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Developing a Family- Focused Nursing Practice Kathryn Hoehn Anderson ● Sharon A. Denham

C H A P T E R 8

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

1. Describe the nature of the individual-nurse-family relationship and its importance in family nursing practice.

2. Describe the characteristics of a family practice model. 3. Discuss family nursing skills used to provide family nursing care. 4. Demonstrate use of a family nursing model and nursing actions to provide family nursing care. 5. Discuss family nursing approaches/models used in family nursing care practice.

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

● Circularity ● Clinical family nursing skills ● Family nursing practice ● Family unit perspective ● Hypothesizing ● Individual-nurse-family

relationship

● Interventive questions ● Neutrality ● Practice model ● Selecting a family nursing

model ● Therapeutic questioning

Introduction

About 35 years ago, the first edition of Family-Focused Care was published, and this thoughtful work crafted some early thinking around nursing actions and family interven- tions (Miller & Janosik, 1980). Since that time, the science around family-focused practice has grown. This chapter considers more current thinking about family practice and explains how this approach can be used in clinical work. By forging an individual-nurse-family rela- tionship with every person receiving care, nurses can build collaborative partnerships with those seeking care. This chapter describes the development and use of an individual-nurse- family relationship, considers the importance of using practice models to guide clinical work with families, and discusses ideas about use of clinical skills in family nursing practice. It explains how to choose and apply a family nursing model when planning care for individual families and addresses the nature and development of the individual-nurse-family relation- ship with family nursing practice. It provides brief explanations of a few select family nursing

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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 03:07:07.

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models, describes several family nursing skills important to master, and provides a case example of family nursing care using the Family Health System model (Anderson, 2000). This chapter describes ways to effectively think family not just as a prelude to providing family nursing care, but throughout the caring endeavors.

Family-Focused Nursing Care

In family-focused care, nurses assume a mind-set that continually thinks family as they care for individuals and their families as a unit of care. Family nurses apply all their skills, using technical, mental, and emotional processes. Family theories, as presented in Chapter 7, can be used to guide clinical practice in the ways nurses give care with families, and take action. Nurses who desire to develop a family nursing practice need knowledge about families in- cluding dynamics, history, health patterns, lifestyles, and culture, member, and community connections.

Providing nursing care from a family unit perspective can be challenging and exciting. The family and nurse become true partners in care. Families have information and expertise about their concerns. Stories from their perspective tell of the stresses, difficulties, and worries ex- perienced. They know what is and is not working. Nurses are in positions in which they can help families manage health and illness, developmental concerns, and transitions (Anderson, 2000). Family nursing can enhance awareness, meaning, and potentials of individuals and families (Hartrick, 1997). Family nursing is intentional collaboration and identifies the best ways to help families achieve their health goals. Family nursing looks beyond the individual and the present and includes family and potential future needs (Fig 8.1).

Family Nursing Practice

Nursing is a practice discipline, both an art and a science. The art of nursing is the thera- peutic use of self in delivery of nursing care, and the science is based on research evidence. Nurses need to read and understand research findings and then use that information to help

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FIGURE 8 -1 Family nursing looks beyond the individual and the present.

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individuals and families promote health and manage illness. More still needs to be learned about the implications of intentional family inclusion in nursing actions (Anderson, 2000). Current knowledge is a foundation that clinicians, researchers, and scholars can build upon and use to develop even stronger evidence about what constitutes family nursing practice.

Family nursing practice addresses the needs of individuals and their families who seek health and illness care services. Thinking family includes learning how those seeking care and their family members relate to one another and what these relationships imply for care. Individuals are not just care recipients, but also partners in care with families who are part of the care experience. Nurses need to know how this happens and what it looks like in practice. These things can be demonstrated in clinical experiences, but also through active learning in the classroom.

Individual- N urse- Family R elationsh ip s

When a family care approach is used, care is centered on the family unit and how to satisfy their health or illness needs (Anderson & Valentine, 1998). The concerns addressed are as- sociated with the individual and who that person views as family. What individual and family perspectives need to be heard? People are social animals, often eager to engage others and be noticed. What happens when we get together with others? We often tell stories about what is happening in our life and find out what is happening in theirs. It happens everywhere—at work, with neighbors, with friends, and in families—people tell stories about their lives as they share their life experiences. During times of crisis, at critical life moments, in health or illness, people often want to tell about what happened and their responses.

Suppose you tempt fate and go out in a snowstorm against your better judgment. Two miles down the road on a steep rural incline you lose control and the car slides off the road and you sit alone in your car. You look around at the lonely desolate place, note the gas tank is half full and the outside temperature is 11 degrees. You put on your hazard lights but know they can’t be seen until someone is dangerously nearby. You grab your cell phone and call someone who cares. Although this person is 30 miles away and not able to help you, the sound of her voice gives comfort and you tell the story of your dilemma. You are in a difficult situation, but here is someone who cares, will listen, and offers comfort. This helps! People usually show up willing to help. Strangers without names suggest tactics that might work, things to try, and ideas to solve the problem. Still fearful and uncertain, you trust their ideas may help get you out of a difficult or troubling situation.

In a way, nurses can be like these strangers, they are present to care in unusual and stressful situations. Individuals and their families enter unfamiliar health care settings filled with fright- ening things, faces, and rules. Often uncertainty about life and what is going on with a health condition is present. A nurse who cares shows up and is prepared to offer help. Though uncertain about the outcome, it is comforting not to be alone. Family nurses reach out to establish a caring connection to individuals and families. It is a relief to meet someone with ideas about things that might help and who is invested in acting in intentional ways to resolve the problem. The history of nursing tells of caring persons available during uncertain times, willing to listen, offer comfort, be present, and provide care.

A narrative or story of personal experience has new meanings, value, and potentials when it is heard and shared with others. Clearly, critical interventions must occur first, but even then care and support are important to care recipients and family units. Family nurses begin relationships by welcoming individuals and families into the relationship, establishing a caring connection leading to an individual-nursing-family relationship, and listening to the health or illness story that communicates individual and family needs and concerns.

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C h aracteristics of th e Individual- N urse- Family R elationsh ip

The individual-nurse-family relationship is a reflective one. This means that what is said or done is thoughtfully appraised from the perspective of others. It allows for acceptance of vul- nerability and examines whether stressors might be physically based, relationship based, or from a prior experience, fears, or external determinants. Nurses establish thoughtful relation- ships with the individual and the family and notices that people often respond out of prior experiences and personal emotional pain. Although the current event might be in sharp con- trast to previous ones, sometimes past events cause lingering impressions that cause present worry, fear, or other emotions. As nurses reflect on the situation at hand, they are careful to put aside biases and assumptions. Assessments help discover the obscure and gain a perspective of patterns and needs. Reflective practice requires checking personal reactions to situations and accepting differences without judgment. It acknowledges various points of view and gives authentic care that is sensitive to other’s needs. The nurse evaluates various needs and whether a partnership to meet family unit goals is being successful. Reflective nurses know that trou- blesome situations are not always due to current circumstances, but may be responses to actions from other circumstances that need addressing from the family perspective.

Stop a minute. Think about what you read in the previous paragraph. How do you define reflective practice? How might reflection cause you to approach a practice situation differently? Do you think about needs and situations before planning care? What are you thinking about after care is given? Do you pause and consider what happened? How did your interaction help the family with healing and easing their suffering (Wright & Bell, 2009)? With helping them with what they are going through? What does the family want to improve in their situ- ation? How might you have done things differently? Take time to reflect before and after care is provided (hypothesizing what is going on). Thus, you consider a variety of options. You might be thinking, “Oh, good, I am already doing just that!” But at other times you might be thinking “I need to learn more about how to think family in action or practice or how to react when others have differing values than mine.” Self-reflection enhances nursing practice.

