Final

Family Follow Through

Brianna Bickel

Minnesota State University, Mankato

May 5, 2015

Running head: FAMILY FOLLOW THROUGH BICKEL 1

FAMILY FOLLOW THROUGH BICKEL 23

Family Follow Through

What is family? A dictionary definition of the word concludes that family is “a basic social unit consisting of parents and their children, considered as a group, whether dwelling together or not” (“Family,” 2015). Although this is a traditional and widely accepted description of the word, family is much more than just parents and their children, especially in the terms of healthcare. Nurses and other healthcare workers know that family is anyone who the patient or client considers family, no matter if they are blood relatives or not. Family loves and cares for one another, makes decisions together, and disagrees with and challenges each other. Family is an ever changing unit of loved ones who are extremely important to one’s overall health and well-being.

Because family plays such a large role in shaping a person’s ideals, beliefs, values, and morals, it is critical that all family members are assessed and taken into consideration when dealing with the illness of a loved one. This paper aims to describe the experience the author had while exploring the importance of family health when working with a chronically ill client within the local community. During the course of several meetings and telephone conversations data was collected and reviewed about the Lawson family (*in order to protect the family’s identity pseudonyms will be used throughout the essay). The following paper will describe these visits including the first one which focused on the Lawson’s illness story, the author’s observations during the initial intake process through the structure of the Calgary Family Assessment Model (CFAM) and Denham’s Family Health Model (DFHM), and the family constructs. The second meeting was designed to offer the family recommendations and apply nursing interventions. The last call to the family and last portion of this paper will address how the family is responding to the provided nursing interventions and the author’s reflection on the family follow through experience as a whole.

Family Illness Story

The Lawson family consists of father Peter (55), mother Taylor (52), and their three adult children Jennifer (31), Michael (28), and Rachel (25). Taylor’s mother Laura (76) is also a vital piece of the Lawson family story. Taylor was the only family member present for the meetings and phone conversations so this paper will be centered on her illness experience. Taylor was born and raised in Madelia, Minnesota where she still lives with her husband Peter and works as an LPN at the local hospital. Taylor has a history of hypertension and elevated cholesterol levels and is a former 30 pack year cigarette smoker.

In the summer of 2005 Taylor was home alone watching television when she suddenly felt a weird sensation at the top of her head. Within seconds the feeling had spread throughout her entire body and she collapsed to the floor. Although Taylor was very weak and in shock she had enough strength to crawl to the telephone and call Peter. When she described what happened he immediately called 911 and an ambulance came to take Taylor to the local emergency room. After multiple tests it was discovered that Taylor had suffered a transient ischemic attack (TIA) due to her worsening cardiovascular disease. Taylor’s left kidney was also functioning very poorly due to artery blockage. She was sent to the Twin Cities for further evaluation and was then recommended to a clinical trial called the CORAL Study. This study was trying to determine if renal stenting for patients with cardiovascular disease, hypertension, and renal insufficiency would produce more favorable outcomes than just medications alone. Taylor was one of the patients, that along with medications, also received the renal stents - with three placed in her left kidney. The CORAL study later determined that the stents offered no extra benefits to patients with renal-artery stenosis, stating “Renal-artery stenting in people with renal-artery stenosis offers no advantages over best medical therapy in reducing hard clinical events” (Wood, 2013). Taylor has not had any further medical complications or issues since 2005 but continues to deal with her cardiovascular disease as it is a chronic condition. She takes her many daily medications with the help of a medication planner, tries to eat healthy especially monitoring her salt intake, and exercises regularly.

Initial Intake Using the Calgary Family Assessment Model (CFAM) and Denham’s Family Health Model (DFHM)

Family interviewing can take many different shapes, for this specific family follow through a combination of both CFAM and DFHM were used to gain knowledge and understanding about the inner workings of the Lawson family. The CFAM focuses on the theoretical foundations “involving systems, cybernetics, communication, and change” (Wright & Leahey, 2013, p. 4). CFAM is broken down into three major categories- structural, developmental, and functional which were all explored through Taylor’s interviews.

