Assessment of Families Family functioning is those behaviors or activities by familymembers that maintain the family & meet family needs, individualmember needs, and society’s views of family. Family health is concerned with how well the family functions together as a unit. It involves not only the health of the members and how they relate to other members, but also how well they relate to and cope with the community outside the family. In fact, family health, like individual health, ranges along a continuum from wellness to illness.
Universal Characteristics of Families Five of the most important family universals for community health nursing are 1. Every family is a small social system. 2. Every family has its own cultural values & rules. 3. Every family has structure. 4. Every family has certain basic functions. 5. Every family moves through stages in its life cycle
FAMILY CULTURE • Birth, or adoption, whose central purpose is to create and maintain a common culture which promotes the physical, mental, emotional, and social development of each of its members • is the acquired knowledge that family members use to interpret their experiences and to generate behaviors that influence family structure and function
It arises from a significant body of literature in the social and behavioral sciences; cross-cultural comparisons and in-depth analyses demonstrate that each family has a “culture” that strongly influences its structure and function. Culture explains why families behave as they do • Three aspects of family culture deserve special consideration: (1) family members share certain values that affect family behavior; (2) certain roles are prescribed and defined for family members; (3) a family’s culture determines its distribution and use of power.
Family structuresor compositions comprise the collective characteristics of individuals who make up a family unit (age, gender, & number). • A growing body of research on family structure & function shows that families have changed dramatically since the nuclear family was the dominant form. Family structures fall into two general categories: traditional & nontraditional
Implications for the CHN First, CHN can no longer hold to a myth that idealizes the traditional nuclear family. They must be prepared to work with all types of families and accept them as valid. Second, the structure of an individual’s family may change several times over a lifetime. A girl may be born into a kin-network, shift to a nuclear family when her parents move, and become part of a single-parent family when her parents are divorced. Finally, each type of family structure creates different issues and problems that, in turn, influence a family’s ability to perform basic functions. Each particular structure determines the kind of support needed from nursing or other human service systems
FAMILY FUNCTIONS Six functions are essential for maintenance and promotion of family health: • providing affection, • providing security, • instilling identity, • promoting affiliation, (5) providing socialization, (6) establishing controls
FAMILY LIFE CYCLE • There are two broad stages in the family life cycle: one of expansion as new members are added and roles and relationshipsare increased, & one of contraction as family membersleave to start lives of their own or age &die.
Stage 1: Married couples(without children)Stage 2: Childbearing families(oldest child, birth-30months) Stage 3: Families with pre-school children(oldest child, 2 1/2-6years) Stage 4: Families with schoolchildren(oldest child, 6-13 years) Stage 5: Families with teenagers(oldest child, 13-20 years) Stage 6: Families as launching centers(first child gone to last child leaving home) Stage 7: Middle-age parents(“empty nest” to retirement) Stage 8: Aging family members(retirement to death of both spouses
Characteristics of Healthy Family 1. A facilitative process of interaction exists among family members. 2. Individual member development is enhanced. 3. Role relationships are structured effectively. 4. Active attempts are made to cope with problems. 5. There is a healthy home environment and lifestyle 6. Regular links with the broader community are established
Legitimate source of authority that is supported and consistent over time, • Stable and consistent system of rules, • Consistent and regular nurturing behaviors, • Effective child-rearing practices, • Stable and well-maintained marriages, • Set of agreed-upon goals toward which the family and individuals work, • Sufficient flexibility to change in the face of both expected and unexpected stressors.
An unhealthy family hasn’t recognized the value of establishing links with the broader community. • This may be because of (1) a knowledge deficit regarding community resources, (2) previous negative experiences with community services, or (3) a lack of connection with the community because of family expectations or cultural practices.
It is important for the community health nurse to assess the family’s relationship with the broader community, in addition to structural and developmental variations, interaction, coping strategies, and lifestyle. • With a comprehensive family assessment, the nurse has a base from which to begin a plan of care.
Family Health Practice Guidance • Family nursing is a kind of nursing practice in which the family is the unit of service It isn’t merely a family-oriented approach in which family concerns that affect the health of an individual are taken into account. Family nursing asks how one provides health care to a collection of people.
Role of the Family Health Nurse • The Family Health Nurse will help individuals and families to cope with illness and chronic disability, or during times of stress, by spending a large part of their time working in patients homes and with their families. • Such nurses give advice on lifestyle and behavioural risk factors, as well as assisting families with matters concerning health. Through prompt detection, they can ensure that the health problems of families are treated at an early stage. • With their knowledge of public health and social issues and other social agencies, they can identify the effects of socioeconomic factors on a family's health and refer them to the appropriate agency.
Role of the Family Health Nurse • They can facilitate the early discharge of people from hospital by providing nursing care at home, and they can act as the lynchpin between the family and the family health physician, substituting for the physician when the identified needs are more relevant to nursing expertise. • The four major types of intervention by Family Health Nurses ñ primary, secondary and tertiary prevention, and crisis intervention/direct care. At the level of primary prevention, they assess the possible presence of harmful stressors or threats to health and work pro-actively to prevent these from impinging on the family.