Actions of th e Individual- N urse- Family R elationsh ip

Nursing actions can support individuals and their family members in many ways. Some nurs- ing actions are aimed at immediate concerns, others are more relevant to the future. Family nurses focus on what the family determines are the priority concerns; the nurse adds expert input for family consideration. For example, a new mother is trying to decide whether to breastfeed her new infant. She may need to learn skills for making the process successful. Her husband and his mother might have an experience in which breastfeeding didn’t work so well and may need information about the long-term health benefits for the child to be able to support the mother’s wishes. When family members are included in the conversation, multiple needs can be addressed. Including family in discussions about breastfeeding could answer questions, explain benefits, and be more useful than just telling the mother that she should breastfeed without considering other family member support. The individual-nurse- family relationship uses a think family perspective including relevant scientific evidence and holistic care for the family unit based on their need priorities. Think about your family and ask yourself, if one of my family members were sick, how would I want to be treated as a family member? How would I want to be included? What would my family prefer? Take a few minutes to review Box 8.1 where you can learn about a family nurse leader from Finland who has been helping students learn about family care for many years.

Initiating th e Individual- N urse- Family R elationsh ip

Individual-nurse-family relationships begin with introductions. Then take time to hear the family health story about their current situation. Communicate the purpose of the

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interaction and help the family share important information and understand the family view of the situation. The nurse can say “Tell me what brings you for care today.” The story is a critical aspect of the initial meeting. The nurse gathers data from the health/ illness story that can be included in the assessment data. It is the opportunity to learn important facts from the person’s or family’s point of view. You might be wondering how you encourage people to share their story in ways you can understand the family’s view about how their illness came about and what needs they perceive. Also, you might won- der how you kindly interrupt someone when the story goes on too long or leads to other unconnected stories. Redirecting the story so that the most valuable information is gained in a timely way is a skill that is learned through practice and using your interviewing skills. Another way to start the interaction with the family is by asking “What brings you here today?” or “What led up to your admission today?” These open-ended ques- tions easily lead to the telling of the health/illness story and get you started with your in- dividual-nurse-family relationship and the nursing assessment. As you listen, ask for clarification if something is not clear, show that you are involved and interested. As you hear the story, you might want to write a few notes about points to discuss in more detail later.

The story might include facts about events leading up to the current care-seeking event or reasons why the situation is happening a certain way. Because of how busy nurses are, if the story interaction goes on too long and you must attend to other things, you can say to the family something like “I want to talk with you more about this, but I need to go and take care of some other important things related to your care (if possible state what this might be). But I will be back in about 10 minutes.” Be sure to return as you stated. If something hinders you, check in and let them know you have not forgotten. Remember, waiting can be a stressful time that seems longer than it really is. These initial interactions set the stage for future ones. When you return, you might ask about pertinent stressors, greatest difficulties or related worries, what is and is not working, or the ways personal and family life is affected.

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BOX 8-1

Family Tree

Pä ivi Å stedt-K urk i, PhD, RN (Finland)

Pä ivi Å stedt-Kurki, PhD, RN, is a professor and chair of the discipline of Nursing Science in the School of Health Sciences, University of Tampere, Finland. A core societal belief held by the Finnish culture is that a patient and his family are the most important participants in health care. The need to advance science in this particular area of health care led to the establishment of Family Nursing Science at the University of Tampere. Dr. Å stedt-Kurki helped to develop a Family Nursing Science curriculum and has served as a supervisor of numerous doctoral dissertations in nursing science in which the topic is family nursing. She is a prolific researcher with over 200 data-based publications in Finnish and English that focus on family health, well-being, and family nursing interventions across the life span. Besides funded research and publications, Dr. Å stedt-Kurki and her colleagues co-developed two family nursing research instruments: Family Functioning, Health, and Social Support Instrument (FAFHES) and Parents’ Perceptions of Care (PPC). In 1999, an International Family Nursing Congress, hosted by the University of Tampere, shared the development of Family Nursing Science in Finland. Dr. Å stedt-Kurki is a national leader and has twice been invited to serve as the chairperson of the Finnish Association of Caring Sciences. She is the Editor-in-Chief of the J ournal of Nursing S cience in Finland (2009–2010). In 2009 Dr. Å stedt-Kurki was honored with a Distinguished Contribution to Family Nursing Award from the J ournal of Family Nursing for her outstanding and sustained leadership in family nursing leadership in Finland.

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It is essential to determine what is most important to the individual and the family and what their concerns are. Communicate clearly in understandable ways. As the picture of the health/illness story emerges and meaningful interactions occur, trust is built and the ground- work for a relationship is established. As time permits, you can ask further questions about values and beliefs, developmental concerns, member roles, family communication, problem solving, conflict resolution, health practices, and routine family behaviors, continuing the process of assessing the family. Take time to consider alternative ways to assist. Avoid assumptions and be sure to get needed facts. The personalized story tells the nurse that this is not just an elderly woman with a broken hip who fell, but that this is a person, part of a unique family unit, who shares a household life in a particular neighborhood and community and is loved and cherished by her family. The families we care for are real people! They have interesting lives, distinct needs, caring friends, and social networks. This meaningful individual-nurse-family interaction is the foundation of family nursing practice.

C aring in th e Individual- N urse- Family R elationsh ip

Traditional nursing education often approaches families as the “context of care”—such as including the parents in the care of a child patient. Family is often highlighted in obstetrical, hospice, or community clinical rotations. In a traditional mode, patients can be viewed as dependent and nurses as experts. Thinking family means that the family unit is the target of care and they are experts about their health and illness condition. Individuals are viewed are independent care-seeking agents who are part of a family. This unit point of view encourages families to participate in their own health achievement with a family nurse. Box 8.2 provides some information about the benefits to families of in-home intervention.

When the family unit is integral to individual needs and best interests, nurses do not just take control or give orders, they identify specific needs of multiple persons in a care situation based on what the family tells them. They unit use supportive therapeutic actions in ways that meet individual and family unit needs and address distinct needs in the best ways possible. Caring interventions are customized to diverse families.

Nurses who think family know the importance of family dynamics and the bidirec- tional influence family unit members have on one another (Anderson & Tomlinson, 1992). Family systems theory tells us that whatever happens to one person influences the family and whatever influences the family also influences persons who compose the family (Denham, 2003; von Bertalanffy, 1968). Family members have influence, roles, and meaning whether an individual is ill or wants to increase his wellness. In thinking family, nurses appreciate that individuals hold common family dynamics and experiences that are foundational to the family.

N ature of th e Family N urse R elationsh ip

Family nursing is different from practice done by social workers or family therapists as discussed in Chapter 7. Family-focused nursing care includes several goals:

• Facilitating individual and family growth • Enhancing individual and family knowledge and understanding • Assisting individuals and family members in managing health symptoms • Following evidence-based prescribed medical and nursing regimens • Promoting and improving individual and family health • Supporting behaviors to maintain and improve individual and family health

Sometimes how to work with families to achieve these goals are taught in a family nurs- ing or community health course, but they are meant to be used in all aspects of providing care. Individual-nurse-family relationships are collaborative partnerships that can be used

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to meet health and illness care needs of all ages in all forms of care settings. When nurses view the family as the expert on its life, they enter into respectful interactions knowing that the family is giving its best efforts (Anderson, 2000).