Structural Dimension of CFAM –

This portion of the interview focused on the internal and external structure, as well as the family context. The Lawson family was described above and a family genogram can be found in appendix A. They are a middle class Caucasian family living in a small rural town in southern Minnesota. They are of the Catholic faith and are a very traditional family. Along with Taylor being an LPN at the local hospital, Peter also works full time as a business man who travels often for his work. All of the Lawson children are out of the family home and living on their own. Jennifer is married with newborn twins and will soon be going back to work as a physical therapy assistant. She and her husband are planning to move to Iowa within the year as a better job opportunity arose for both of them there. Michael is single and living in the Twins Cities. He works full time as a truck driver so he is often in different areas of the country and cannot visit home too often. Rachel is living in South Dakota where she is attending college and working part time as a waitress. Laura, Taylor’s mother, is a widowed homemaker who is suffering with dementia. Taylor and her brother Jason recently decided to move Laura into a local nursing home in order to keep her safe.

Developmental Dimension of CFAM –

According to the Family Developmental Theory, “family interactions among family members change over time in relation to structure, function (roles), and processes” (Kaakinen & Harmon Hanson, 2010, p. 77). This holds true in many ways for the Lawson family who are in the middle aged parents’ phase of family development. This stage includes Peter and Taylor becoming empty nesters and reestablishing their own hobbies, goals, etc. For Peter he is focusing his energy on things like home improvements, golf, and camping while Taylor enjoys scrapbooking, reading, and going on walks.

Another aspect of being at this developmental stage is that Taylor has now become part of the “sandwich generation”. This means that in addition to helping support her children she has also now become responsible for caring for her own mother. Laura who has been struggling with dementia did not want to leave her family home but Taylor, along with her brother Jason, felt it was no longer safe for Laura to live independently. It was a difficult decision that has left both women feeling helpless and stressed. Taylor is also having to deal with cleaning out and selling Laura’s home and managing all of Laura’s finances as well as monitoring Laura’s healthcare decisions. It is a lot of responsibility and Taylor feels stressed because of it.

Functional Dimension of CFAM –

Before Taylor’s diagnosis and surgery the Lawson family tried to be healthy but it was not a priority. Now Taylor puts her health at the forefront and encourages her family members to do the same. Taylor has quit smoking, watches what she eats, and likes to go for walks or to Zumba fitness classes. Although Taylor was initially forced to stop working for a bit after her health scare, she and her family have been back to their normal routines for years. Her and Peter equally share financial and household duties and the children pitch in when they can. Peter has attempted to quit smoking multiple times but has never stuck with it for more than a few weeks which causes Taylor great concern for his health.

DFHM –

Along with the three major components of the CFAM, Taylor was also asked questions regarding the seven functional processes of the DFHM. The DFHM was created by Dr. Sharon Denham to gain a deeper understanding of how individual members within a family interact with one another and the world around them to, “realize health, mediate well-being, and cope with illness and disease” (Denham, 2002). The seven functional processes that were the focus of Taylor’s interview included caregiving, cathexis, celebration, change, communication, connectedness, and coordination.

Within the Lawson family Taylor feels that she has always been the main caregiver to her children, her husband, and her parents. This all changed however when she suffered her TIA. Peter and her eldest daughter Jennifer stepped up to fill the caregiver role, making sure Taylor took her medications and looking after the younger children while Taylor was at doctor appointments. Now that Taylor is well again she has stepped back into her caregiving role focusing now on her ailing mother and making sure all of her affairs are in order.

In viewing cathexis within the family, Taylor believes that she and her husband both spent more time focused on Michael as the children grew up. She believes this happened because he was the only brother and was often excluded, although not on purpose, from his sister’s activities. He is also a diabetic and needed more attention for that reason. This was especially relevant in 2010 when Michael was attending college in St. Cloud and suffered the effects of an insulin pump malfunction. The entire pump’s insulin content was emptied into his blood stream and he went into a coma for three days and had to spend several weeks in the ICU. Although Michael is now fully recovered both Peter and Taylor tend to worry more about him and his health than their daughters.

The Lawson family is of the Catholic faith and celebrate all the major Catholic holidays including Easter and Christmas. They also celebrate Halloween, Thanksgiving, New Years, etc. as well as family birthdays. Because the Lawson children live so far away they cannot always celebrate together as a family, but Thanksgiving and Christmas are usually always together. Taylor’s job as an LPN at the local hospital also makes it difficult to get all holidays off of work. The family’s favorite holiday is the Fourth of July because they all come together at the lake and spend a few days camping with one another.