Role of the Family Health Nurse • They may help the family build up their resistance resources by providing health education and support, and by assisting them to mobilize other resources, monitoring the integrity of the system pro-actively by identifying potentially harmful stressors. • At the level of secondary prevention, they may become actively involved in screening and vaccination programs. Because of their expert knowledge of their particular caseload of families, they will detect the onset of health problems at an early stage, prompting quick action to minimize disruption of the individual and the family and calling on other relevant expert resource personnel as necessary.
Role of the Family Health Nurse • In tertiary prevention, they are involved in rehabilitation and rebuilding the family's resistance resources. • The fourth mode of intervention, the provision of direct care, is the traditional role of the nurse when the family's or individual's coping mechanism has been breached, for example by illness. • Here, the Family Health Nurse works in partnership with the family or individual to achieve, as appropriate, cure, rehabilitation, palliation and/or support.
Five principles guide and enhance family nursing practice • work with the family collectively, • start where the family is, • adapt nursing intervention to the family’s stage of development, • recognize the validity of family structural variations, • emphasize family strengths
Emphasize Family Strengths • CHN tend to focus their attention on family weaknesses, looking for & referring to them as needs or problems. • This negative emphasis can be devastating to a family and can undermine any hope of a truly therapeutic relationship between nurse and client. • Instead, families need their strengths reinforced. Emphasizing a family’s strengths makes people feel better about themselves. It fosters a positive self-image, promotes self-confidence, and often helps the family address other problems.
FAMILY HEALTH ASSESSMENT To assess a family’s level of health in a systematic fashion, three tools are needed: • a conceptual framework on which to base the assessment, • a clearly defined set of assessment categories for data collection, • a method for measuring a family’s level of functioning.
Conceptual Frameworks • A conceptual framework is a set of concepts integrated into a meaningful explanation that helps one interpret human behavior or situations. • Three frameworks that are particularly useful in community health nursing are presented here: the interactional, structural- functional, and developmental frameworks.
The interactional framework describes the family as a unit of interacting personalities and emphasizes communication, roles, conflict, coping patterns, and decision-making processes. • This framework focuses on internal relationships but neglects the family’s interactions with the external environment
The structural-functional framework describes the family as a social system relating to other social systems in the external environment, such as church, school, work, and the health care system. • This framework examines the interacting functions of society and the family, considers family structure, and analyzes how a family’s structure affects its function.
The developmental framework studies families from a life-cycle perspective by examining members’ changing roles and tasks in each progressive life-cycle stage. • This framework incorporates elements from interactional and structural-functional approaches so that family structure, function, and interaction are viewed in the context of the environment at each stage of family development.
Data Collection Categories • family strengths and self-care capabilities, • family stresses and problems, • family resources. • Family demographicsas a family’s composition, its SES & the ages, education, occupation, ethnicity, & religious affiliations of members. 2. Physical environmentdata describe the geography, climate, housing, space, social and political structures, food availability and dietary patterns, and any other elements in the internal or external physical environment that influence a family’s health status.
3. Psychological and spiritual environmentrefers to affectional relationships, mutual respect, support, promotion of members’ self-esteem and spiritual development, and life satisfaction and goals. 4. Family structure and rolesinclude family organization, socialization processes, division of labor, and allocation and use of authority and power. 5. Family functionsrefer to a family’s ability to carry out appropriate developmental tasks & provide for members’ needs
6. Family values and beliefs might deal with raising children, education, work, religion, making & spending money, health, & community involvement. 7. Family communication patternsinclude the frequency and quality of communication within a family and between the family and its environment. 8. Family decision-making patterns; how decisions are made in a family, by whom they are made, & how they are implemented. 9. Family problem-solving patternsdescribe how a family handles problems, who deals with them, the flexibility of a family’s approach to problem-solving, and the nature of solutions.
10. Family coping patternsencompass how a family handles conflict & life changes, the nature & quality of family support systems, & family perceptions & responses to stressors. 11. Family health behaviorrefers to familial health history, current physical health status of family members, family use of health resources, and family health beliefs. 12. Family social & cultural patternscomprise family discipline and limit-setting practices; promotion of initiative, creativity, and leadership; family goal setting; family culture; cultural adaptations to present circumstances; and development of meaningful relationships within and outside the family.
The genogram • The genogram displays family information graphically in a way that provides a quick view of complex family patterns. • It is a rich source of hypotheses about a family over a significant period of time, usually three or more generations. Family relationships are delineated by genealogic methods, and significant life events are included (e.g., birth, death, marriage, divorce, illness). • Identifying characteristics (e.g., race, religion, social class), occupations, & places of family residence are also noted. Again, this tool is used jointly with the family. • It encourages family expression and sheds light on family behavior & problems
HEALTH ASSESSMENT An assessment of family health will be most accurate if it incorporates the following five guidelines: 1. Focus on the family as a total unit. 2. Ask goal-directed questions. 3. Collect data over time. 4. Combine quantitative and qualitative data. 5. Exercise professional judgment.
