family Nursing Theories and Models

Using family nursing theories to guide nursing actions begins with careful assessment of situations involving those seeking care. Nurses who work with families recognize the in- terdependence of families with other social units and larger communities. Nurses who think family assess family needs and capacities for supporting health and illness. Family nursing theories provide perspectives for planning, implementing, and evaluating care (Box 7.1).

Theories are like road maps; they suggest paths of action or directions to a desired des- tination. A mapped destination can be compared to a desired goal or outcome. Assessment data provide specific information about things to consider in choosing destinations and directions. Assessment continues along the path to the destination and ensures that the

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BOX 7-1

Usefulness of Family Theories

Family theories can suggest ways nurses can:

● Empathize with and interpret family members’ strengths and limitations. ● Comprehend the family and community context that influences needs and outcomes. ● Collaborate or partner with family units throughout the health or illness experience.

Family nursing practice, like most other aspects of nursing practice, requires the nurse to have a cadre of strategies in the nursing practice toolkit:

● Scientific or evidence-based knowledge ● Experience with various methods of communicating ● Skills for interacting in culturally sensitive ways ● Theoretical ideas for forming and directing nursing practice ● Artful ways to partner with individuals and family members whenever and wherever nursing

care is provided

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target point is reached in an efficient and timely way. Theories equip nurses with particular mind-sets that can help them think about their actions in coherent ways. Along the path to meeting goals, nurses make meaningful discoveries about family fears, uncertainties, and strengths that can be used in work with families (Meiers & Tomlinson, 2003).

Planned strategies for reaching goals need to be analyzed to see which strategies best fit with the family. For instance, if you were taking a trip, you might consider the type and size of luggage, what things to take along, best ways to travel, and how much money will be needed. Planning for family care uses the same process. Moving from a novice nurse to an experienced one takes time and effort (Benner, 1982). Beginning nurses learn basic tasks through direct instruction. As they become experts within the clinical context, they develop an intuitive grasp of clinical nursing practice. Family-focused nursing can seem incredibly challenging to the novice, but becomes less daunting with experience. Theory can guide family-focused practice, redirect courses of action when needed, and help nurses use nurse-family relationships to clarify ideas and employ the best actions in timely ways.

Family Nursing Theories and Models

Family nursing science addresses broad ideas to help nurses understand how families influence and are influenced by illness experiences and the ways members support others, increase healing, and decrease suffering (Wright & Bell, 2009). Family nursing theories can enhance understanding about the family process to promote well-being and health and manage ways illness events affect families. Five family nursing theories or models that guide nursing actions are presented in the following section. Each theory provides a unique framework or way to think about family-focused nursing practice. Family nurses can use theories and models to guide partnerships with families.

Calgary Family Intervention Model

Wright and Leahey (2013) developed the Calgary Family Assessment Model (CFAM) and the companion model, the Calgary Family Intervention Model (CFIM). These models have led the way for family nursing practice worldwide by helping nurses identify family strengths, resources, and actions to take in situations of health and illness. The CFAM sug- gests that illness situations have concerns primarily focused on a particular member, but the situation is best evaluated when related problems are linked within the larger family context. The CFAM guides the nurse to assess family developmental stages, structure, and function to gain the relevant information for guiding nursing actions. The CFIM is strength based and resiliency based with the goal of supporting optimal family functioning. CFIM- guided nursing actions promote, improve, or sustain family functioning in the cognitive, affective, and functional domains associated with family life (Box 7.2). Nursing actions are tailored to family needs and an area of family functioning is identified for action. The CFIM can guide actions across a range of health promotion and illness situations.

Family Health System Model

The Family Health System Model (FHS) considers family health and informally guides family nursing practice (Anderson & Tomlinson, 1992). This model assumes that family health is systemic, process based, and includes individual and family unit interactions. The health of the individual affects the whole family. Changes in health demand or imply needed changes in member roles, household resource demands, or alterations in daily

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activities. These changes influence the individual and the family simultaneously. The FHS proposes that family health and illness events include biopsychosocial aspects along with contextual systems. The goal is to achieve optimal responses in five realms and assessment in these realms can inform nursing actions (Box 7.3).

This model also suggests that it is impossible to separate family health into truly inde- pendent realms because they interact and are deeply intertwined. Nurses can use these realms to guide thinking and clinical practice in integrated ways. Individual family members and the family unit are viewed as a whole. This approach to nursing practice uses a com- prehensive family assessment to address health and illness concerns (Anderson, 2000). For example, the nurse using the FHS would plan nursing actions that simultaneously consider the developmental task of becoming a new parent, of learning to interact with health care providers of a medically fragile child, the concurrent stress of family financial concerns, and the value of maintaining family privacy. The family-focused nurse is alert to the delicate intertwining and stressful nature of this situation.

Family Management Style Framew ork

The Family Management Style Framework (FMSF) is based upon ideas about the family’s response to childhood chronic illness (Knafl & Deatrick, 1990). This model has been

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BOX 7-2

Using the Calgary Family Intervention Model (CFIM)

Several nursing actions may be guided by the CFIM:

● Commending family and individual strengths ● Offering information and opinions ● Validating or normalizing responses ● Encouraging the telling of illness narratives ● Drawing forth family support ● Encouraging family members to be caregivers and offering caregiver support ● Encouraging respite ● Devising rituals

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

BOX 7-3

Aspects of the Family Health Systems (FHS) Model

The FHS model identifies five realms of the family health experience:

● Interactive processes such as relationships, communication, support, nurture, other roles ● Developmental processes such as family transitions, task completion, individual development ● Coping processes such as problem solving, resource use, handling of stress and crisis ● Integrity processes such as values, beliefs, identity, rituals, and spirituality ● Health processes such as health beliefs and behaviors, illness stressors, caretaking

Source: Anderson, K. A., & Tomlinson, P. S. (1992). The family health system as an emerging paradigmatic view for nursing. Image: J ournal of Nursing S cholarship, 2 4 , 57–63.

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refined over the past two decades (Knafl & Deatrick, 2003, 2006) and has three major components—the definition of the situation, management behaviors, and perceived con- sequences. The Family Management Measure (FaMM) developed from this model meas- ures ways families manage caring for a child with a chronic illness condition and how this care management fits into everyday family life (Knafl et al., 2009). Take time to review Box 7.4 as it provides additional information about Dr. Kathy Knafl, an important American family nurse leader. Box 7.5 describes more about Dr. Janet Deatrick, an expert working with children and their families. Family members are viewed as important persons who shape and manage children’s chronic conditions and incorporate chronic illness man- agement into family life. The three components of this model shape the ways family mem- bers manage efforts. Families managing childhood chronic diseases do so in five different styles: thriving, accommodating, enduring, struggling, and floundering. Nurses working with families with young children or teens can use this theory to identify factors that sup- port or impede optimal care of the child and support family functioning as illness care is provided, recognizing that the care approaches needed by families will be diverse and cul- turally distinct. For instance, three different families with female 7-year-olds with leukemia are likely to approach care needs and manage situations differently.