Change has been a large part of the Lawson’s, especially Taylor’s, life recently. Besides the biggest change of dealing with her mother’s move into a nursing home, Taylor is also dealing with a major career change. She is moving on from the hospital she has worked at for the last 20 plus years to be an LPN at a community clinic. She is very excited about the change and the slower pace of the clinic but is having a hard time adjusting to the new computer system. She has been taking software training classes at Minnesota State University, Mankato but her computer skills are not the best and it is causing her a lot of anxiety. Taylor is also concerned that her daughter Jennifer is planning to move to Iowa within the next few months with her newborn twins. Taylor hates having to see them leave and wishes they would stay closer.

Although all of Taylor’s children live pretty far away from her and Peter, she believes that they have very open and healthy communication amongst each other. Taylor is able to call each of her children about once a week and spends a half hour to an hour on the phone with them discussing their lives. Peter does not call the children as often but gets updates from Taylor instead. Peter and Taylor’s communication is very honest and they do not hide anything from each other. Although Taylor thinks this is a good thing, she says it has led to many small arguments in the past.

Being in such a small community Taylor believes she has a great connection with all of her family members, immediate and extended. Jennifer and Rachel are extremely close and although Michael is close with his sisters as well, the two girls have always been inseparable. As the children have grown older and moved away from home Taylor has noticed that Peter is not as involved as he once was, especially with Rachel as she is all the way out in South Dakota. The addition of Jennifer’s new twins has helped to reconnect the family recently and Taylor is concerned that when they move to Iowa this bond may weaken.

With the Lawson children being out of the house Taylor feels like she has a lot less to coordinate than when they were children. She does still schedule all of her and Peter’s doctors and dentists appointments as well as keeping track of Laura’s health visits. Taylor coordinates most of the family meals and celebrations/get-togethers as well. Peter takes charge of planning camping trips and vacations for the family and manages most of the bills and finances.

Family Constructs

When interviewing a family it is important for the nurse to pick up on themes that continue to emerge throughout the conversation. These themes can be called family constructs and can be used to determine the best nursing actions and interventions for the family. According to Eggenberger, Meiers, and Krumwiede, family constructs are very unique to the individual family and help to establish interventions based on “the perspective of multiple family nursing theories, frameworks, and models” (2014). Within the Lawson family two major family constructs were identified during the interviews with Taylor, family communication and family transitions.

Communication is an essential aspect of family life that can be verbal or nonverbal and individual or shared. It is “a family process used to express emotion and ideas, knowledge and skills related to health” (Denham, 2003). For the Lawson family communication is especially important because they all live a far distance away from each other and do not get the opportunity to see one another often. The distance makes it difficult for them to stay up-to-date with each other and forces them to rely on technology instead of having face to face encounters. Although Taylor does call each of her children about once a week, she worries that Peter is slowly losing contact with the kids. She is also concerned that she will not be able to bond well with Jennifer’s new twins once they move away to Iowa so maintaining good communication with them is very important to Taylor.

Family transition is considered “the period in which a change is perceived by a family member” and “denotes a change in needs, health status, and expectations or abilities that require new knowledge or change in behaviors” (Meleis, 1991). The Lawson family is currently undergoing multiple family transitions which is causing excitement, uncertainty, and stress for all the family members. The biggest transition that is occurring is with Laura and her health. Not only is her dementia worsening which creates changes in her abilities, but having recently been moved into a nursing home also creates new expectations for Taylor. Along with dealing her mother’s affairs, Taylor is also transitioning into a new job position. She is having to learn new skills in order to work at the community clinic and it is very overwhelming to her. The Lawson children are experiencing some transitions of their own, especially Jennifer. Her and her husband recently entered a completely new stage of life by becoming parents to twins and are having to learn everything that goes along with that. On top of being new parents they are also planning a move and career change which has added a lot of anticipation and stress for not only them but also Taylor and the entire family.

Family Level Nursing Interventions

During the second meeting with Taylor three different nursing recommendations and actions were suggested. They were based on the previously discussed family constructs and focused on bettering the family communication, helping Laura and Taylor adjust to Laura’s move into the nursing home, and encouraging an increase in Taylor and Peter’s physical activity levels.

