Family Nursing: Assessing and Supporting Family Health, Exams of Nursing

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BSNC 1000

BSNC 1000 FINAL MODULE 9 - Family

BSNC 1000

Family -Are self-defined; is a set of relationships that each patient identifies as family and who influence each other's lives and depend on one another for support, regardless of whether actual biological or legal ties exist.

• Each person has an individual definition of who or what constitutes family/ Family Nursing Based on the assumption that every person, regardless of age, is a member of some type of family form and carries family experiences that have profound influences on their lives and approaches to health care.
• Promotes, supports, and provides for the well-being and health of the family and individual family members. -Health Promotion What is the goal of family nursing? Is to help the family and its individual members achieve and maintain optimal health throughout and beyond the illness experience. What are the types of family? -Traditional: Consist of a mother and father -Extended: nuclear family and other relatives -Step: formed when at least one child in a household is from a previous relationship. -Blended: when both parents bring children from previous relationships into new -Single-parent family: consists of one parent and one or more children.

-Other family forms Ideas of Structure-function theory

• it defines family as a social system.
• Family is viewed as open to the outside system, but boundaries are maintained.
• Family is viewed as passive in adapting to outside system and therefore is not viewed as a change agent.
• it examines families in terms of:

1. Relationships with, for example, government, health care, and religious institutions
2. Family patterns in relation to society
3. How well the family structure performs its functions Structure-function theory definition

• family is viewed as an organization arrange in a structure with a hierarchy that enables it to perform necessary functions Structure-function theory -Social system with functional requirements -Family's relationship (in context with) other major social structures

• illness of a family member results in the alteration of the family structure and function
• e.g., if a single mother is ill, she cannot carry out her various roles, so grandparents or siblings may have to assume childcare responsibilities
• family power structures and communication patterns are affected when a parent is ill Systems theory
• views the family as a unit
• theory that describes the interconnected elements of a system in which a change in one element affects all of the other elements
• encourages CHNs to view clients as participating members of a family
• determine the effects of illness or injury on the entire family system (family = client)
• emphasis on the whole rather than on individuals
• A system is composed of a set of interacting elements
• Each system can be identified and is distinct from the environment in which it exists. Developmental theory

• assist CHNs in anticipating clinical health concerns in families
• identifying family strength
• assessing the family's developmental stage
• assessing if the family is meeting the requirements of that stage
• assessing the family's developmental history
• assessing the availability of resources needed for performing developmental tasks Interactional theory
• explore individual family member's perceptions, interactions, and communication processes with other members
• Family is viewed as interacting personalities -Family is examined by the symbolic communications by which family members related to one another. -Each member occupies a position to which a number of roles are assigned. Assumptions of structure-function theory
• A family is a social system with functional requirements.
• A family is a small group that has basic features common to all small groups.

• Social systems, such as families, accomplish functions that serve the individuals in addition to those that serve society.
• Individuals act within a set of internal norms and values that are learned primarily in the family through socialization. Ideas of Systems theory
• It is influenced by theory from physics and biology.
• A system is composed of a set of interacting elements.
• Each system can be identified and is distinct from the environment in which it exists.
• An open system exchanges energy and matter with the environment (negentropy).
• A closed system is isolated from its environment (entropy).
• Systems depend on both positive and negative feedback to maintain a steady state (homeostasis).
• Seeking therapy when the marital relationship is strained is an example of using negative feedback to maintain a steady state. Assumptions of systems theory
• Family systems are greater than and different from the sum of their parts.

• There are many hierarchies within family systems and logical relationships between subsystems (e.g., mother-child, family-community).
• There are boundaries in the family system that can be open, closed, or random.
• Family systems increase in complexity over time, evolving to allow greater adaptability, tolerance to change, and growth by differentiation.
• Family systems change constantly in response to stresses and strains from within and from outside environments. There are structural similarities in different family systems (isomorphism).
• Change in one part of family systems affects the total system.
• Causality is modified by feedback; therefore, causality never exists in the real world.
• Family systems patterns are circular rather than linear; change must be directed toward the cycle.
• Family systems are an organized whole; therefore, individuals within the family are interdependent.
• Family systems have homeostasis features to maintain stable patterns that can be adaptive or maladaptive Ideas of Developmental theory
• Principles of individual development are applied to the family unit.
• The stage of the family unit is determined by age of the oldest child.