Illness B eliefs Model

The Illness Beliefs Model (Wright & Bell, 2009) was developed as a clinical practice model to use in family care. The model is used to identify and enhance the therapeutic ways nurses help families who are suffering in their experience of serious illness. It is

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BOX 7-4

Family Tree

K athleen K nafl, PhD, FAAN (United States)

Kathleen Knafl, PhD, FAAN, a Professor and Associate Dean for Research and Frances Hill Fox Distinguished Professor at the University of North Carolina at Chapel Hill, is a renowned scholar. Dr. Knafl has developed a program of research focused on describing distinct patterns of family response to the challenges presented by childhood chronic conditions leading to descriptions of family management styles that can influence family outcomes. She has explored the interplay between the ways family members define disease conditions and manage family life in the context of a child’s chronic condition. She is widely published and recognized as an expert in family and research methods.

Dr. Knafl serves as a consultant to universities and mentors other researchers. She sits on editorial boards for Research in Nursing and Health, Nursing O utlook , and the J ournal of Family Nursing and serves as a consultant to the National Institutes of Health, universities, and researchers. She was intricately involved in the formation of the International Family Nursing Association (IFNA) and instrumental in organizing the first IFNA conference in Minneapolis, Minnesota, in June 2013 and continues to serve as a leader in this organization, among others.

In collaboration with her colleagues, Janet Deatrick, RN, PhD, FAAN, and Agatha Gallo, RN, PhD, FAAN, she worked to develop the Family Management Measure (FaMM) , a valid and reliable measure of how families manage a child’s chronic condition that will foster the development of interventions that support the quality of life of families living with a chronic illness. Dr. Knafl has long believed that nurses and other health care professionals can play pivotal roles in helping families adapt to a child’s chronic condition. She emphasizes that we must understand the different ways families manage a child’s chronic conditions, relationships between family management styles, and child and family outcomes.

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used to discover family core and value-laden beliefs that may constrain or facilitate health or healing. Constraining beliefs are those that are self-sabotaging to health and may be debilitating. For instance, a belief that one is completely responsible for care of an illness, accident, or injury can influence engagement of family caregivers. Similarly, in a family that feels suffering is deserved and to be endured, the family may not seek outside help in times of need. Once beliefs are identified, they can be discussed with family members and might direct ways to collaborate and solve problems. The Illness Beliefs Model can be used to create therapeutic conversations that uncover and challenge constraining beliefs. It can also be used to facilitate beliefs that lead to more healthful actions. The nurse carefully listens to what is said, observes nonverbal actions, and identifies with the family what is needed.

Family Health Model

The Family Health Model (FHM), described earlier in Chapter 2, is used throughout this text- book to demonstrate ways health and illness are intricately linked with individual, family, and community lives (Denham, 2003). This theory explains or predicts some ways ecological ideas can influence family health and illness and describes ways interdependent member interactions influence outcomes. The family household niche, a central aspect of the FHM, is where:

• Family health is potentially produced or threatened. • Individuals are socialized about health and illness. • Rituals and routine patterns with health potentials and threats are practiced.

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BOX 7-5

Family Tree

Janet Deatrick , PhD, RN, FAAN (United States)

Dr. Janet Deatrick, a Professor of Nursing at the University of Pennsylvania’s School of Nursing in Philadelphia, Pennsylvania, has served as the Co-Director of the Center for Health Equity Research. Dr. Deatrick is an expert in advanced practice pediatric nursing and caring for children with chronic conditions such as cancer. In 1995, she received the Christian and Mary Lindback Award for Distinguished Teaching. In 1997 she was recognized for her contributions to nursing research and she won the Excellence in Nursing Research Award from the Society of Pediatric Nurses.

Her efforts to explain children’s and family’s involvement in health-related decisions and careful observations of family management of childhood illness provide invaluable information to clinicians. Her theory-based efforts provide direction for pediatric nursing and research. She is well respected for her methodological expertise in qualitative, mixed methods, and family research. Current research focuses on caregivers and adolescent and young adult survivors of childhood brain tumors living at home with their parents. This research extends family management into oncology populations and provides a family context to caregiving research.

She has been the Principal Investigator for a series of studies funded by the Oncology Nursing Society Foundation and National Institutes of Health/National Institute of Nursing Research (NIH/NINR) regarding caregiver and survivor perception of family management and quality of life. Results will be used to develop interventions to enhance caregiver’s perceived competence and survivor’s quality of life. Dr. Deatrick’s research collaborations with Dr. Kathleen A. Knafl has helped to develop the Family Management Measure (FaMM). This measure systematically recognizes multidimensional family processes involved in disease management for children with serious health problems. Dr. Deatrick has supported the development, mission, and conferences of the International Family Nursing Association.

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The domains of the FHM, contextual, functional, and structural, provide ways to view how complex systems influence multimember households’ responses to health and illness over time. The three domains suggest areas to assess; ways to identify, plan, and implement nursing ac- tions; and methods for evaluating care outcomes. For example, the core processes—caregiving, cathexis, celebration, change, communication, connectedness, and coordination—are ways to think family and plan nursing actions. The core processes are explained in more depth in Chapter 14. Nurses who think family can use the FHM to address multiple household factors that come into play with health or illness. For example, Mr. Smith is a long-time employee of Amazon. He has received a promotion to manage an outlet store in a rural area. After only living in an urban area, he is uncertain what the move will mean for his family. The promotion means a large pay increase and an opportunity to move up in the company, but his wife has lupus and regularly sees a specialist in their current community. She has had flare-ups over the past few months and he is worried about her changing care providers. The move means finding a new specialist and the nearest one will be an hour drive. If he decides to move and his wife is admitted to the hospital where you work, the FHM can help you understand the family’s multiple stressors and plan ways to best address care needs.

Major Realms of Family Science Important for Family-Focused Care

The realms of family coping, development, interactions, and integrity are areas that must be considered when thinking family. These realms are relevant to family nursing practice (Anderson & Tomlinson, 1992) and are common areas of consideration across family sci- ence, family therapy, and family nursing theories and models. Regardless of the theory or model chosen to guide assessment and to guide nursing actions, consideration of these realms can broaden family-focused nursing practice. Various approaches can be taken to family-focused care while considering these major realms.

Family Coping

Family losses are central to stressful events (Boss, 2003). Illness places great demands on individuals and family capacities as stressors pile up and vulnerability increases (Kaakinen, Coehlo, Steele, Tabacco, & Hanson, 2015). Material and emotional resources can be severely strained by the stress of illness experiences. Usual ways of managing may be ineffective when unexpected events occur or severe long-term illness is experienced. Even families that usually manage daily stressors well may be poorly equipped to handle crisis, illness consequences, or permanent disabilities. Daily family life presents many areas to balance and it can be challenging to manage normal health-promoting measures or other changes, especially when multiple crises are occurring simultaneously.

Nurses may observe only a small portion of a family’s illness experience and may be oblivious to the extensive or long-term effects of illnesses that remain after the acute episode is over. Families are often ill prepared to cope with chronic conditions, accidents that cause lasting changes, or terminal diagnoses. Nurses often focus on the immediate tasks of care delivery, but may be blinded to the troubling effects a situation has on the family unit. It often seems easier to attend to technology and teach about medication use, for instance, than attend to coping challenges for families.

Paying attention to emotional, functional, social, or resource difficulties in family coping is different from the more familiar nursing tasks of providing acute care. Illness can have an aftermath that extends far beyond the present. Injuries, terminal illness, and birth

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anomalies are often unexpected and alter the family’s future and sometimes the family’s identity in irreversible and tragic ways. To understand and support family coping, it is help- ful for the nurse to learn the following:

• Usual actions or responses to sudden unknown or difficult events • The ways members have cared for one another in past troubling times • Strategies they have used successfully to handle other difficult problems

How families manage stress provides insight into possible solutions for other troubling times. Stress can disturb the equilibrium or balance that most families try to achieve. Man- aging stress often requires problem-solving skills of multiple-member households. Stress is often viewed from past personal experiences and perceptions. Thus, persons from a single family can experience shared experiences differently. Unexpected events can create strains and demands for which families are ill prepared and have no previous experience.