Caring interactions involve listening to the family, validating key concerns, noting ex- pectations, and integrating family strengths and desires (Anderson, 2000). Nurses with this mind-set are open to the unexpected and alert to unusual or different family responses in meeting the primary concerns confronting the family (Kaakinen, Gedaly-Duff, Coehlo, & Hanson, 2014; Wright & Leahey, 2013) reflecting a nonjudgmental view of the family.

Family nurses create the context or atmosphere for therapeutic interactions to occur. Those seeking care are often unsure what to expect, so nurses take their clinical expertise into the family’s world (Fig. 8.2). Nurses describe ways they can assist, explain environ- ments or systems, address concerns, and clarify information not well understood. However, the family is always the expert when it comes to what is happening in their personal lives. Nurses learn about their needs directly from them.

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BOX 8-2

Evidence-Based Practice in Family Nursing

Community Interventions for Families W ith Children

Attention deficit-hyperactivity disorder (ADHD), a condition that negatively affects children and families, is on the rise and affects about 4% to 7% of children worldwide. A nurse case management program intervention named Parents and Children Together (PACT) has been developed to focus on assessment and service delivery. A total of 87 families participated in this study. PACT focuses on family support, empowerment, and a strength-based perspective. The main aim of this form of nursing intervention is to focus on family support rather than disease management. The PACT intervention has four steps:

● Assessing strengths, resources, and risks to determine family level of need ● Setting goals and identifying type and level of services needed ● Providing direct service ● Ongoing monitoring

Nurse case managers (NCMs) received a month of intensive and specialized training focused around the common concerns experienced in families with a child who has ADHD. The intervention was family directed and the NCM was primarily a resource and facilitator. Families were not sure what to expect when they agreed to participate in the intervention and later said many of their perceptions were wrong, as were those of other health care providers. After working for an extended time with families (12 months), the NCM was observed to be like family because she understood the situations and believed the families. The PACT was a collaborative relationship designed to provide supportive services and not direct intensive care. Mothers of the children were highly satisfied with the intervention and thought the intervention was effective. A subset of the mothers (N = 17) reported that learning more about the neurobiology of the disorder and how problems were linked to executive function gave them more confidence in their parenting as they realized the behavior was not linked to poor parenting. Although providing a yearlong program in most situations is not feasible, several important things were learned. Families needed clear education about the physiology of the disease, the role executive function plays in child behavior, and parenting techniques for behavioral challenging behaviors. PACT is an example of a home visit nursing intervention, and study findings suggest that family education, ongoing assessment and monitoring, problem-solving skills, crisis intervention, and knowledge about community resources helped families be more successful in their daily management of this childhood disorder.

Source: Kendall, J., & Tabacco, A. (2011). Parents and children together: In-home intervention for families with children with attention-deficit/hyperactivity disorder. In E. K. Svarsdottir and H. Jonsdottir (Eds.), Family nursing in action (pp. 185–216). Reykjavik: University of Iceland Press.

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A legendary family therapist, Virginia Satir (1967), said, “I believe the greatest gift I can conceive of having from anyone is to be seen, heard, understood and touched by them. The greatest gift I can give is to see, hear, understand and touch another person. When this is done, I feel contact has been made” (p. 31). Of course, Satir does not mean physically touching, but touching the heart through a caring tone and actions. These words are still true and hold wisdom for designing individual-nurse-family relationships. Nurses who think family respect the challenges being faced by the individual and family unit and assist those seeking care in recognizing their strengths and using them to solve problems.

Steps in Delivering Family Nursing Care

In family-focused nursing care, numerous skills are needed for competent care delivery. Although nurses who think family know that the individual and family are not separate, they also know that families do not always behave in unison. Some families are tragically fragmented by long histories of tragedies, misunderstandings, conflict, and selfishness. Thinking family does not imply that nurses need to solve family problems. Many issues require the skills of advanced practice nurses or therapists. Nurses need to direct their care toward specific concerns linked with health and illness at the generalist nurse skill level. When deep-seated emotional or social problems are identified, the family nurse advises the physician or other medical team member about them and they are often referred to another interprofessional health team member. Nurses who use sound nursing practices know the limits of their scope of practice, but they can act as connectors as they facilitate improved well-being of the family unit in areas requiring skill beyond their education. Thinking fam- ily includes some philosophical ideas about “doing for” and “being with.” These ideas are fully discussed in Chapter 13.

In clinical nursing practice, family nurses consider ways family members’ reciprocal re- lationships influence care outcomes. In collaboration with the family, intentional actions requiring numerous skills with families are used to set goals, plan care, find strategies that

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FIGURE 8 -2 Nurses initiate the conversation and create the context for therapeutic interactions with the individual and family.

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will work, and identify how successful outcomes can be measured. Family care approaches include neutrality, hypothesizing, and circularity (Wright & Leahey, 2013). Nurses also use interventive questions to discover what is most needed and facilitate problem solving.

Neutrality

A neutral view, not taking sides or making judgments, helps nurses be respectful of families’ abilities and gain humility (Wright & Bell, 2009). Neutrality describes the nurse’s attitude to- ward the family system that constrains them from taking sides or placing blame (Wright & Bell, 2009). The essence of neutrality is curiosity; this means that the nurse will entertain al- ternative points of view to more clearly understand a situation (Cecchin, 1987). You may not understand the multiple interpretations of a behavior, an event, a relationship, or interaction observed or experienced, but by taking a neutral stance you remain open to the many possi- bilities presented. Being neutral allows time to interpret conversations and events in ways different from your personal life experience. Neutrality implies that it is okay for families to act differently from the ways other mainstream families might respond. It implies that nurses do not need to decide how things get done. Family nurses foster openness and curiosity about the ways family members engage with and respond to health and illness problems. This attitude can help families consider ways to be open to other viewpoints also.

Hypothesizing

Hypothesizing is the use of propositions or hunches that suggest areas to explore, things that can help the nurse connect or attribute meanings to behaviors (Wright & Leahey, 2013). It keeps one open to the possibilities about what dynamics are at work in a situation. It can guide the use of questions or discussions, help the nurse weigh alternatives or op- tional actions, and explore potential strategies for problem solving. For example, you might wonder what happens if a family member is unsure how to act in a hypoglycemic event. Suppose the family member is afraid, freezes, and does nothing. Or suppose the family member knows something sweet should be given and has the person consume a big glass of orange juice and a candy bar. What might be the consequences of the family member’s actions? Suppose the family knows exactly what to do, but the problem is something else. Can you see how hypothesizing helps you see needs from varied viewpoints? Being curious and considering possibilities is part of critical thinking.

Using questions to confirm a hypothesis can lead to thinking about life or illness differently. As the nurse works with a family member, she might ask: Suppose your husband gets weak, says his lips are tingling and he starts perspiring, what would you do? What do you think about when that happens to him? Or if the nurse wants to educate about nutrition, he might say: If you went shopping and had to buy items for three well-balanced meals for a day, what things would you buy? Use of hypothesizing questions can validate the nurse’s ideas and guide their thinking and responses (Wright & Bell, 2009). A nonconfirming reply to a hypothesis can prepare the nurse to revise the teaching to be done as new information is included. A hypothesizing view opens the door for new possibilities and alternative explanations.

Circularity

Circularity refers to reciprocal influences that occur as questions are used to understand family behaviors and confirm or discard hypotheses made (Wright & Leahey, 2013). Circularity focuses on the interactions within the individual-nurse-family relationship and observations about family member interactions. It is useful to note how thoughts, feelings, and actions

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affect and influence member interactions. Circular communication shifts the focus so that clearer understandings about what is experienced in a particular situation are expressed in ways that others hear firsthand. Sharing effects of personal thoughts, feelings, and actions on others allows others to hear and sense agreement or disagreement, emotional pain, or uncer- tainty. The nurse listens carefully to what is said and how it is said to see if actions or behaviors are congruent. It is sometimes helpful to review a member’s interactional patterns with other members and ask the individual to clarify more about his or her communication. The purpose of circular communication is to learn more about what the family is thinking and feeling during clinical and familial interactions. The reciprocal nature of communication becomes important and useful in planning intervention questions, as will be discussed later.