As previously stated the Lawson family lives in multiple different states and cannot visit each other as often as they would like. Taylor brought up the concern that once Jennifer moves to Iowa she will not be able to bond as well with the new twin babies because she won’t be able to see them as often. She was also concerned about Peter’s lack of communication with the other children as well, especially Rachel who is in South Dakota. After establishing that Taylor had a laptop with a built-in webcam the author presented the idea of Skype. Skype is a popular internet calling application that allows you to video chat with anyone around the world who also has Skype installed on their computer. It is a great way to keep in touch with friends and family members who are far away and lets you not only hear them but see them as well. In her article Using Skype to Support Palliative Care Surveillance, author Jacqueline Jones describes the many benefits of using Skype to promote family communication including having no geographical boundaries, being able to witness nonverbal cues, being able to share visual images, and the simplicity and inexpensive nature of the program (2014).

Although Taylor thought this sounded like a great idea and was very excited about the idea of being able to actually see her grandchildren, she was still a bit apprehensive due to her lack of computer skills. The author thought Taylor might be concerned about this and while using the assistance of The Beginner’s Guide to Skype webpage, the author was able to teach Taylor how to download the application and use the basic functions.

Another area the author hoped to address with Taylor was the stress from Laura moving into a nursing home. An article published in the Journal of Gerontological Social Work tackled the many different emotions associated with such a move for both the resident and the family members, stating “Moving into a nursing home represents a monumental life change, one most older adults, and their adult children, hope to avoid at all costs” (Sussman & Dupuis, 2014, p. 438). Although Taylor feels much stress about the move and having to arrange all of Laura’s affairs, she still longs to stay connected with Laura and wants to see Laura happy.

Knowing that one of Taylor’s hobbies is scrapbooking the author brings some supplies to the meeting and suggests that Taylor explore the idea of scrapbooking at the nursing home with Laura. Doing this would allow the women to spend quality time together, participate in a favorite hobby, recount family memories, and produce a keepsake for generations to come. Author Mary Kohut agrees and describes how creating a scrapbook with an ailing family member can celebrate life events, provide a tangible means for healing, and preserve family stories and legacies (2011).

During the initial intake Taylor mentioned her appreciation for exercise and wanting to stay healthy, but was disappointed by the lack of resources the small town of Madelia offered. Knowing that the warm weather was coming Taylor made it clear that she would love to go on daily walks with Peter but also wanted to avoid walking on the busy streets. After some research the author was able to find a great website called TrailLink.com which offers different walking, running, and biking trail maps around the Madelia area. It gives you the location, length, and surface type of the trail as well as reviews from other users. It is a very simple website to navigate and you do not need much computer knowledge to look at the trails online.

According to an article published in the Journal of Women’s Health, daily walking is a low intensity exercise that can have many health benefits including increasing cardiovascular fitness, decreasing blood pressure and cholesterol levels, improving bone and muscle strength, reducing body fat, and decreasing stress levels (Serwe, Swartz, Hart, & Starth, 2011). Along with the physical advantages of walking Taylor could also use the time to get out and explore nature and her community. Taylor could also use the daily walks to encourage Peter to come along in order to improve his health. Research has shown that a married individual’s health habits and use of preventive medical care are significantly influenced by his or her spouse’s behaviors (Falba & Sindelar, 2008). So with Taylor out exploring new walking trails Peter will hopefully become interested as well and take part on her daily walks. This would help both of them improve their health and fitness while also allowing them to spend quality time together every day.

Family Response

The last conversation with Taylor was a follow up to determine how the presented nursing interventions worked for the Lawson family, beginning with the use of Skype. Although Taylor was originally a bit apprehensive to try Skype she has since grown to really appreciate it. Because she had someone there to help her download the program and walk her through how to use it, it was much easier for her to learn. She said her and Peter have replaced the weekly phone calls and now use Skype to video chat with their children at least once a week, especially Rachel since she is so far away. Taylor imagines that once Jennifer moves to Iowa they will be Skyping several times a week and loves the fact that she will get to see the twins grow and develop even from a distance. Jennifer also likes the idea because she knows she will need to ask Taylor parenting questions and Skype will make it easier by being able to show Taylor things instead of only being able to describe problems verbally over the phone. Both Taylor and Peter agreed that learning about Skype has made them both more technology savvy and more comfortable when using the computer. Taylor is even looking into possibly getting a smartphone so she can FaceTime with her children and grandchildren when she is away from home, but that is just an idea at the moment.

As for the scrapbooking recommendation Taylor has not yet started creating anything with Laura but plans to in the near future. Along with the supplies given to her by the author she has also started collecting some crafting supplies of her own. While cleaning out Laura’s old house in preparation to sell it, Taylor stumbled upon a closet full of picture albums and boxes. Taylor plans to sort through these photographs and pick out ones she thinks Laura would gain the most memories from so they can be added to the scrapbook. Taylor was very touched by this nursing recommendation and loves the fact that she will be able to keep it even after Laura passes away and then hand it down to her own children.