Managing Family Stress

Family stress occurs when the family unit is challenged by an environment that overwhelms collective resources and threatens member well-being and health (Boss, 2003). Hill (1971), one of the original family stress researchers, proposed the ABCX model. In this theory, the “A” factor pertains to the stressor or the provoking event that places pressure for change on the family system. Illness is often a stressor. The “B” factor represents the strengths and resources of the system that enable the family to deal with stressors (e.g., financial, cogni- tive, social support needs). The “C” factor is the meaning or perception of the event for the family. The meaning a particular family gives an event influences their perceptions. Reactions are based on perceptions of what is or might occur rather than the reality of the event. The “X” factor is the outcome of the “ABC” process; the outcome can be viewed as low to high stress or a crisis. Family resources, the B factors, are critical because they influence the ways family members manage the stress factors (McCubbin, McCubbin, Thompson, & Futrell (1998). Individual and family problem-solving abilities, communi- cation patterns, flexibility, cohesion, and boundary clarity are some of the resources that influence family stress management (Kaakinen et al., 2015).

Figure 7.1 depicts the way the ABCX theory might work in the following situation. A 23-year-old husband (A. H.) and father is diagnosed with an aggressive form of acute myel- ogenous leukemia (AML). Think about his hospitalization and isolation in a bone marrow unit away from his child and other family members (the A factor). The strengths and re- sources of supportive parents, his faith community, the joy of being a parent of a 1-year- old (C. H.), and a happy marriage to B. H. are positive B factors. However, the lack of full health insurance coverage and worries about high out-of-pocket costs are negative B fac- tors. The AML diagnosis is a perceived threat to this short marriage, new parenting role, and future plans, dreams, and family goals (the C factors). The resulting X factor may be the high stress as a result of the perception of threat to the integrity of the family. In daily work, nurses frequently meet families coping with high stress X factors yet may not com- prehend the meaning of the stress to the family.

McCubbin and Patterson (1983) further developed Hill’s (1971) ABCX model by adding the notion that family stressor pileup occurs when unresolved aspects of an initial stressor accumulate. An accumulation of stressful events limits abilities to resolve one problem before another event occurs. Thus, family resources are depleted. An example might be a family with a child diagnosed with cystic fibrosis who experiences frequent critical exacer- bations requiring repeated hospitalizations. At the same time, an older sibling is experiencing bullying in school. The mother loses her job, which is the only job that has the needed health insurance. Pileup is a frequent occurrence in families with aging or younger persons and

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families with chronically ill family members. Technological advancements and innovative new therapies mean that today’s families are living with uncertainties and tenuous situations of illness and it’s not clearly visible unless a family assessment is done. Families that com- municate easily with one another and have satisfactorily resolved problems in the past are likely to have a more effective toolkit for managing stress than others. Families with fragile communication or ongoing conflict might find resolving their coping difficulties hopeless.

N ursing C are to E nh ance Family C op ing

A goal for family-focused nursing is to assist persons and families in decreasing the stress linked with health and illness experiences and to help them find supports to en- hance healing, manage care situations, and promote family health. The important topic of support is covered in Chapter 15. Identifying forms of family stress and coping during clinical experiences is important for providing family-focused nursing care (McCubbin et al., 1998b). Practical ways to solve problems and support networks are to mediate the negative stress effects and enhance well-being (Hupcey, 1999; Peterson & Bredow, 2004). Caregiving strategies, such as planning, monitoring, protecting, inquiring, vigi- lance, and balancing, assist family units in meeting life demands as they manage illness symptoms (Eggenberger, Krumwiede, Meiers, Bliesmer, & Earle, 2004). Family inquiry into the illness trajectory or treatment helps a family develop illness perspectives and

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A.H., a 23-year-old husband (married 2 years with a 1-year-old son), diagnosed with aggressive form of acute myelogenous leukemia

A (Event)

Minimal coverage health insurance Wife enrolled in college Healthy marriage to B.H. New job Commitment to parenting of C.H. Extended family provide positive social support

B (Resources)

Marriage too short Future family dreams may not be realized Afraid of cancer

C (Perception of the Event)

Degree of stress or crisis (low to high)

X (Perception)

FIGURE 7 -1 Family care based on Hill’s ABC-X Model of Family Stress. Adapted from Hill, R. (1971). Families under stress. Westport, CT: Greenwood Press (original work published 1949).

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actions that enable them to create a protective environment (Meiers, Eggenberger, Krumwiede, Bliesmer, & Earle, 2009).

Family-focused nurses encourage growth and support for family coping linked with illness by preparing families to use strategies that reduce stress. Health education, counsel- ing, and coaching to support coping of specific families are tools family nurses use. For in- stance, teaching and informing parents of a medically fragile child to organize the medical care area in the child’s bedroom can reduce the stress of finding things, reduce the illness reminders scattered through the house, and meet safety needs. Nursing care helps the family to have as normal a family life as possible.

Nurses can use research findings about strengths and resiliency to help families navigate through life transitions, crisis, and stress (McCubbin, McCubbin, Thompson, & Fromer, 1998a). Have you ever wondered why some people manage better than others? Have you met families that successfully manage problems and grow from stressful events while others dete- riorate? Knowledge about a family’s strengths and resiliency factors can help nurses establish relevant nursing actions to identify and support existing strengths. For example, A. H. gains joy and a high level of satisfaction from being with his 1-year-old child. Even though he is in protective isolation for treatment of AML, finding ways for him to remain connected could be health producing and stress reducing. Perhaps regular visual and audio connection (e.g., Skype, Face Time) through use of a computer, smartphone, or tablet would be helpful. Table 7.1 provides some other ideas for specific nursing actions to support A. H. and his family’s coping using various perspectives from the five nursing models described earlier.

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TABLE 7 -1 Nursing A ctions to Support Family Coping Based on Family Models

FAMILY NURSING MODEL K EY MODEL CONCEPTS POSSIBLE NURSING ACTIONS

Calgary Family Intervention Model

(Wright & Leahey, 2013)

Family Health System Model (FHS)

(Anderson & Tomlinson, 1992)

Family Management Style Framework (FMSF)

(K nafl et al., 2009)

• Provide literature to address uncertainties about care and community resources.

• Commend family strengths: “ Your family seems to work very well together to meet your challenges.”

• Identify specific questions of concern and collaborate to identify possible options for solutions.

• Help family members to understand why various members might be coping differently.

• Arrange time for a family conference.

• Identify ways spirituality or faith may play important roles in healing processes.

• Guide the parents in conveying information about family member condition to siblings, friends, church members, and extended family.

• Discuss perceptions of illness events.

Support the cognitive domain of family functioning.

Support five processes (i.e., interactive, developmental, coping, integrity, health).

Identify important aspects of the family’s definition of the situation, management of behaviors, and perceived consequences of the condition on family life.

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Family Health Model

(Denham, 2003)

Illness Beliefs Model

(Wright & Bell, 2009).