Circular communication goes two ways (Fig. 8.3). The nurse listens and reflects in a clear, open, and neutral way about what was heard. Then in a caring manner, the nurse assists the family members to respond to what has been said. For example, a mother and an older daughter are talking with the nurse about the ways their father/grandfather is reacting to his growing memory loss. The mother says, “I just cannot bear that he is so confused all the time. He repeats things over and over and seems to remember less every day.” The nurse replies with a reflective statement, “He remembers less every day.” “Yes,” the mother con- tinues, “he cannot remember if he has eaten his meals and is continually asking to eat. This is so distressing to me and it causes the children to get frustrated and sometimes be mean to him.” The nurse turns to the daughter and facilitates circular communication: “Your mother is saying that you and your siblings get frustrated with your grandfather’s forgetfulness and repetition.” The nurse looks at the daughter and silently waits for her response. The daugh- ter answers, “It upsets me to hear him say the same things over and over. He used to play games and sing with us when we were younger. He is not like the grandfather I used to know.” The nurse goes on and clarifies meanings: “You are worried about your grandfather forgetting?” The conversation continues as they all express feelings, concerns, thoughts, and begin to understand each other’s actions. The focus is on “I feel” and not accusatory. At conversation’s end, the nurse has gained great insights into what is happening with this family. This information provides accurate information about members’ responses to the person and the disease. Facilitating circular communication helps families. What is learned can be a foundation for goal setting, coping in new ways, and steps family members can take.

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Spouse Wife

Patient Husband

Husband Speaks/Acts to Wife

Circular Communication When Husband First Starts

Conversation With Wife

Wife Speaks/Acts in Response to Husband

Husband holds thoughts and feelings about what he says and does in response to previous interaction

Husband with his thoughts and feelings about her verbalization

Wife responds to thoughts and feelings

about what he says and does

Wife verbalizes her response to husband

based on her interpretation of her feelings and thoughts

about what he said

FIGURE 8 -3 Circular communication between husband and wife.

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Interventive Q uestions

A family-focused response that builds upon circular communication is a behavioral obser- vation interventive question (Loos & Bell, 1990). For example, “What is it like for each of you when your father/grandfather is confused?” The mother and daughter look at each other. The mother answers, “It is difficult for me; I just want him to be happy and at peace, but my daughter and other children seem angry with him all the time.” The daughter replies, “Mother, we want him to be happy, too; we are afraid when he gets angry and acts out. We do not know what to say to him. We are afraid of what he might do.” With interventive questions, the nurse further facilitates communication between the daughter and the mother. This interaction suggests specific ways the nurse can follow up to provide needed education about the disease, safety concerns, respite care, and family stress management. Through communication, nurses can identify strengths to be commended and use these strengths to facilitate problem solving.

Family Nursing Practice and Assessment Processes

When conducting a comprehensive assessment, explore all relevant areas linked with the med- ical condition and family dynamics. Nurses often focus on physiological needs, but persons cannot be reduced to parts and individuals cannot be isolated from families. Therefore, the psychological, emotional, spiritual, and social aspects are also pertinent to medical care needs. Of course, as nurses we are always concerned about safety at home and in acute care settings.

Individuals have real lives outside health care settings; they are children, parents, spouses, partners, grandparents, cousins, aunts, and uncles. They are friends, neighbors, students, workers, housewives, and retirees. In their communities they are volunteers, civic leaders, coaches, local officials, and community leaders. They are people who others care about and they care about others. People have intimate and valued relationships that are part of their history and personal life stories. Health care settings are intrusions or interruptions in real life. Health and illness are often taken for granted until they become personal events. When health concerns arise, we often meet changes and transitions that last forever. Illness is often a threat, the possibility of a fear-filled future. The following sections describe ways to focus on care linked with the family unit.

Therapeutic Q uestioning

Nurses have long asked questions of individuals and families in their clinical practice. Starting in the 1950s, Hildegard Peplau (1952, 1997) suggested that focused attention be given through therapeutic relationships. Her perspective suggests that nurses take a reflective stance in nursing practice. An analysis approach to therapeutic questioning in interviewing, assess- ment, and interventions has now been developed (Wright & Leahey, 2013) based on the work of Tomm (1987, 1988). In their work Wright and Leahey articulated ways to skillfully formulate and use questions:

• Engage all family members and focus the meeting with the family. • Assess the impact of the problem or illness on the family. • Elicit family problem-solving skills, coping strategies, and strengths. • Use “interventive” questioning to invite change. • Request feedback about the meeting with the family.

Don’t underestimate the power of using questions. Sincere questions curiously asked provide information, encourage reflection about experiences, and move people toward

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healing processes (Wright & Leahey, 2013). Well-thought-out intentional questions can successfully guide family discussion and imply directions for changes. Interventive questions used during assessments or stand-alone questions in health or illness discussions can help in the search for directions of meaningful change.

Conducting Family Interview s

The “15-minute family interview” (Wright & Leahey, 2013) provides a guide for you to ac- tively engage family members in dialogue focused on perceptions of the illness experience. It is used as an introduction to start a relationship with the family; it is not designed to substitute for a full family assessment, but it is a beginning. The 15-minute interview can be completed with a care recipient and at least one other family member. This allows a meaningful but nonthreatening way to begin to listen and interact with families. This interview method can guide novices to master new skills. Assessments should always start with the specific needs individuals present as we can never assess everything possible. However, keep in mind that these presenting needs always have family factors to consider in planning nursing actions.

Th e 1 5 - Minute Interview

When first learning to use a 15-minute interview, students or nurses might want to choose the individual and family member to interview as new experiences cause apprehension. Some nurses have little conversation with a family beyond answering direct questions, telling them they will ask the doctor, interacting during the admission session, providing care directions, or delivering discharge instructions, so this can be a bit frightening. Even nurses in home care report that even though they have conversations with families all the time, they do not think about having therapeutic conversations (Anderson & Friedemann, 2010; Anderson & Valentine, 1998).

When preparing for the 15-minute interview, consider where this will occur. Ideally, you will conduct this in a place where you will not be interrupted. You want to make sure everyone is comfortable before you begin and start with introductions. In this interview, it is a good idea to write the questions to be asked on a piece of paper before the interview (Box 8.3). They will be used after the introductions are made. Have some paper available to make notes.

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BOX 8-3

15 -Minute Family Interview Q uestions: Mak ing a Family Connection

These eight therapeutic questions should be included in the 15-minute interview:

1. How can we be most helpful to your family and friends during your hospitalization (or care episode at home)?

2. What has been most or least helpful in your past hospitalizations or clinic visits? 3. What has been the greatest challenge facing you or your family members during this

hospitalization, clinic, or home care visit? 4. Which of your family members or friends would you like us to share information with? 5. What do you need to best prepare you and your family members for discharge? 6. Who do you believe is suffering the most in your family in this hospitalization, clinic, or home

care visit? 7. What is the one question you would like answered now in our meeting? 8. How have I been most helpful in this family meeting? How could we improve?

Source: Wright, L., & Leahey, M. (2013). Nurses and families: A guide to family assessment and intervention (6th ed., pp. 271–272). Philadelphia: F. A. Davis.