Since the second meeting Taylor has been using the TrailLink website and going on daily walks if the weather permits. She has tried several of the new trails and found a few that she really enjoys. She believes she walks longer on the trails, because of the beautiful scenery, than she used to walk when she was just on the streets around her home. On one of her walks she discovered a walking club for local women which she is highly considering joining over the summer. Physically she has lost several pounds, feels less tired and stressed, and is happier overall (she thinks this could also have something to do with the recent gorgeous weather!). Peter accompanies Taylor on her walks about three times per week, he would like to do more but he is often away for business. Taylor stated that going on walks with Peter is like a mini date and enjoys getting to spend extra time with him while also improving their health. The only concern Taylor has is about continuing her walking routine once it starts getting cold out, but the women’s walking club gave her some suggestions, like using the local high school field house, that she plans to look into.

Family Follow Through Reflection

Going into this family follow through experience I was very nervous and had no idea what to expect. I had never interviewed a family on my own before, much less drive out to their house and interview them there. I had no information on the Lawson family besides that Taylor had a chronic condition, so I really had to prepare for any and everything. For me even the telephone call to set up the interview was extremely intimidating, but I was pleasantly surprised how easy the entire process was. Taylor could not have been more welcoming and open about her family’s experiences and struggles, which in turn made me feel more comfortable. I was surprised how effortlessly the conversations flowed. Unlike earlier family interviews I did not need to follow a specific set of questions, instead I brought up a general topic and then could direct the conversation based on Taylor’s responses. I was also amazed at how easily I thought of interventions that were family and not medically based. It really did show me how much my thought process has developed since the first semester of nursing school. Telling Taylor the interventions I thought of was a little trickier, because I did not want to come across as being bossy or make it seem like her family needed a ton of help. However she responded well to my suggestions and it was not as awkward as I thought it would be. I was glad to be a part of the Lawson’s follow through from beginning to end, it was very satisfying. Overall I thought this was a great learning experience for assessing a family and researching appropriate interventions.

Conclusion

Family, whether good or bad, is one of the major components to one’s sense of self, their values and beliefs, and their healthcare experience. This becomes even more important when a family is dealing with an illness or chronic disease like the Lawson family is. The goal of this paper was to express what was learned after engaging with the Lawson family over several weeks. First the family’s illness story was shared and an initial assessment was conducted. Next nursing recommendations were made and interventions applied based on themes and family constructs picked up on during the previous interview. After some time had passed the Lawson family then communicated back on how the interventions had worked for them and an evaluation of the process as a whole was completed. A family genogram, ecomap, attachment diagram, and circular conversation diagram were also created to better understand the Lawson family and how they manage a chronic illness (See appendixes). Overall a great deal was learned and not only about the Lawson family, but also about family assessments, therapeutic communication, and creating and evaluating suitable family level nursing interventions. Family is whatever a patient or client decides it is, but no matter what it will always have an impact on one’s life and I am glad I got the opportunity to share in the Lawson’s definition of family.

References

Denham, S. A. (2002). An ecological model of family health. Family health: A framework for nursing (pp. 1-31). Philadelphia, PA: F. A. Davis Company.

Denham, S. A. (2003). Family health: A framework for nursing. Philadelphia, PA: F. A. Davis Company.

Eggenberger, S., Meiers, S., & Krumweide, N. (2014). Family constructs and family focused nursing actions. Unpublished manuscript.

Falba, T., & Sindelar, J. (2008). Spousal concordance in health behavior change. Health Services Research, 43(1 Part 1), 96-116.

Family. (2015). Dictionary.com. Retrieved from http://dictionary.reference.com/browse/family

Jones, J. (2014). Using Skype to support palliative care surveillance. Nursing Older People, 26(1), 16-19.

Kaakinen, J. R., & Harmon Hanson, S. M. (2010). Theoretical foundations for the nursing of families. In J. R. Kaakinen, V. Gedaly-Duff, D. Padgett Coehlo, & S. M. Harmon Hanson (Eds.), Family health care nursing (4th ed., pp. 63-102). Philadelphia, PA: F. A. Davis Company.