Consider another situation. Suppose a small child is hospitalized after a severe insulin reaction that resulted in a seizure, broken teeth, and a skeletal injury from the fall that occurred during the seizure. His parents are extremely frightened as nothing like this has ever happened before. The nurse uses the Family Management Style Framework to assess coping and the plan of care (Knafl & Deatrick, 2003, 2006). What can the nurse do to identify the important aspects of the family’s perceptions of the situation? Can the nurse guide the parents to diabetes-related care management information that can be conveyed to extended family, school teachers, and school friends? How can the nurse learn the fam- ily’s typical management style? Think about one of the other family models previously dis- cussed; what approaches might this model suggest? The Family Health Model (Denham, 2003) might encourage the nurse to use the structural domain and think about family health routines. The nurse might spend time doing health teaching specifically around diet or physical activity to prevent future insulin reactions. A family-focused nurse could affirm the family’s positive behaviors and seek ways to build on family strengths.

Family Development

Family development is another area relevant to family-focused nursing practice. Nurses learn about various individual human developmental theories such as those of Maslow (1954), Piaget (1967), and Erickson (1950), but receive less education regarding family development theories (Table 7.2). Similar to individual development, family development describes stages or phases with associated tasks to be accomplished (Carter & McGoldrick, 1999; Duvall, 1977).

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TABLE 7 -1 Nursing A ctions to Support Family Coping Based on Family Models— cont’d

FAMILY NURSING MODEL K EY MODEL CONCEPTS POSSIBLE NURSING ACTIONS

• Affirm management behaviors. • Acknowledge fears and trauma

caused by illness events throughout management of the chronic illness.

• Provide information about specific pain management techniques and fatigue management strategies.

• Listen to concerns of anticipatory grief.

• Draw on the support of the church community for respite care so that couple time is preserved.

• Create a trusting, calm environment that invites open expression of family members’ fears, anger, suffering and sadness, and beliefs about the illness experiences.

• Commend family members for positive actions taken.

• Invite questions and take time to carefully answer them.

Address core processes (e.g., caregiving and cathexis).

Foster conversations of affirmation and affection.

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CHAPTER 7 ● Using Family Theory to Guide Nursing Practice 177

TABLE 7 -2 Middle Class North A merican Family L ife Cy cle

STAGE TASK OF STAGE RELATIONAL STANCE OF THE NURSE

Source: Adapted from Carter, B., & McGoldrick, M. (1999). T h e e x p an d e d family life c yc le : In d iv id u al, family an d s o c ial p e r s p e c t iv e s (3rd ed.). Boston: Allyn & Bacon.

Encourage independent decision making about health, lifestyle choices, intimate peer relationships, work and financial independence.

Support the new couple in their process of constructing new family health routines.

Co-construct plans and action strategies with the family that promote healthy family lifestyles that meet unique child and family development needs.

Assist families in negotiating new family goals that integrate independence of adolescents. Counsel families on strategies for safe care of and resources for family elders.

Encourage families to establish new forms of relationships from parent to adult to adult to adult as they consider various health and illness-related needs.

Suggest creation of traditions and rituals that help families stay connected through shifting roles and identify ways these might be health or illness related.

Accept emotional and financial responsibility for self.

Commit to new transitional family system.

Accept new members born or adopted into the family system.

Increase flexibility of family boundaries (e.g., children’s growing independence, grandparent’s increasing frailties).

Accept the exits from and entries into the family system.

Accept and adapt to the shifting of generational roles.

Leaving home as single young adults

J oining of families through marriage: the new couple

Families with young children

Families with adolescents

Launching children and moving on

Families in later life

Family L if e C ourse

Family units and the members who compose them mature and develop over time through various developmental stages of family life (Bianchi & Casper, 2005). Developmental theories often leave gaps about such issues as launching family members at older ages into adulthood, when children leave home but return later with or without offspring, elders moving in with adult children, and the uncertain implications of aging family constellations living longer. In the past, individuals found life partners, had children, and lived together in a separate house- hold until death. Marriage disruption, increased nonmarital cohabitation, out-of-wedlock childbirths, and multigenerational households alter the family landscape. Social mobility and migration create sometimes less than ideal geographical separations for many families. More research evidence is needed about these challenges to family development.

Family Life Course Theories consider that individuals transition from one stage of life to another (Bengston & Allen, 1993). This perspective involves the ideas of time, context, process, and other factors (Box 7.6). In Family Life Course Theory, early life events have implications for future life. Family life course is more about the evolutions families go through than fixed stages and expectations of those stages. These evolutions take in the total experience rather than a sequential ordering of age-linked events. Life course transitions can cause family conflict

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and disturbances. Think about your personal life course, which is likely briefer and different from that of your parents or grandparents. Variations among past state, current situation, and future hopes can affect responses to personal or family crisis. Talk to someone older and get a sense of how generational differences color the life course and help explain actions taken.

Families try to manage conflict and disturbances by decreasing chaos and disorganiza- tion. Family-focused nurses realize that life course transitions affect life management. Some families can adjust roles more easily than others. Think about the transition from being childless to being a parent. Once this change occurs and if the child tragically dies, the par- ent is unlikely to return to the same state of childlessness experienced before the birth. Many perspectives in this growing field still need to be explored, such as relationships of internal family dynamics and causal relationships, psychological processes, and social in- teractions. Social policies and preventive interventions need to consider what is experienced during these life course transitions (Mayer, 2009).

U ncertainty of th e L if e C ourse

Over time, families with children go through transitions. The empty nest might occur as chil- dren leave home and establish families in a different household. Some families have numerous life transitions at the same time (e.g., divorce, remarriage, parenting younger children, launch- ing young adults, giving birth, caring for elder kinfolk). Families experience transitional points at disparate points in time. Many transitions do not fit neatly into past ideas of family devel- opment stages. Life events occur along a time trajectory linked with others in an extended family cohort across generations and time. How families change, operationalize daily lives, or structure their time to nurture and protect members is strongly influenced by the family’s context and place in history (McCubbin et al., 1998b). Current experiences influence future behaviors. When nurses think family, they consider member placement and note life aspects that will influence care, well-being, and resources needed by those seeking care. A nurse’s re- lational stance with those seeking care should acknowledge “not knowing” and curiosity about the family’s developmental story (Wright & Leahey, 2013).

G oals to E nh ance Family D evelop ment

In the developmental realm, family nurses aim to support individual and unit development throughout the life course (Table 7.3). A life course transitional approach can be useful. For instance, when caring for a family in which a 15-year-old son is learning to manage his diabetes independently, his father might be drawn away regularly to care for his 73-year-old paternal grandfather with dementia. The nurse can assist the family in

178 CHAPTER 7 ● Using Family Theory to Guide Nursing Practice

BOX 7-6

Concepts in Life Course Theory

Life course theory principally involves the following ideas:

● Life changes are considered over a lifetime, not just at particular episodes. ● Lives are considered across a large series of cohorts rather than by a single family lineage. ● Lives are considered across life domains (e.g., work and family). ● Development is linked to personal characteristics, individual actions, cultural frames, and

institutional structures. ● Lives are lived in the context of others (e.g., couples, families, cohorts).