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Nurses sometimes worry the first time they do a family interview, mainly for the following reasons:

• I do not know how the family will respond. Will they answer the questions? Will they think I am invading their privacy? Will they ask me something I don’t know?

• I really do not know how to talk with families. I have never done this before. • I usually avoid deep conversations with families.

Being prepared ahead of time helps. Knowing exactly what you will do with your planned questions helps. All new nurses experience some anxiety as they learn new things, but re- member that individuals and family members are usually pleased to have conversations with nurses who are interested in them.

As you begin family conversations, focus on listening and truly hearing what is said. This can be difficult when you are nervous. What is the story they want you to hear? How can you acknowledge that you hear what is said? In what ways can you affirm the family and the concerns they express? Of course, courtesy and politeness are important. Open and welcoming introductions set the stage for what follows. An open and caring milieu or atmosphere can be infectious. Keep in mind that sometimes we can ask questions that people do not want to answer. If they refuse to answer a question, just skip it and go on. If it is really important, you might want to return to it later after you sense you have gained their confidence or trust. An initial encounter done with an ill-mannered approach can be damaging. But a friendly, sincere, and engaging approach can lead to a valued relationship. Initial impressions count! Those made in the first minutes count and can be lasting (Wright & Leahey, 2013). As you listen, commend—highlight good things about the family. Note the strengths you observe or hear as you talk together.

Nurses are often amazed at how well a family interview goes. Most families are pleased when someone talks with them and are thankful for time to share concerns and needs. The 15-minute interview provides an initial communication experience and provides opportu- nities to gain new insights, and gaining self-confidence through a successful interview ex- perience and is a major step in talking and working with families. The 15-minute interview structure of engaging families can provide a memorable experience that offers insight into the value of thinking family for you. One question, item 7 in Box 8.3, gives you a chance to learn what others view as a priority need. Often, at the end of the interview, family members might say that this is the first time anyone ever asked them about what is hap- pening and listened to what they had to say. So interview skills are important and can lead to therapeutic conversations and valued relationships.

Follow - U p to th e 1 5 - Minute Interview

After the 15-minute family interview, review the clinical record and see if the information gained has previously been noted. Often, it isn’t there. Although nurses traditionally gather some information about families during admission assessments, it’s not always documented.

After you have completed the interview and documented important information, take some time to reflect. Evaluate yourself. What is your response to the interview? Is there any- thing that caused you to respond negatively or in an extremely positive manner? If so, what caused this response in you? Mature family nurses recognize that the thinking family aspect of practice must occur before, during, and after caring events. At the end of the interview, you can begin thinking out loud with the family or other members of an interprofessional team about follow-up steps. What nursing actions are aligned with the information just obtained? What hypothetical steps with the family validate what you have heard the family share. Reflective evaluation, critical thinking skills, and clinical judgments based on nursing knowledge serve as guides for the planning of nursing actions and care to be delivered.

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Using Interventive Q uestioning in Family Nursing

As previously mentioned, therapeutic questions are open-ended and elicit information that goes beyond mere facts or details. It is a skill to know what types of questions to ask and when to ask them. Questions can obtain various forms of information to help:

• Get a straight answer • Direct the response of the individual-family • Facilitate family’s reflection about their lives • Explain beliefs and behaviors • Encourage family members to consider alternative ways to view or solve a problem

Interventive questions help the nurse identify the family’s cognitive and emotional experiences linked with health or illness. Interventive questions provide ways to view member differences and similarities. Here are some examples of interventive questions:

• How is this illness affecting your family? • Tell me about the ways (name a person) is managing the extra caregiving tasks. • What seems to be the most troubling thing for your family in managing this situation? • How does this illness situation most interfere with family life? • When Mom is doing caregiving tasks, what do you think she is thinking about? • While your Dad is struggling to walk with the walker, what changes in the household

are each of you thinking are needed for his safety?

Interventive questions engage cognitive and emotional processes and often are less physi- cally focused, but the answers provide a wealth of information about the family’s response to the health or illness issue. Responses elicited can help members think about an issue from a different view. These questions can be used while a genogram or ecomap is completed. As the family tells their stories, nurses make sure that things are heard correctly and interpreted accurately. It is good to ask questions that provide needed clarification and double check what has been said. Key concerns get validated. Critical thinking and expert nursing knowledge are included in the analysis of the situation as clinical judgment is used to weigh potential actions in asking further questions or facilitating family interactions and change. Wright and Leahey (2013) and Loos and Bell (1990) offer extensive lists of differing types of interventive questions for your review.

Using Genograms in Family Nursing Practice

Genograms and ecomaps, tools discussed in earlier chapters, can be combined with your 15-minute interview and your formal family assessment. The genogram uses a family tree structure to document member relationships and other family information. Family members often get engaged as they provide family information and jointly share the record of family life patterns of three generations. Completing this tool gives the nurse and family time to share understandings of the family structure, relationships, critical family events, and health histories. The nurse can guide the genogram interview and information gathering so that it supports individual’s medical needs, but also highlights important family health information. The structural map of a family case genogram is shown Figure 8.4.

Using Ecomaps in Family Nursing Practice

The ecomap, discussed in Chapter 5, highlights the family’s connection to its environment and identifies the strengths of the bonds among individuals, family members, community

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agencies, and other resources (Fig. 8.5). This tool provides information about ecological systems connected with the family microsystem (Denham, 2003). This visual representation shows family support networks, external stressors, and support agencies linked with the family unit. Information gained from an ecomap suggests the number, purposes, nature, and usefulness of member interactions with various community and social sectors. This ecological information can be used to evaluate the community resources needed for goal setting and planning nursing actions.

Additional Family Assessment Tools

Besides the tools and skills just described, three other commonly used family assessment tools may be used to guide a family assessment:

• Friedman’s Family Assessment Model [Long Form] (1998) • Hanson and Mischke’s Family Systems Stressor-Strength Inventory [FS3I] (2001, cited

in Hanson & Kaakinen, 2005) • Friedemann’s Assessment of Strategies in Families—Effectiveness [ASF-E] (1998)

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M-1955

M-1983

b-1958 HTN, Leg Swelling

b-1968b-1966 b-1970 d-1987

Car Accid

b-1955 HTN, MI X2

b-1963 d-2013

MI, HTN

b-1979 Healthy

b-1964 Diabetes, HTN, Increase Chol

b-1936 d-2006

GI bleed, Sepsis

M-2008 M-2011

b-1984 HTN, Obesity

b-2009 Healthy

b-2010 Allergies

b-1986 HTN

b-1982 Overweight

b-1998 Overweight

b-2009 Healthy

b-2011 Healthy

b-1935 d-1997

MI ASHD

M-1962

b-1944 d-2011

Diab Comp

b-1942 d-2002

CA Lung

Wilson Family Genogram

= Dead

FIGURE 8 -4 Wilson family genogram.

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Friedman’s Family Assessment

Friedman’s (1998) Family Assessment Model—Long Form (FAM) covers six broad cat- egories: identification data, developmental stage and history, environmental data, family structure, family functions, and family stress and coping. Each category has several sub- categories. Nurses assessing families decide which categories are most relevant as they tailor an assessment strategy. The topical areas can be a bit lengthy for a novice nurse and require the use of a written form for notes as the assessment is completed. Review- ing the full assessment form can provide some excellent ideas of family life for discus- sion. For example, if you are caring for a hospitalized person who will be available for several days, then you could select relevant topics and discuss different areas with care delivered on subsequent days. This allows discussion of many things, but avoids single long or drawn-out interviews. It can also be used successfully to engage different family members at various times. A cultural component is also included in this assessment.