• Identified family tasks need to be accomplished during each stage of family development.
• Developmental concepts include moving to a different level of functioning, implying progress in a single direction.
• Family disequilibrium and conflicts are described as occurring during transition periods from one stage to another.
• The family has a predictable natural history designated by stages, beginning with the simple husband- wife pair.
• The group becomes more complex with the addition of each new child.
• The group again becomes simple and less complex as the younger generation leaves home.
• The group comes full circle to the original husband-wife pair.
• At each family life-cycle stage, there are developmental needs of the family and tasks that must be performed.
• Achievement of family developmental tasks helps individual members accomplish their tasks. Assumptions of developmental theory
• In every family, there are both individual and family developmental tasks that need to be accomplished for every stage of the individual and family life cycle that are unique to that particular group.
• Families change and develop in different ways because of internal and environmental stimulations.

• Developmental tasks are goals to work toward rather than specific jobs to be completed at once.
• Each family is unique in its composition and complexity of age-role expectations and positions.
• Individuals and families are a function of their history, as well as the current social structure.
• Families have commonalities despite the way they develop over the family lifespan.
• Families may arrive at similar developmental levels through different processes Ideas of Interactional theory
• Family is viewed as interacting personalities.
• Family is examined by the symbolic communications by which family members relate to one another.
• Within the family, each member occupies a position to which a number of roles are assigned.
• Members define their role expectations in each situation through their perceptions of the role demands.
• Members judge their own behaviour by assessing and interpreting the actions of others toward them.
• Central to the interaction approach is the process of role taking.
• The ability to predict other family members' expectations for one's role enables each member to have some knowledge of how to react in the role and indicates how other members will react to performing the role.

Assumptions of interactional theory

• Complex sets of symbols having common meanings are acquired through living in a symbolic environment.
• Individuals distinguish, evaluate, and assign meaning to symbols.
• Behaviour is influenced by meanings of symbols or ideas rather than by instincts, needs, or drives; therefore, the meaning an individual assigns to symbols is important to understanding behaviour.
• The self continues to change and evolve over time through introspection caused by experience and activity.
• The evolving self has several dimensions: the physical body and characteristics and a complex social self. The "me" is a conventional, habitual self that consists of learned, repetitious responses. The "I" is spontaneous to the individual.
• Individuals are actors as well as reactors; they select and interpret the environment to which they respond.
• Individuals are born into a dynamic society.
• Individuals learn from the culture and become the society.
• Individuals' behaviour is a product of their history, which is continually being modified by new information.

Advantages of structure-function theory

• Comprehensive approach that views families in the broader community in which they live Limitations of structure-function theory
• Static picture of the family, which does not allow for dynamic change over time Advantages of systems theory
• Views families from both a subsystem and a suprasystem approach
• Views the interactions within and among family subsystems as well as the interactions among families and the larger supersystems, such as community, world, and universe
• Focus is on the interaction of the

family with other systems rather than on the individual, which is sometimes more important Advantages of developmental theory

• Provides a basis for forecasting what a family will be experiencing at any period in the family life cycle (e.g., role transitions and family structure changes) Limitations of developmental theory
• Model was developed at a time when the traditional nuclear family was emphasized Advantages of interactional theory
• Focus on internal processes within families, such as roles, conflict, status, communication, responses to stress, decision making, and socialization

• Processes, rather than end products, of social interactions are major focus; thus, this framework used by many nurse scholars Limitations of interactional theory
• Broadness and lack of agreement about concepts and assumptions of the theory, which has made it difficult to refine
• Families considered as closed units with little relation to the outside society Calgary Family Assessment Model (CFAM)
• a family systems nursing models that takes a holistic approach to assess family health
• conducts a structural, developmental, and functional assessment Structural assessment

Examine the internal structure, external structure, and context that shape a family Internal structure The people who are included in the family and how they are connected to each other External structure The relationships the family has with people and institutions outside of the family Context The whole situation or background relevant to the family

• e.g., ethnicity, race, social class, religion, environment Developmental assessment Examine the family life-style stages (transitions), associated developmental tasks, and the attachments for the family (emotional bonds formed between members) Stages of the family life-cycle
• leaving home; single young adults
• the joining of families through marriage; the new couple
• families with young children
• families with adolescents
• launching children and moving on
• families later in life

Families later in life

• Accepting the shifting of generational roles
• Maintaining own and couple functioning and interests in face of physiological decline; exploration of new familial and social role options
• Support for a more central role of middle generation
• Making room in the system for the wisdom and experience of the elderly, supporting the older generation without overfunctioning for them
• Dealing with loss of spouse, siblings, and other peers and preparing for own death; life review and integration Functional assessment
• Focuses on how family members interact and behave towards each other by observing their interactions
• 2 sub-categories: instrumental and expressive functioning Instrumental functioning
• normal activities of daily living
• e.g., preparing meals, sleeping, and attending to health needs
• activities can become a challenge with onset of illness and disability