Source: Mayer, K. U. (2009). New directions in life course research. Annual Review of S ociology, 3 5 , 413–433. doi: 10.1146/annurev.soc.34.040507.134619

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CHAPTER 7 ● Using Family Theory to Guide Nursing Practice 179

Calgary Family Intervention Model (Wright & Leahey, 2013)

Family Health System Model (FHS)

(Tomlinson, Peden-McAlpine, & Sherman, 2012)

Family Management Style Framework (FMSF)

(K nafl et al., 2009)

Family Health Model (Denham, 2003)

TABLE 7 -3 Nursing A ctions T h at Support Family Development

FAMILY NURSING MODEL K EY CONCEPTS NURSING ACTIONS • Ask, “ What could your son do that

would help you know how to help him manage his diabetes? ” and “ How long do you think you will be able to help your father manage living at home? ”

• Use questions to facilitate conversation and encourage the family to reflect upon possible impending changes from various member perspectives.

• Make commendations as appropriate.

• Consider ways families interact as they mature and evolve over time.

• Identify which of the five processes are most affected by the developmental changes within the family.

• Identify which member processes require priority attention at any one time.

• Invite the adult father to share his views of the grandfather with dementia and the extent to which those views focus on normality (e.g., life not challenged by needs of dementia) or dementia-related deficits (e.g., abilities, activities, and life compromised by dementia).

• Follow up with a focus on the resources and abilities needed to assist the teenage son in maintaining normality in the face of managing diabetes (e.g., abilities to balance among activity, food, and insulin).

• Compare, contrast, and commend for thriving in this difficult context.

• Facilitate a conversation to discover the abiding family goals: “ Within the next year, what do you hope to accomplish as a family? ” and “ What are your most significant health needs as a family? ”

Support behavioral functioning throughout developmental transitions.

Support five family processes (i.e., interactive, developmental, coping, integrity, health) as the members mature.

Consider the implications of the complexities of family life and parenting goals as needs of both teenager and an elderly grandfather are considered while son adjusts to care needs of a diabetes diagnosis.

Coordination processes

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negotiating practical family goals and help integrate independence for the teenage son while counseling the father on strategies for safe care and resources for the aging grandfather.

Developing families will likely inhabit a variety of households in various geographical lo- cations over time and form unique attachments. Life events that occur in various places can influence individual life courses, which may or may not remarkably affect the family unit. As advocates, family nurses can be aware of the sociopolitical and economic environments of the communities where they are employed and seek ways to strengthen the context that influences family development (Denham, 2003). From this perspective, community-minded, family- focused nurses might advocate for after-school child care, anti-bullying policies, and contexts that support healthy eating and physical activity. An occupational health nurse can advocate for work safety policies that protect family members so that they can continue to econom- ically provide for the family. Nurses who think family identify and address developmental concerns in the care they provide.

Family Interactions

Family interactions are dynamic, but at the same time have some consistency of pattern. Family interactions establish, build, and maintain relationships and are used to meet family goals and needs (Anderson & Tomlinson, 1992). Family interactions evolve over time and through life

180 CHAPTER 7 ● Using Family Theory to Guide Nursing Practice

Illness Beliefs Model (Wright & Bell, 2009).

TABLE 7 -3 Nursing A ctions T h at Support Family Development— cont’ d

FAMILY NURSING MODEL K EY MODEL CONCEPTS POSSIBLE NURSING ACTIONS

• Based upon the common family goals, discern from the family the abilities and skills they believe they will need to accomplish these goals.

• Set goals and identify ways the family can work together as a team to accomplish them.

• Talk together about ways to evaluate whether goals have been met.

• Construct a family genogram and ecomap together that will reveal the illnesses across the generations.

• Identify resources that can be drawn upon for support and information.

• Ask the questions: “ What is one characteristic that you most appreciate about [your father] [your son] [your grandfather]? ” and follow up with “ Who do you count on most for support these days? ”

• Remain curious about the answers. Focus the conversation to build on the family’s strengths and ability to problem solve together.

Create a collaborative relationship and remove obstacles to change.

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course transitions (Cowan & Cowan, 2003). These interactions include verbal and nonverbal communication, nurturance patterns, and expressions of intimacy (Anderson & Tomlinson, 1992). Family members provide mutual support when their interactions are satisfactory. The larger community provides supports and barriers for family units. Box 7.7 provides a case study for you to consider nurse partnerships with individuals and their families. Take some time to reflect about the best answers to the questions about a family-focused perspective.

Family E x osystems

The family household is the principal place where members interact in interdependent ways and interface with their many environments (Bubolz & Sontag, 1993; Denham, 2003). On a grand scale, one can imagine that family units are in some ways interdependent with all the world’s people. For example, go through your closet and examine the labels on clothes. See where the items are produced and consider how you are intricately connected with persons the world over. Family units are continually influenced by many forces outside household boundaries. The word exosystem is used in ecological theory to describe the

CHAPTER 7 ● Using Family Theory to Guide Nursing Practice 181

BOX 7-7

Family Circle

Travis was born prematurely and discharged to go home at 4 months with his parents and 7-year- old twin siblings Brianna and Troy and a 4-year-old sister, Janie. Travis’s primary health problems are bronchopulmonary dysplasia, oral aversion, pulmonary arterial hypertension, and right-sided cardiac failure. He is receiving home low-flow oxygen therapy by nasal cannula, furosemide (Lasix) and digoxin medication therapy, occupational therapy for the oral aversion, and feedings by percutaneous endoscope gastrostomy (PEG) tube. You are the home care nurse who provides direct care for the child overnight on weekends and during parent’s workdays. Travis is now 6 months old. His parents work at a local factory. Some days they are on the same schedule and some days they have few overlapping hours. On some days Brianna and Troy are home for a portion of your shift. Janie is sometimes there when Mom or Dad is doing household tasks. You notice Janie is engaging in activities that do not seem safe for her age level (e.g., riding her tricycle on a country road, climbing the kitchen counter to retrieve a sharp knife, playing in the wading pool outside for long periods unattended). When Janie is near Travis, her speech is loud and it is difficult to calm Travis. Meanwhile, Travis is not gaining weight and is lagging in achieving developmental milestones. Mom and Dad are struggling with household bills and are considering filing for bankruptcy.

Q uestions from a traditional perspective:

1. What are the nursing problems you are managing for Travis? 2. What are the nursing actions you consider important to improve Travis’s growth and

development? 3. What are your goals for Travis’s care?

Q uestions from a family-focused perspective:

1. What model or models of family-focused care do you believe could be helpful for Travis’s family that would best support his growth and development?

2. What are your goals for this family’s care from the different perspectives of the five family nursing models presented in this chapter?

3. What are the key concepts of concern regarding family coping, family development, family interaction, and family integrity for Travis’s family?

4. List the proposed nursing actions you consider most important in the realms of family coping, family development, family interaction, and family integrity?

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settings wherein a person may not actively participate but is still affected. For example, a parent’s employer might alter the costs and services of health care insurance available to employees and families. These decisions greatly influence the members, but these members are not a part of the decisions made. Families interact with many social structures that af- fect their lives even when they are not noticed.