Family Systems Stressor-Strength Inventory

The Family Systems Stressor-Strength Inventory (Hanson & Mischke, 2010) focuses on the stressful situations occurring in families and the strengths families use to maintain healthy family functioning. This assessment requires each person to complete an individual form before

210 CHAPTER 8 ● Developing a Family-Focused Nursing Practice

Extended Family

Work

Friends

Church

School

Friends

Boyfriend

Couple Friends

Guy Friends

Video Games

Health Care

Oldest Daughter

and Family

Wilson Family Ecomap

Maria

Daughter at Home

Son and Wife 3 Children

FIGURE 8 -5 Wilson family ecomap.

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meeting the family nurse. Although some questions ask for facts, others ask members to describe things. The assessment is scored for each family member and the nurse notes if stres- sors require primary, secondary, or tertiary intervention. A primary care intervention might be suggesting birth control pills to a newly married couple who are both in school and do not feel ready for children at this time in their relationship. A secondary care intervention might engage a mother and her 15-year-old daughter with diabetes in a discussion about dietary and food selection to help avoid elevated glycemic readings. A tertiary care intervention could be a discussion about how family members will rotate caregiving shifts for their dying father. The written descriptions provide supplementary information that clarifies aspects of family life useful in developing a plan of care. This form of assessment could be useful in situations when working with family needs that extend over time.

ASF-E Assessment Inventory

Friedemann’s ASF-E assessment inventory (1998) is based on a family nursing model called the Framework of Systemic Organization (1995). This model has a client-centered approach that focuses on strengths rather than problems. The assessment tool measures the family’s basic organization and focuses on four targets or components of family life:

• Stability: how the family is organized and connections with each other • Growth: the ways families adjust to change and unexpected happenings and individual

family members development and growth • Control: how the family adjusts to individual and family changes and considers family

rules, roles, and ways of acting • Spirituality: how the family keeps connected emotionally, ways different individuals

seek meaning in life, and satisfaction with community activities and relationships

When the different family life target levels are calculated, the nurse and the family together determine areas in which the family wants to work. This includes setting goals and deciding on strategies aimed at what the family wants to happen. Scoring the ASF-E is a way to gain some understanding about the ways a particular family functions. Areas in which they might be stuck or not achieving health in the four target areas are identified and then the nurse assists the family to develop self-motivated change plans. Box 8.4 pro- vides information about a family nurse leader in Switzerland and has developed many re- sources for teaching nursing students ways to work with families.

O ther Family Tools

Family nurse researchers have developed instruments to assess various family concepts. Among these are family management style (Knafl & Deatrick, 2003), family coping (McCubbin et al., 1983), social capital in families (Looman, 2006), family functioning (Feetham & Humenick, 1982), family health promotion (Pender et al., 2010), and fam- ily health routines (Denham, 2003). Some of these ideas were introduced in Chapter 7, and more about their use is described later in this textbook.

Family Nursing Practice Models

Family nursing models are guides that emphasize family as the unit of care and consider ways individual members affect the health of the whole family and how families affect the individuals (Anderson, 2000; Wright & Leahey, 1984, 2013). Nurses who think family

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intentionally include the family unit whether they are physically present or not. Become familiar with the various family theories and models and find one that best fits your personal beliefs. Experienced nurses often use more than a single theoretical perspective in their family work. As a novice family nurse, it is good to work from one theoretical approach. The model you select will serve as a guide for your family nursing practice

Family Health System Model

The Family Health System (FHS) model (Anderson, 2000; Anderson & Friedemann, 2010) gives some ideas about ways theory guides family nursing practice. This model builds on the work of other theories including Family Systems Theory (von Bertalanffy, 1968), the Illness Beliefs Model (Wright & Bell, 2009; Wright, Watson, & Bell, 1996), the Family Stress Theory (Anderson, 1994; Hill, 1958), and Change Theory (Watzlawick, Weakland, & Fisch, 1974). The FHS model (Anderson, 2000; Anderson & Friedemann, 2010; Anderson & Tomlinson, 1992) identifies family nursing care processes and shows not only how to think family, but also what to do when working with families across the continuum of care.

The FHS model (Fig. 8.6) provides an integrated approach to examine family health by considering the dynamics of families in five realms of family life: interactional, develop- mental, coping, integrity, and health realms (Anderson, 2000; Anderson & Tomlinson, 1992). These realms can be used to examine family life dynamics, strengths, and concerns across the life span. The overall goal of the FHS approach is improved health and func- tioning for family units. It is expected that assessments will address both family and indi- vidual health and that nursing care will reflect the family system and individual interactions. This care approach has been the basis for advanced practice nurses (APNs) at the Family

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BOX 8-4

Family Tree

Barb ara Preusse-Bleuler, RN, MNS, (Sw itz erland)

Barbara Preusse-Bleuler, RN, MNS, is a lecturer and faculty member at the School of Health Professions, Institute of Nursing, Z urich University of Applied Sciences, Switzerland. Over the past 13 years, the university revolutionized nursing education to include bachelor’s, master’s, and doctoral programs. In 2000, Professor Preusse-Bleuler attended a program about Family Systems Nursing and the Calgary Family and Assessment Models taught by Dr. Kit Chesla at the Lindenhof Hospital and School in Berne. This experience profoundly influenced her and she developed a passion and vision for family nursing care. In the first Practice Development Project at the Lindenhof Hospital, guidelines and instruments were created to adapt the Calgary Models to Swiss nursing practices. Preusse-Bleuler discovered that the participatory approach of Action Learning and Action Research were effective tools for developing family nursing knowledge, attitudes, and skills with practicing nurses. This approach invited nurses to think systemically about families and illness and reflected a systemic way of working with nursing teams. From these experiences, Preusse-Bleuler wrote a handbook; developed instruments for effective skills training with self-learning; used peer-to-peer learning opportunities; designed education and training courses for beginning and advanced nurses; and developed sustainable implementation concepts for family nursing practice (all in the German language). In 2009, Preusse-Bleuler translated Wright and Leahey’s Nurses and Families: A G uide to Family Assessment and Intervention into German with a second German edition in 2013. These products are being used to translate family nursing into various practice settings across several regions in Switzerland. Preusse-Bleuler’s work has focused tirelessly on promoting family nursing in her teaching and supervision with the goal of ensuring that family nursing is an integral part of daily nursing practice in Switzerland.

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Nursing Center (Anderson & Valentine, 1998). The theoretical focus has been used in un- dergraduate and graduate family nursing programs, a framework in dissertation research (Byrd & Garwick, 2006), in community health agencies, and as a theoretical heuristic model for family nursing practice (Bomar, 2004).

The FHS model proposes that the five realms of family life are foundational to approach- ing the nursing care of families. Box 8.5 shows the family concepts that are included in each realm; other conceptual ideas may be added as nurses see fit. While considering the five realms, note the family strengths and areas of concern in each realm.

Box 8.6 provides a list of the assumptions underlying the FHS model (Anderson, 2000; Anderson & Tomlinson, 1992). This model encourages nurses to do three things:

1. View family as the expert on its life. 2. Engage the family system interaction with an attitude of respect for the family. 3. Believe that the family is giving their best effort to their family life.