Expressive functioning

• the ways in which people communicate
• can be altered by disease (e.g., evokes anxiety and grief)
• many sub-categories: emotion, nonvernal, verbal Elements of relational inquiry into families (11)
• entering into relation
• being in collaborative relation
• inquiring into the family health and healing experience
• following the lead of families
• listening to and for
• self-observation -letting be and change
• collaborative knowledge development
• pattern recognition
• naming and supporting capacity
• emancipatory action Entering into relation
• Getting "in sync" with a family
• Conscious participation—walking alongside the family
• Stopping to look, listen, and hear
• Unconditional positive regard
• Being in sync

Inquiring into the health & healing experience

• Inquiry into what is meaningful to the family
• Keeping family at the centre of view Following the lead of families
• Taking cues from families
• Taking a stance of curiosity, unknowing, and uncertainty
• Using theoretical knowledge to enhance sensitivity to family experience
• Scrutinizing theoretical and expert knowledge against family experience General characteristics of a family
• protection
• nourishment
• socialization of family members Crisis-prone families
• lack of resiliency
• lack of hardiness
• belief that they lack control of their environment Family hardiness
• internal strengths and durability of the family unit
• sense of control over the outcome of life

• perceiving change as beneficial and growth producing
• active rather than passive approaches to stressful events
• can transcend inevitable life changes Family resiliency
• the ability of the family to cope with expected and unexpected stressors, role changes, developmental milestones, and crises
• goal is to thrive and grow with knowledge acquired through challenges Factors influencing family resiliency
• positive outlook
• spirituality
• flexibility
• cohesiveness
• clear communication
• financial management
• shared family involvement in recreation, routines, rituals
• support networks Signs of caregiver role strain (caregiver burnout)

• depression
• physical and/or emotional exhaustion
• denial
• anger
• social withdrawal
• sleepiness
• poor concentration
• health concerns
• financial/workplace stress Challenges of familial caregiving
• competing role responsibilities (e.g., work, home)
• advanced age of the caregiver
• high-intensity caregiving needs
• insufficient resources (e.g., financial, education)
• poor self-reported health
• living in the same household with the care recipient
• prior relational conflicts between the caregiver and the care recipients
• dementia of the care recipient
• cultural differences

Family capacity building -Recognizing family strengths and working with the family to build upon those strengths to facilitate health.

• involve all family members , regular meetings
• caregiver support groups
• respite care, Adult Day Program
• mobile HC service
• transportation, housekeeping, legal resources Factors influencing family dynamics
• relationships
• number of children
• parental presence
• chronic diseases
• abuse or violence
• culture
• SES
• employment
• parenting practices

Example of poor family resiliency Cancelling appointments with the family services team Relational apporach -Inquiry for family nursing that is guided by conscious participation with clients using a number of relational skills including listening, question, empathy, mutuality, reciprocity, self-observations, reflection, and a sensitivity to emotional context.

• use communication to gain contextual knowledge about the family
• build strength
• recognize differences
• do not take sides How do nurses begin the relational process and what do they aim for? -Aims to build on family strengths, recognize differences among family members without taking sides or reinforcing power relationships. -Begins by entering into relation, inquiring into the family health and healing experience, following the lead of families, and learning to let be. -Inquiring and listening for what is meaningful and important to the family is central relational family nursing practice and requires considerable awareness of both self and others. Relation Inquiry approach

-Nurses seek to expand their contextual knowledge of families, developing a more in-depth and comprehensive consideration of the historical, economic, political, social, environmental, and geographics influences at play when families, and the quality of work life experienced by nurses. what are the 3 Relational Capacities? -Ways of being in relationships -Understanding another's personal meaning -Expressing/sharing your own personal meanings Family as Context

• traditional focus that places the individual first and the family second -serves as a strength or stressor to individual health and illness issue -Nurse more interested in the individual and realizes that the family influences the health of the individual. Family as Client
• The family is first, and individuals are second. -Focus is concentrated on how the family as a whole is reacting to the event when a family member experience a health issues -Family as a while and how they are coping. Family as a System -Focus is on the family as a client

-Focuses on individual members and the family as a whole at the same time. -Interaction among family members become the target for nursing intervention. Family as a component of society

• family is seen as one of many institutions in society, along with health, education, religious, or financial institutions -Family is a basic or primary unit of society, as are all the other units, and they are all part of the larger system of the society, What is Family-centered care assessment based on? -Communication, shared decision-making, Health promotion, Strengths-Based care, Family support, Care setting Practices, Cultural Competence, and Care Coordination. Functional families demonstrate effective coping within the family unit, provide autonomy, and are responsive to the particular interests and needs of individual family members.