Family relationships affect members’ health-seeking behaviors and family caregiving during illness. Individual personality, knowledge, motivation, and self-efficacy are some factors that can influence care behaviors. Some families faced with a stressful situation may disagree loudly and argue with great intensity when they disagree. These arguments may be usual communi- cation patterns for a particular family, but upsetting to the nurse hearing the boisterous debate. Other families may be sullen, speak little, or seem overtly courteous and respectful of one an- other. Nurses observe outward behaviors, but these actions only reveal some parts of the family relationship. Observations might not always indicate how a family truly values its members or reveal how care is provided. Member roles influence individual actions. For instance, in an immigrant family from Sudan the mother expresses care for her family through traditional cooking and baking to retain memories of the country of origin. Family-focused nurses know that the behavioral patterns are tied to roles and values. The nurse does not usually aim to alter roles, but to understand and help family units use them beneficially in member care. For example, the family-focused nurse works with the mother in a Sudanese family to design a family-level intervention to improve nutrition that incorporates new information about low- fat cooking methods (Epstein, Ryan, Bishop, Miller, & Keitner, 2003).

Family C ommunication

Nurses need to know how family members communicate with one another. Communication is essential to relaying biomedical information and helping families with self-care or care management. Some messages are factual or intended to inform, but others are emotional. Family communication conveys beliefs and values linked with the past, present, and future. Language is used to share relevant information. Families have unique interpretative patterns developed over time that help members understand meanings. Nurses might not understand nonverbal family cues but can notice whether they seem congruent with what is said. Families often have their own language through which they privately share things. For example, Amish family members often live in the midst of an American or English community but hold very different ideas about appropriate behaviors. They interact with those outside their sect or community but hold unique ideas about electricity, automobiles, and technologies. They be- have differently than those in the mainstream. Intentional minimal use of motorized vehicles, varying educational forms, and faith guide their lifestyles from birth to death. Family-focused nurses caring for the Amish will need to interact in some different ways. Listen to your emo- tional responses to families and recognize that there are likely reasons why a family is atten- tive, anxious, hostile, or withdrawn during care situations (Wright & Leahy, 2013).

Family Sup p ort

Families and communities frequently provide support to one another when a crisis occurs. For example, if a family has a member diagnosed with cancer, extended family, friends, and others might reach out and offer supports. A series of fund-raising events to raise money for medical costs might be organized. Where you live matters, and family and social resources may or may not be well met by agencies. When supports are lacking, those with inadequate resources can experience great despair. Amish families, for instance, do not usu- ally have health care insurance and are largely self-employed. They depend upon one another for support. Family health is affected by whether members interact in health-producing or

182 CHAPTER 7 ● Using Family Theory to Guide Nursing Practice

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health-negating ways as they live and interact outside the view of nurses and other health care professionals (Denham, 2003). Through the individual-nurse-family relationship, sup- portive partnerships aimed at providing for individual and family needs can be formed.

G oals to E nh ance Family Interaction

Family-focused nurses purposely think family and use intentional actions to assist individ- uals and family units to strengthen their capacities and face life transitions linked with health and illness. Nurses who think family set goals that support families in constructing life patterns that enhance health and manage illness. Nurses can use therapeutic conversa- tions as they collaborate and co-evolve with the family during care experiences (Benzein & Saveman, 2008). Therapeutic conversations facilitate reciprocity, or mutual give and take, as nurses and families share opinions and values. This partnership focuses on the care responsibilities that best support identified family needs.

When nurses think family and caring actions are co-constructed, they are meaningful to the nurse, the individual needing care, and the family unit (Meiers & Tomlinson, 2003). Co-construction of meaning is central to caring in the family health experience; it is devel- oped through caring interactions and partnerships. These interactions help the nurse to know the family and advocate for their identified needs using an existential and intentional perspective (Meiers & Brauer, 2008). This means the nurse respects the humanity of each person and recognizes they are self-determining and have free will (Gadow, 1989). The nurse in partnership practice with families seeks to understand the family’s point of view of the world to inform nursing action. Family goals are set to reach mutually agreed upon out- comes. The family-focused nurse using this approach is, “someone you can share things with . . . who feels concern . . . , but doesn’t put the pressure on you . . . so you just kind of relax and . . . know that there are other people close by that care ...” (Meiers, 2002, p. 60). Table 7.4 provides ideas for building therapeutic individual-family-nurse relationships.

CHAPTER 7 ● Using Family Theory to Guide Nursing Practice 183

TABLE 7 -4 Nursing A ctions to Influence Family H ealth Beliefs T h rough Family Interactions

NURSING RELATIONAL SPECIFIC NURSING ACTION GOALS SUBCONCEPTS STANCE ACTIONS

Recognize the power of co-constructed meanings.

Create a context for an ongoing collaborative relationship.

Prepare the environment: Introduce yourself, offer the

appropriate physical greeting (e.g., eye contact, handshake, smile).

Prepare for the session:

• Outline goals for the interaction (e.g., I would like to discuss how I can be most helpful to you with choosing healthy eating approaches).

• Approach the nurse- family interaction as the major form of co- construction.

• Nurse authenticity facilitates insight.

• Caring actions hold potential for enhancing the family health experience.

Approach meetings with the goal of developing a therapeutic alliance.

Nurse-family interactions (verbal and nonverbal) implicitly influence interdependen t and dependent future.

First impressions are long lasting.

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184 CHAPTER 7 ● Using Family Theory to Guide Nursing Practice

TABLE 7 -4 Nursing A ctions to Influence Family H ealth Beliefs T h rough Family Interactions— cont’ d

NURSING RELATIONAL SPECIFIC NURSING ACTION GOALS SUBCONCEPTS STANCE ACTIONS

• Offer a plan for your time together (e.g., Today, I would like us to get to know each other; help me understand who is in your family and a bit about your family health background).

• Offer ideas for the timeline for meetings (e.g., I will spend about 1 hour with you today and then an hour every 2 weeks).

Ask the following questions:

• Have you previously sought help as a family for healthy eating ideas?

• What is the worst advice that you have been given by a provider about healthy eating?

• What is the best advice you have been offered by a provider about healthy eating?

Create the genogram (and ecomap, if appropriate):

Ask the names, ages, occupations, & health concerns of family members.

Follow questions in the instance of illness:

• What is the one characteristic that best describes X?

• What have you come to appreciate most about your XXX since this illness began?

Follow with questions for health promoting actions:

• Who do you count on the most for support these days?

• Is there anyone else that you consider to be like “ family” ?

• Are there any particular religious or spiritual or cultural beliefs that are helpful or not helpful to your or your family’s health?

Manners matter.

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CHAPTER 7 ● Using Family Theory to Guide Nursing Practice 185

Focus the therapeutic conversation.

Remove obstacles to change needed in the health care situation.

TABLE 7 -4 Nursing A ctions to Influence Family H ealth Beliefs T h rough Family Interactions— cont’ d

NURSING RELATIONAL SPECIFIC NURSING ACTION GOALS SUBCONCEPTS STANCE ACTIONS

End the session with the following:

• Have you had a chance to tell your story?

• Is this way of working a good fit for you?

• How are you hoping that we can be of most help to you?

• What is causing you the biggest challenge these days?

• What are you hoping we could talk about today?

• If you could have just one question answered in our work today, what would it be?

• Clearly address any nonverbal or verbal behavior that suggests there has been coercion to participate or signs of disinterest or resentment.

• We cannot proceed as if this is a helping session because we need to talk about [ the situation] .

• What should we do about this?

• Then proceed to co-construct a solution with which all can move forward.

• I would be interested in knowing what is troubling you today.

• Listen and try to understand the situation.

• Acknowledge and clarify any misconceptions.

Ask these questions if not already used:

• What is the worst advice that you have been offered by a provider about healthy eating?

• What is the best advice you have been offered by a provider about healthy eating?

Adopt an attitude of constant vigilance against the idea that you have any degree of certainty about the family’s perception.