CHAPTER 8 ● Developing a Family-Focused Nursing Practice 213

Integrity Realm • Family values • Family beliefs • Family meaning sharing • Family identity • Family rituals • Family spirituality • Family culture and practices • Other integrity concepts Developmental Realm

• Current family transitions • Family stage task

completion/progression • Individual development

issues that impact family development

• Development of health issue and family impact

• Other development concepts

Interactive Realm • Family relationships • Family communication • Family nurturing • Intimacy expression • Social support • Conflict resolution • Roles (Instrumental

and expressive) • Family leisure life • Other integrity concepts

Coping Realm • Problem solving • Use of resources • Family life stressor and

daily hassles • Family coping strategies

and effectiveness • Coping processes continued • Past experience and

handling crises • Family resistance resources • Other coping concepts

Health Realm • Family health beliefs and

beliefs about health concern or problem

• Health behaviors of family • Health patterns and health

management activities • Family caretaking

responsibilities • Disease conditions,

treatments and consequences for the family

• Family illness stressors • Relationship with health

care providers and health system access

Family Health

Family Health System Model

FIGURE 8 -6 Family Health System model.

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BOX 8-5

Family Concepts of Five Realms of Family Life: Family Health System Model

1. Interactive processes ● Family relationships ● Family communication ● Family nurturing ● Intimacy expression ● Social support ● Conflict resolution ● Roles (instrumental and expressive) ● Family leisure life ● Other interactive concepts

2. Developmental processes ● Current family transitions ● Family stage task completion/progression ● Individual development issues that affect family development ● Development of health issue and family impact ● Other developmental concepts

3. Coping processes ● Problem solving ● Use of resources ● Family life stressors and daily hassles ● Family coping strategies and effectiveness ● Coping processes utilized ● Past experience with handling crises ● Family resistance resources ● Other coping concepts

4. Integrity processes ● Family values ● Family beliefs ● Family meaning sharing ● Family identity ● Family rituals ● Family spirituality ● Family culture and practices ● Other integrity concepts

5. Health processes ● Family health beliefs and beliefs about health concern or problem ● Health-promoting behaviors of family ● Health patterns/practices and health management activities ● Family caretaking responsibilities and impact ● Disease conditions, treatments, and consequences for the family ● Family illness stressors ● Relationship with health care providers and health system access

In family-focused nursing, the individual-nurse-family partnership is used to promote family health through caring interactions that utilize family strengths to address health concerns. In the FHS model, the individual-nurse-family work values the family beliefs about the illness, and acknowledges the amount of family stress created by the health or illness situation and needs for providing care. It considers the ways family members interact with each other around family health issues and identifies the environmental

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influences and the resources available to the family. Individuals and families often need assistance as they manage the changes and transitions associated with health and illness.

The FHS model encourages family nurses to consider ways family interactions and beliefs influence integrity, coping, and development as they relate with each other, work together or function (e.g., decision making, problem solving), create meanings, resolve con- flicts, manage stress, and improve health (e.g., family caregiving, family health promotion). Families use roles to achieve family tasks. Also, families have shared beliefs, rituals, and routines relevant to health and illness. The family health realms can be used to address all forms of care needs. By using family strengths, family nurses focus on things to address, change, or accomplish related to the family’s health goals. With each individual situation, attention is given to examining family concerns and strengths in each of the FHS realms to achieve a family’s desired outcomes and change. This model can prompt nurses to consider coordinated care across settings and include the family household, and not merely focus on the acute care setting.

H osp ital to H ome: C linical E x amp le U sing th e FH S in Family C are

Consider the goal of strengthening a family’s ability to manage a health-related situation. A couple is taking their first child home from the hospital. The family nurse who worked with them during labor and delivery is planning two home visits the first week after dis- charge as the family requested. The nurse schedules the visit to ensure that both parents will be home. An earlier assessment indicated the couple has a strong caring relationship. The father wants to be involved in every step of his new son’s care and his wife is breast- feeding. When the nurse visits the family home, assessment of the baby and mother are completed. However, the nurse also discusses concerns previously voiced by the couple during the hospitalization:

• Adjustment to life at home with the baby (developmental realm) • Ways the baby is included in their lives and particular stressors (coping realm) • Family rituals that are valued to be included in family life (integrity realm) • Interactions with each other and extended family (interactive realm) • Concerns linked with health promotion and health intervention (e.g., immunizations,

healing after birth, pumping for extra milk, health questions) (health realm) • Time for the couple relationship (interactive realm).

In assisting the family to organize their resources to deal with family issues from each realm, the nurse uses the FHS model to work with them in ways to address specific concerns

CHAPTER 8 ● Developing a Family-Focused Nursing Practice 215

BOX 8-6

Assumptions of the Family Health System Model

1. Family health is systemic and process oriented. 2. Family health includes an interaction of biopsychosocial and contextual phenomena. 3. Family health incorporates the health of the collective and the interaction of the health of the

individual with the collective. 4. The goal for intervention in family health includes an optimal response in each of these five

realms of family experience. 5. All families have the capacity for transforming their quality of life and family health. 6. The interaction of the caring and informed family nurse and the family working together will

facilitate movement toward family health.

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and work toward achieving goals. The couple had addressed the first five areas previously mentioned, but they had not discussed the last concern. The nurse spoke with the couple about ways to keep their relationship strong. For example, they might arrange help to care for the baby so they could continue to have some time together. Research shows that couples who take regular date time weekly of at least 2 hours have more successful marriages (Gottman & Silver, 1999; Gottman & Silver, 2013). Working with families encourages nurses to provide holistic care.

Family Assessment U sing th e FH S Model

In the FHS approach, the individual-nurse-family partnership is used to identify the family’s main concerns. The nurse starts with “thinking family” and uses interviewing, caring, and perceptive skills to establish a connection with family members. He realizes that the family members are the expert on their life and believes they try their best to manage health and illness. While listening during the initial contact, the nurse makes observations about mem- ber interactions. A 15-minute interview could be used. The genogram (see Fig. 8.4) and the ecomap (see Fig. 8.5) can be used to gather other family information. As the family story is told, identify strengths that permeate their lives. Write them down for later use and share when appropriate. For example, if the primary concern is stress with an illness (cop- ing realm) or arrangement of care for an elderly member to stay at home (health realm), then these points are the focus of the care interventions. The FHS model can address many family life areas and care is always based upon family priorities using family strengths.

Family H ealth Interventions

The individual-nurse-family partnership is used to develop strategies aimed at goals. Family dialogue can help the nurse learn beliefs about things that will or will not work, what they are able and willing to do, and what is needed. As families talk, they often identify potential solutions without the nurse’s guidance. During the family interaction, ensure neutrality, hypothetical thinking, and circularity. Check to see if there are care aspects that need to be coordinated. Using combined suggestions from the family and the nurse’s expertise, set goals and make decisions about concrete intervention strategies that family members value.

Plans for family interventions are results of collaborative partnerships. Review findings from research literature to identify what evidence exists that supports family interventions (Melnyk & Fineout-Overholt, 2010). The number of intervention studies and evidence for family nursing continue to grow. For example, a demonstration project at a large medical cen- ter in Wisconsin studied 50 families managing different chronic illnesses (Anderson & Valen- tine, 1998, 2000). The results indicated that many families dealing with chronic illnesses discussed a need for a variety of interventions. Table 8.1 gives examples of these implemented family interventions. In this project, families were given a copy of the plan as a reminder of options they had developed (Anderson & Valentine, 1998). The family nurse verified and validated with the family their working care plans. Documentation of the plan in the patient/family record provided a record for the family nurse and others. Written comprehensive family assessment summaries may also be completed for report purposes.