Nursing Process Components Applied to Families as Clients • Assessing, planning, implementing, and evaluating nursing care are steps used to deliver care to clients in acute care settings and in the extensive clinic system. These same steps are used with families & aggregates in CHN. • The steps do not change, but because the context and client focus are different, external variables that have not been encountered in other contexts must now be considered.
Assessment of Home Environmental Conditions • Conditions in the neighborhood and home environments reveal important assessment information that can guide planning and intervention with families. While traveling to and arriving at the family home, you have been gathering information about resources and barriers encountered by the family. • This information is used during planning with the family. • It is important to remember that neighborhood conditions and even the physical appearance of the apartment or house may belie the family’s values, resources, and goals. They have little control over the neighborhood or, frequently, the building they live in, especially if they are renting.
Planning to Meet the Health Needs of Families During Home Visits • The greatest barrier to a successful family health visit is a lack of planning and preparation. A visit is not successful just because the nurse enters a home or other setting where clients are present. • A successful family health visit takes much planning and preparation & requires accurate documentation and follow-up. • In addition, safety measures must be followed, not only while traveling in the neighborhood, but also in the home.
Assessing, Teaching,& Referring • Assessing family health may be done informally through observation and occasional questioning, or it can take a more formal approach. • Specific questions may be asked of each family member, and such information as health data and family history may be included. Physical data such as height, weight, pulses, temperature, and blood pressure are recorded on an assessment tool.
With young children, specific assessment questionnaires or tests may be conducted to measure how well they are meeting growth and developmental tasks. One familiar test that has been used for decades is the Denver Developmental Screening Test (DDST). • The results of this gross assessment screening test provide the nurse with information about the child’s growth and developmental progress and can be used to teach families anticipatory guidance, as well as how to provide growth-enhancing experiences
Important characteristics of Healthy families 1. A facilitative process of interaction exists among family members. 2. Individual member development is enhanced. 3. Role relationships are structured effectively. 4. Active attempts are made to cope with problems. 5. There is a healthy home environment and lifestyle. 6. Regular links with the broader community are established
Empowering Families • The ultimate goal is to assist the family in becoming independent of your services. This is accomplished by the approach used in conducting the visit. How you structure the nurse–client relationship also influences the outcomes. Four thoughts will help to clarify your working relationship with families: • The family functioned in a manner that worked for them before you ever met them. • If you ever feel obliged to do something for a family, consider who did this before you were available. • Find family strengths even in the most deprived family situation. • If you were in a similar situation, would you manage, cope, or function as well as the members of this family?
Evaluating Implemented Family Health Plans • The evaluation process leads to a reassessment of your work with the family & a determination of what is needed in preparation for the next visit. This reassessment helps you in further individualizing services to the family. • Evaluation of the structure- process of the visit and your self-evaluation can be done informally in a reflective manner. Outcomes are documented in the client record, and the evaluation becomes formalized. • A thorough evaluation also assists you in making the most appropriate referrals and contacting key resources to meet family needs.
Families in Crisis • Facing Violence from Within and Outside the Family • Family crisis is a stressful and disruptive event (or series of events) that comes with or without warning and disturbs the equilibrium of the family. A family crisis can also result when usual problem-solving methods fail.
Developmental Crises • When developmental crises occur, people feel threatened by the demands placed on them and have difficulty making the changes necessary to fit the new stage of development. • During the process of normal bio-psychosocial growth, people go through a succession of life cycle stages, from birth through old age. • Each stage is quite different from the previous one, and transitions from one stage to the next require changes in roles and behavior. There are periods of upset and disequilibrium.
Developmental crises arise from both physical and social changes. Each new life stage confronts people with changed relationships, responsibilities, and roles. • The transition to parenthood, for example, demands a change in role from caring for oneself and one’s mate to include nurturing, caring for, and protecting a completely helpless infant. Relationships with adults, children, and even one’s own parents also change.
Situational Crises • Is a stressful, disruptive, event arising from external circumstances that occurs suddenly, often without warning, to a person, group, aggregate, or community. • Typically, the external event requires behavioral changes & coping mechanisms beyond the abilities of the people involved. Such events are not predicted, expected, or planned. • CHN see an almost infinite variety of situational crises, including debilitating disease, economic misfortune, unemployment, physical abuse, divorce, unwanted pregnancy, sudden death of a loved one. • In each situation, people feel overwhelmed and need help to cope. Skilled intervention can make the difference between a healthy and an unhealthy outcome.
Family Violence Againest Children • As a cause of morbidity among children, communicable diseases “are coming under control through a combination of health promotion, prevention and simplified standard treatment regimens. • But at the same time, the healthy G&D of many children is threatened by very rapid, often disruptive social, cultural and economic changes”
Major Differences between developmental crisis and situational crisis
Child abuse • Is the maltreatment of children. It may include any of the following: physical, emotional, medical, or educational neglect; physical punishment or battering; and emotional or sexual maltreatment and exploitation. Types can occur alone or in combination