Approach the situation with the courage to identify issues that are implicit and not within the realm of usual social conversation, things that might impede therapeutic conversation.

Acknowledge and talk about any strong emotions that seem to be present.

Proceed from the perspective that the family’s beliefs and expectations about the therapeutic process may be unclear.

Discover the family’s perceptions and clarify the therapeutic work.

A family member who does not want to be present or is present under duress can be an obstacle.

A family member who is dissatisfied can be an obstacle.

Unclear expectations about the therapeutic conversation can be an obstacle.

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Source: Meiers, S. J ., & Tomlinson, P. S. (2003). Family-nurse co-construction of meaning: A central phenomenon of family caring. S c an d in av ian J o u r n al o f C ar in g S c ie n c e s , 1 7 ( 2 ) , 193–2 01. Wright, L. M., & Bell, J . M. (2009). Creating a context for changing beliefs. In L. M. Wright & J . M. Bell (Eds.), B e lie fs an d illn e s s : A mo d e l o f h e alin g (pp. 143– 178). Calgary, Alberta, Canada: 4th Floor Press.

TABLE 7 -4 Nursing A ctions to Influence Family H ealth Beliefs T h rough Family Interactions— cont’ d

NURSING RELATIONAL SPECIFIC NURSING ACTION GOALS SUBCONCEPTS STANCE ACTIONS

• Probe the idea that there has been a lack of fit between family and provider expectations.

• Affirm the fact that the family is the expert about their experience.

• Support the family’s decision not to continue with care by a specific provider if the fit is not right for them.

How can I/we be helpful to you in a way that is different than other providers?

Ask the referring person to have the family speak directly with you to set the initial contact time and purpose.

Seek to learn about the family’s previous experiences within the health care system.

Honor family relationships with other health care providers.

Encourage family self- referral to give the family opportunity to clarify their perspective.

Previous negative experiences with health care providers can be an obstacle.

Simultaneous involvement with multiple health care providers can be an obstacle.

Unrealistic or unknown expectations of the referring person about care or treatment can be obstacles.

Family Integrity

The family integrity realm is the final area to explore. The term integrity refers to strength, solidarity, stability, and wholeness. Elements of family integrity are linked with family iden- tity, values, boundaries, and health beliefs (Anderson & Tomlinson, 1992). Families create and maintain integrity through a variety of means and seek to retain it as they interact with larger societal systems (Box 7.8).

Family B oundaries

Family systems can be described along a cohesion continuum from disengaged, to engaged, to enmeshed or along an adaptability continuum from rigid to flexible (Olson, Russell, & Sprenkle, 1989). Things that complement family identity are beneficial but those that com- pete can create conflict and discord. For instance, family members can get caught between family and caregiving system boundaries. Families that might have been viewed as strong for years may be splintered, as responsibilities for care of an aged parent compete with needs to support children in school activities. Family disagreements can occur. A young

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teen insists she wants a visible tattoo because friends have gotten them. Parents do not want to allow the outside world to negatively influence their family ways. Nurses who think family consider family boundary issues in their practice. As nurses involve family dyads (e.g., parent-child, sibling-sibling, husband-wife), the goal is to create care approaches to respect existing system beliefs and practices and maintain integrity or wholeness of the family (Tomlinson, Peden-McAlpine, & Sherman, 2011).

Families create boundaries that determine “who is in” and “who is out,” which describes who is or isn’t included in the family circle of care and decision making. Family-focused nurses are attentive to the ways persons receiving care define family. Family boundaries are often renegotiated over time. This change is not always the result of conscious effort but might evolve from trial and error as attempts are made to reach valued goals. Family members may have boundaries with one another as well as with those outside the family. Siblings often set boundaries for one another. Nurses working with families need to be sen- sitive to what boundaries exist and what they mean. Who gets told the good or bad news in a health care situation is influenced by family boundaries.

Family Identity

Family identity involves common, mostly shared perceptions, goals, and values about who members are in relationship to others. Family identity influences unit behaviors, relation- ships with the external world, and internal interactions with each other. Wright and Leahy (2013) state “as a family thinketh, so it is.” For instance, a family may see itself as “busy” and make choices based on current involvements. Families may demonstrate a range of behaviors that identify their commitment and loyalty to each other. A big brother may step in when children bully his younger brother.

The family’s shared identity is linked to the family’s history. For example, a Sudanese family may have a history as political refugees, and traumatic experiences and great loss

CHAPTER 7 ● Using Family Theory to Guide Nursing Practice 187

BOX 7-8

Basic Family System Tenets

Family systems theorists propose the following basic tenets that are linked with integrity of these unique family systems:

● A family system is a set of interrelationships of interdependent persons who mutually influence each other; what happens to one component influences all other components.

● A family system has a hierarchy of components (e.g., subsystems, systems, suprasystems, exosystems).

● Family systems are surrounded by permeable boundaries that interface with larger environments.

● Family boundaries vary in permeability; some boundaries are open, others are closed, and some are more flexible.

● Family systems take things in and have outputs that cross its boundaries. ● Family systems use a variety of means to reach the goals to communicate with one another

and manipulate information relevant to family identity. ● Feedback loops regulate the family system, and information exchange occurs among system

components, the system, and its multiple environments.

Source: Whitchurch, G. G., & Constantine, L. L. (1993). In P. Boss, W. Doherty, R. LaRossa, W. R. Schumm, & S. K. Steinmetz (Eds.), S ourceb ook of family theories and methods: A contex tual approach (pp. 325–352). New York: Plenum.

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may have occurred during that time. Even in a different environment, the family might find it difficult to trust those outside the immediate family. Outsiders include nurses and other health care providers. The nurse caring for such a family must invest time and gain their trust. Without trust, counsel may go unheeded.

Family values are connected to family identity and influence priorities. For instance, time given to physical activity in families differs. Some families value growth and change, and others resist it. Family identity plays roles in determining power structures and de- cision making. For instance, parental power can be used to control children or to strengthen their spirits and encourage personal choices. Family identity often guides choices of personal relationships. For example, if a family values getting regular physical activity, young adults are likely to choose physically active friends. Nurses who think family know when issues concerning family identity might need to be assessed and be included in a care plan. In some communities, the nurse might need to work with com- munity elders to discern community-held beliefs about family identities and values.

Family H ealth R outines and R ituals

Family values can shape stories about health experiences and influence the behaviors, rou- tines, and rituals of family health. Knowing about health beliefs helps family nurses better understand reasons for decisions and actions, especially when a new or ambiguous situation is faced (Antonovsky & Sourani, 1988; Reiss, 1987). Rolland (2003) identified some beliefs for nurses to inquire about:

• Causes of illness influenced by and outcomes of usual family life • Meanings attached to symptoms linked with religion or culture • Influences of prior generations • Anticipated points of difficulty in managing an illness or promoting health

Family health beliefs influence health-seeking behaviors and family health routines. Health-related activities such as adhering to immunization schedules, going to the doctor, implementing dietary changes, and maintaining hygiene are influenced by family health beliefs (Denham, 2003). Health beliefs are influenced by the family’s culture, values, edu- cation, and history, which are all linked to family integrity.