Kohut, M. (2011). Making art from memories: Honoring deceased loved ones through a scrapbooking bereavement group. Art Therapy: Journal Of The American Art Therapy Association, 28(3), 123-131. doi:10.1080/07421656.2011.599731

Meleis, A. I. (1991). Theorectical nursing: Development and progress. (2nd ed.). Philadelphia, PA: J. B. Lippincott.

Serwe, K. M., Swartz, A. M., Hart, T. L., & Strath, S. J. (2011). Effectiveness of long and short bout walking on increasing physical activity in women. Journal Of Women's Health (15409996), 20(2), 247-253. doi:10.1089/jwh.2010.2019

Singh, K. (2014). The beginner’s guide to Skype. Retrieved from http://mashable.com/2014/07/09/skype-for-beginners/

Sussman, T., & Dupuis, S. (2014). Supporting residents moving into long-term care: Multiple layers shape residents’ experiences. Journal Of Gerontological Social Work, 57(5), 438-459. doi:10.1080/01634372.2013.875971

TrailLink.com. (2015). Madelia, Minnesota trails and maps. Retrieved from http://www.traillink.com/city/madelia-mn-trails.aspx

Wood, S. (2013). CORAL: Stents no benefit in renal-artery stenosis. Retrieved from http://www.medscape.com/viewarticle/814539

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

FAMILY FOLLOW THROUGH BICKEL 20

Appendix A

Family Genogram

WA 69

LA 76

BL 42

TL 42

Heart Disease – Open Heart Surgery Skin Cancer

Dementia Uterine Cancer

Heart Attack

Colon Cancer

Lung Cancer

Works Full Time Smoker

ML 28

Student High BP & Cholesterol

Truck Driver Diabetic/Neuropathy

PT Assistant Newborn Twins

RL 25

JB 31

Car Accident

Very Healthy

Pacemaker Battery Malfunction

MA 50

JA 58

AL 51

JL 47

TL 52

PL 55

LPN, Heart Disease, Past TIA, High BP & Cholesterol

Appendix B

Family Ecomap

Camping

Catholic Religion

Travel for Work

Smoking

Golf

New Job Position

Mom’s Affairs

Children & Grandchildren

Exercise

Heart Disease

TL 52

PL 55

Appendix C

Family Attachment Diagram

RL 25

ML 28

JB 31

TL 52

PL 55

Key:

Strong Attachment

Moderate Attachment

Stressful Attachment

Appendix D

Family Circular Conversation Diagram

LA cannot make decisions about her healthcare, finances, etc.

TL becomes concerned for LA and feels obligated to take over LA’s affairs

TL becomes stressed and more withdrawn from LA

LA’s dementia is worsening, feels burdensome to children - especially TL

Appendix E

Family Therapeutic Letter

Dear Teresa and family,

I would like to start by saying a big thank you for allowing me to come to your home and learn about your wonderful family. I can honestly say I was a little bit nervous before our first meeting and had no idea what to expect. I had never done a family interview on my own before, and I had especially never driven out to the client’s home to meet with them, so it was all pretty intimidating in the beginning. However, from the moment I called you being lost on the wrong street and you being so kind to direct me to your house over the phone, I knew it would be a great experience!

Our meeting and phone conversations have taught me a lot to help expand my nursing knowledge. I was able to administer a full family assessment, pick out different family constructs, research and present several family level nursing recommendations and interventions, and respond to your personal feedback. I was also able to strengthen my therapeutic communication skills and become more independent as a student nurse. All of the information obtained during our conversations will be compiled into an academic essay (with the names of your family members changed) to present my findings and knowledge about your family. The two major themes, or family constructs, I picked up on while talking with you were family communication and family transitions. Based on those I recommended Skyping to stay in touch with your children and creating a scrapbook with your mother in order to help both of you adjust to her move into the nursing home, as well as preserving her precious memories. I also informed you of different walking trails around your area because maintaining your health is important to you. I hope you found these recommendations helpful and continue to use them throughout your life.

I feel very fortunate having met you, even if it was only for a short time. You are a very strong woman who has kept going even through truly difficult times. You are a role model to both your children and me as a future nurse. I would like to thank you again for being so welcoming and honest while answering my questions. You have really impacted my learning experience and I feel like I can now better communicate and care for my future patients. I hope the family follow through was a great experience for you as well. I wish you and your family much happiness now and in your future endeavors!

Again thank you for everything, it is very much appreciated!

Sincerely,

Brianna Bickel, Student Nurse

Minnesota State University – Mankato