Ongoing evaluation of progress toward achieving family goals or outcomes is essential. Were the goals met? If not met, why not? How effective was the family intervention? What did or did not work? What kinds of follow-up are needed (e.g., education, coaching, demonstrations)? It is important to check with the family at subsequent meetings or interac- tions about their progress toward the goals. Commend them for successes; encouraging and empowering support family unit efforts. Evaluation and continued planning are essential parts of continuing care. Consider family feedback, revision of care outcomes, or other

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TABLE 8 -1 Family Interventions in Select Ch ronic Illnesses ( A nderson & V alentine, 2 0 0 0 )

Cancer • Managing care demands and coverage, dying, fears, and loss

• Unresolved family issues and plans after death

• Sibling and health care professional (HCP) conflict

• Equitable caregiving

• Decrease strain on children’s families

• Home health nurse referral

Cardiac conditions • Family difficulty, fears, stress, and anxiety impact on family life

• Impending death and restructuring of life focus on quality

• Health condition and focus on patient affecting marital quality

• Broadening of social support

• Fear of pain and depression

• Grief and impact on family

• Clarify and problem-solve family-HCP conflicts

Chronic pain • Provide information about falls, illness, and medications

• Promote clear understanding of disease process

• Facilitate open communication in family

• Problem-solve to coordinate care between home, acute care, and outpatient or physician care

• Referral for home environment evaluation

• Referral for home health nurse

• Discuss with family:

• Nature of conflicts, sense of burden, and issues to problem- solve

• Independence maintenance

Dementia • Explore division of labor by family members

• Community support planning

• Discuss with family:

• Disease process

• Develop communication tracking system,

• Address family stress concerns and future

• Wishes for death experience with family

• Advanced directives and quality of life (Q OL)

Diabetes • Develop plan to maintain caregiver health

• Referrals, financial concerns, and home health nurse

• Discuss with family:

• Family-HCP conflicts and problem-solve solutions

• Future trajectory of illness and meanings for illness

• Issues related to family communication C o n t in u e d

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TABLE 8 -1 Family Interventions in Select Ch ronic Illnesses ( A nderson & V alentine, 2 0 0 0 ) — cont’ d

Primary family interventions— • Interventive questioning common to all chronic conditions • Work out equitable distribution of care and caregiving plan

• Depression evaluation

• Strategies for social and community support

• Referrals to HHN, financial concerns, respite, home environmental evaluation

• Develop safety plan

• Concrete family interventions

• Managing care demands

• Arrange care coverage

• Unresolved family issues

• Sibling and HCP conflict

• Grief, fears, anxieties

• Illness trajectory and resultant planning

• Facilitate open communications

• Role changes; family stress

• Relationship quality changes and desires

Stroke • Reframe personal attacks and soften with illness in mind

• Increase social activities

• Organize caregiving

• Referral for depression evaluation

• Discuss difficulties, roles changes, household functioning

nursing actions to incorporate over time. Evaluation enables systematic and timely analysis of progress toward meeting goals. Most families work hard to improve their family life and make needed adaptations to the health and illness situations and they are the experts at determining what worked and what did not. Through respectful listening, determine the best ways to help the family improve their life, alleviate suffering and emotional pain, promote health, and keep the family safe.

Terminating Relationships

Nurses do not always think about how they will end a relationship. In today’s busy health care settings, persons are usually in and out of acute care settings quickly and it might not seem necessary to consider the relationship’s end. However, even briefly formed ties need and deserve an appropriate ending. Once a bond has been formed, a need to acknowledge the separation that is to come exists. For example, if it is an inpatient setting in the United States, the discharge might be from hospital to home with follow-up care with a primary or specialty care practice. If more intensive care is required, the termination might result in a transfer to a step-down care setting, assisted living, nursing home, or home care agency. It is always important to acknowledge the individual and family members and assist them as they transition to the next stage of their care or health journey.

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It is important to begin thinking of ways to build a culture of health in our nation (Lavizzo-Mourey, 2014). This implies taking a bigger picture of what defines health in our nation. The Robert Wood Johnson Foundation and others are encouraging us to con- sider ways costs, benefits, and effectiveness of treatment and prevention provide highly valued care. A culture of health could mean many things, but it begins in family house- holds and communities. It involves living in ways that allow us to be and stay healthy. This involves caring in ways that not only address acute care needs, but see each care contact as a way to empower the family and motivate individuals. According to Hibbard, Stiockard, Mahoney, and Tusler (2004), achieving quality health outcomes must enlist activated persons who possess the following qualities:

• Believe personal roles are important. • Have the needed confidence and knowledge to take action. • Actually take action to maintain and improve health. • Maintain actions to achieve outcomes even under stress.

A culture of health could include safe homes, violence prevention, proper use of med- ications, healthy weights, and physically active lives. Finding ways to increase personal activation has great potential for improving health outcomes (Greene & Hibbard, 2011); testing of family inclusion seems a logical nursing intervention.

Discussing things that might occur with the transfer, discharge, or departure provides a chance to ask additional questions and express concerns. Depending upon the depth of the relationship, a smooth termination with the family can include things such as brief letters to the family, commendations on strengths observed, compliments about progress made, wishes for sustained progress, and hope for the future (Wright & Leahey, 2013). If ongoing care is necessary, provide a review of the plan of care that needs further attention. Also furnish written and oral instructions, but ensure that they are created based on literacy, culture, and language needs, considering the resources that families have at home to be able to carry out the family interventions. A final conversation might include things like having them tell you about the most helpful thing in your work together or what they wished had been different. Responses can be insightful and help the nurse truly gain

CHAPTER 8 ● Developing a Family-Focused Nursing Practice 219

BOX 8-7

Family Circle

A family is having trouble with their middle-school-aged son after being given family rules about coming home on time and completing family chore tasks. The parents are afraid that their son has befriended a group of older teens who are known to use drugs and alcohol. The parents think their family life is out of control and are not happy when their son disappears and does not contact them for a whole weekend. They are especially concerned because he has long had a history of attention deficit-hyperactivity disorder (ADHD) and has been in trouble in school. In addition, their family history indicates that alcoholism and addiction have been problems for many ancestors. When his mother takes him for his clinic visit, she says: “ Our son is completely out of control and so is our family because of him.” The family nurse wants to complete a family assessment during the visit.

1. Think about this family and identify areas you want to assess. 2. How can you use the 15-minute interview with this family? 3. List three interventive questions you might use. 4. What aspects of each family realm need addressing? 5. How will you go about discussing a plan to change the “ sense of no control” this family is

experiencing?

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empathy for their challenges. The termination process involves some reflection by the nurse about what has been learned from this family interaction. Families have lessons to teach nurses. Thank the family and share what you have learned from them, and tell them what you will carry with you in your practice with other families, including differences learned from culturally diverse families. Evaluate yourself. What went well? What do you wish you might have done differently? Family nurses with years of practice can often recount lessons learned and wisdom they were taught by those receiving care. Take some time to work with others in your class to review the case study in Box 8.7. Talk together to decide the best ways to answer each of the questions.

Chapter Summary

Nurses often focus on the immediate needs of those in their care. Pressing demands that appear to require urgent attention are often given the priority. Holistic family care involves a larger perspective, one that includes the family unit, family relationships, and support sys- tems. Nurses usually focus on the individual, but this does not regularly include an integrated individual-nurse-family approach. Sometimes nurses want to interact with families but they are uncertain where to begin or what to do. Thus, care often responds to expediency, imme- diacy, critical incidents, or unplanned interruptions. This chapter described many nursing skills and actions useful in establishing relationships and providing care with families. This chapter describes the importance of the individual-nurse-family relationship as an intentional relationship at the core of family nursing practice. A number of approaches, skills, and tools that family nurses can use in practice are described. The Family Health System model (An- derson, 2000; Anderson & Tomlinson, 1992) is used as an exemplar model to demonstrate one approach to family nursing. Thinking family employs a mind-set that facilitates nursing family care that integrates background knowledge about families, health and illness, caring, and the nursing process with family nursing assessment and intervention skills, evidence- based practice knowledge, and communication skills that promote family health.

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