Family health routines are the usual daily activities (e.g., sleep, physical activity, diet) that promote or attend to health or illness care needs in daily life and are shaped by health beliefs and other family factors (Denham, 2003). Routines help families maintain member integrity and support the household production of health. Family health routines are shaped by val- ues, attitudes, family influences, sociocultural mores, and faith. Rituals tied to traditions, celebration, and commemoration of special occasions can also influence some routines. Family-focused nurses recognize that they are temporary guests as they work with family health routines and honor family integrity (Denham, 2003; Tomlinson, Peden-McAlpine, & Sherman, 2011). More needs to be learned about the ways nursing interventions can make important differences for the health of individual members (Box 7.9).

G oals to E nh ance Family Integrity

Family nurses consider family integrity in terms of family interactions, boundaries, identity, and routines. Nurses who think family know that care involves more than merely telling others what to do. Caring actions employ strategies that use trusting relationships to meet goals. Family-focused nurses avoid a “one size fits all” approach and communicate through specific messages for each family’s needs and situations. For example, Todd, a 5-year-old boy, was lying on the sidewalk in front of the family’s home after a hit-and-run motorcycle accident.

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His father was working in the yard at the time of the accident. He called for emergency help. He accompanied the child to the emergency department. Todd was admitted to the pediatric intensive care unit (PICU). His mother was en route from an out-of-town business trip and could not be reached. Todd suffered multiple skeletal fractures and a possible spinal injury. In the opinion of the PICU diagnostic team, Todd needed a contrast MRI (magnetic resonance imaging) to determine the presence and extent of the spinal injury. However, because of the nature of the injury and the need for sedation, the MRI was considered a high-risk procedure. Todd had lost a considerable amount of blood and needed a blood transfusion. Dad was the sole decision maker and was having a difficult time deciding whether to have the MRI or blood transfusion done. Table 7.5 provides some suggestions for appropriate nursing actions that can support family integrity in this situation. The five family nursing mod- els explained earlier in this chapter suggest various ways to consider family integrity and approach family care.

CHAPTER 7 ● Using Family Theory to Guide Nursing Practice 189

BOX 7-9

Evidence-Based Family Nursing

Global changes in health care are needed to reduce the costs of that care. Increased demands on nurses and other health professionals call for some changes in the health care systems. Short hospital stays and intense care needs, along with early discharge, call for shifts in the ways nursing is done. Family members need information, skills, and support to adequately provide quality coordinated care. A children’s hospital in Iceland has been testing family interventions to identify and better respond to family needs. As new knowledge is identified and evidence of best practice becomes available, questions about how to translate this knowledge into clinical practice are often unanswered. The best ways to provide family nursing in a systematic way are a concern because there has been little evaluation of the effects of family nursing interventions on family relationships and family outcomes. A study investigated the effects of a short therapeutic conversation to see if it made differences in the ways families perceived support (Svavarsdó ttir & Sigurdardottir, 2011). Thirty families of hospitalized children were randomly divided into a control group and an intervention group. All took part in a 15-minute or less therapeutic conversation. Those in the intervention group also participated in an average 25-minute family interview in which the nurse drew a genogram and an ecomap with help from the family. Therapeutic questions were used: What is the greatest challenge your family is facing? Who is suffering most? What one question do you need answered? Also, tailored questions about the specific child’s condition were asked. After this interview those in the intervention group completed questionnaires while the child was still an inpatient (time 1). They then completed the surveys again on the fifth day after discharge (time 2). Those in the control group also completed surveys during the inpatient stay and again on the fifth day after discharge. Of those who started the study, 13 intervention and 11 control families completed all surveys. No significant difference was found on perceived family support between the experimental or control group at the beginning of the study or after the 15-minute therapeutic conversation. Those in the experimental or intervention group reported better family support after the 25-minute intervention than did the control group. Also, those in the intervention group experienced a significantly higher level of family and cognitive support after this intervention compared to before the intervention. Perceptions of family collaboration and problem-solving skills were the same in the intervention and control groups. Findings indicated that family intervention makes some differences, but more study about family practices that create efficient and valued outcomes is needed.

Source: Svavarsdó ttir, E. K., & Sigurdardottir, A. O. (2011). Implementing family nursing in general pediatric nursing practice: The circularity between knowledge translation and clinical practice. In E. K. Svavarsdó ttir & H. Jó nsdó ttir (Eds.), Family nursing in action. Reykjavik, Iceland: University of Iceland Press (pp. 161–184).

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190 CHAPTER 7 ● Using Family Theory to Guide Nursing Practice

TABLE 7 -5 Nursing A ctions to Support Family Integrity Based on Family Models

FAMILY NURSING MODEL K EY CONCEPTS NURSING ACTIONS

Calgary Family Intervention Model (Wright & Leahey, 2013)

Family Health System Model (FHS) (Tomlinson, Peden-McAlpine, & Sherman, 2012)

Family Management Style Framework (FMSF) (K nafl et al., 2009)

Family Health Model (Denham, 2003)

Acknowledge the difficulty this must be causing the father and the threat posed by this injury to the family unit. State, “ This must be difficult and frightening for you. How are you doing, especially without your wife here? Would you like to share what your thoughts were as this was happening? Is there someone I can call for you who could support you right now; a family member, friend or your clergy person? ”

Assist the father in enacting his parenting role. For instance, state, “ Your son may not be awake and or respond to you right now, but you can help him by sitting here at the bedside, touching his face, his arms, giving him a hug and kiss, and talking to him. He needs your strength and we are pretty sure he will sense your presence. If there are specific things you can do to help with his care, we invite you to do so if that is acceptable to you.”

During moments of critical care it might not seem obvious to address family management. In this case, the father might be inexperienced with some nurturing roles. However, as time goes by and both parents are available, strategies for care management will likely need to be identified.

Confirm parental roles and the uncertainty of the situation; show curiosity about normal family activities. For instance, state, “ You are being strong for your son right now; this is important. What would your wife do if she were here? Would it be helpful for us to keep a few notes for her about what is happening so she can catch up when she arrives? What are you most concerned about her missing? Could we keep a journal for her and your son? ”

Support the affective domain of family functioning.

Strengthen family boundaries, roles, values, meaning.

Not always applicable to a critical illness situation

Connected family processes, meanings of external environments, and family routines

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Illness Beliefs Model (Wright & Bell, 2009)

CHAPTER 7 ● Using Family Theory to Guide Nursing Practice 191

TABLE 7 -5 Nursing A ctions to Support Family Integrity Based on Family Models— cont’ d

FAMILY NURSING MODEL K EY CONCEPTS NURSING ACTIONS

Strengthen facilitating beliefs and challenge constraining beliefs. Interpret what is happening physiologically and medically. Explain goals of medical care. Allow the father to share his feelings about the accident. See what questions about care need answers, clarify errors in understanding the situation.

Intersection of family member beliefs, cultural values of those needing care and the health care providers linked with suffering

Chapter Summary

Various theories can guide the delivery of family-focused nursing care. Theories provide perspectives and ways to think about approaching care. Family science and family therapy theories and models suggest ideas about how nursing actions can be aligned with care needs. Several family nursing theories have been identified as ways to think about different care approaches. Nurses who think family use theories to intentionally select nursing ac- tions to meet family goals. Collaborative individual-nurse-family relationships are formed to plan actions that meet goals relevant to the health or illness need. In family-focused care, nurses give attention to family realms of concern (i.e., family coping, family develop- ment, family interaction, family integrity). These realms can be assessed and then plans of care determined. Nursing actions are intentional, respect the family experience, and address meaningful concerns from the family unit perspective.

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