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The Child in the Context of Family. Family-Centered Care
Chapter 3 By Nataliya Haliyash, MD,BSN Lecture Objectives Discuss
definitions of family
State some nursing theories that provide guidance for understanding
families Discuss social science theories that explain family
dynamics, processes, and tasks Identify family assessment tools
Describe different types of family structures Learn parenting tasks
and parenting styles Discuss the role of the nurse in supporting
caregivers and their child-rearing practices Describe the elements
of family-centered care and provide examples Identify language that
reflects family-centered principles Two ways that nurses identify
families (by Gilliss (1993))
family as contex: individuals are assessed, the emphasis is on the
individual family as a client: family is treated as a set of
interacting parts and assessment of the dynamics among these parts
is emphasized The legal definition emphasizes relationships through
blood ties, adoption, guardianship, or marriage. The biological
definition focuses on perpetuating the species. Sociologists define
the family as a group of people living together. Psychologists
define it as a group with strong emotional ties. Traditional
definitions usually include a legally married woman and man with
their children. Family is a group of two or more persons related by
birth, marriage, or adoption and residing together. the U.S. Bureau
of the Census (2000) Definitions of family The family, despite its
changing and increasingly diverse nature, remains the basic social
unit. The word "family" refers to two or more persons who are
related in any waybiologically, legally, or emotionally. Patients
and families define their families. In the patient- and
family-centered approach, the definition of family, as well as the
degree of the family's involvement in health care, is determined by
the patient, provided that he or she is developmentally mature and
competent to do so. The term "family-centered" is in no way
intended to remove control from patients who are competent to make
decisions concerning their own health care. In pediatrics,
particularly with infants and young children, family members are
defined by the patient's parents or guardians. Nursing theories for
understanding families
Neuman's System Theory (1983): The family is described as an
appropriate target for both assessment and nursing interventions.
The way each member expresses self influences the whole and creates
the basic structure of the family. The major goal of the nurse is
to help keep the structure stable within its environment. Nursing
theories for understanding families
Roy's Adaptation Theory (1983): The client is an individual,
family, group, or community in constant interaction with a changing
environment. The family system is continually changing and
attempting to adapt. The goal of nursing is to promote adaptation
and minimize ineffective responses. Social Sciences Theories for
understanding families
Structural-Functional Theory: The family is viewed as part of the
social system, with individuals being parts of the family system.
The family, as a social system, performs functions that serve both
the individual and society. Individuals act in accordance with a
set of internalized norms and values that are learned primarily in
the family through socialization. Five functions of the family
important to understand:
Affective Socialization and social placement Reproductive Economic
Health care The affective function is one of the most vital
functions for the formation and continuation of the family unit.
This function refers to the family meeting the needs for love and
belonging of each member. The family is a home base where the
individuals can express their true feelings and thoughts without
fear of rejection. Socialization and social placement function
refers to teaching children how to function and assume adult social
roles. This function involves the acquisition of internal controls
needed for self-discipline and values such as what is right and
wrong according to society. The health care function includes
provision of physical necessities to keep the family healthy, such
as food, clothing, and shelter as well as health care (Friedman,
1998). The family keeps its members well by passing on attitudes,
values, and behaviors that promote health and by caring for them in
times of illness. Social Sciences Theories for understanding
families
Duvalls developmental or life-cycle theory (1977): Families
experience growth and development in much the same way as
individuals. Critical role transitions of individual members, such
as birth, retirement, and death of a spouse, are viewed as
resulting in a distinct change in the family life patterns.
Families develop and change over time in predictable ways. Families
and their members perform certain timespecific tasks that are
decided upon by themselves, within their cultural and societal
context. Family behavior is the sum of the previous experiences of
its members as incorporated in the present and in their
expectations for the future. 8 Duvall's Developmental Stages
Beginning family Childbearing family Families with preschool
children Families with school-aged children Families with teenagers
Families launching young adults Middle-aged parents Families in
later years FAMILY ASSESSMENT is the process of collecting data
about the family structure, and the relationships and interactions
among individual members. It is a continuous process. Its aim is to
generate Nursing diagnoses with goals and interventions for care
created in collaboration with the child and caregivers. Assessment
Instruments
A genogram is a format for drawing a family tree that records
information about family members and their relationships over a
period of time, usually three generations. An ecomap is a visual
representation of a family in relation to the community. It
demonstrates the nature and quality of family relationships and
what kinds of resources or energies are going in and out of the
family. Genogram Ecomap In-depth Family Assessment
Calgary Family Assessment Model (Wright & Leahey, 1994): Gather
information about family structure, development and functioning.
Friedman Family Assessment Model (Friedman, 1998): consists of six
broad categories of interview questions. FAMILY STRUCTURE The
nuclear family is defined as a husband, wife, and their
childrenbiological, adopted, or both (Friedman, 1998) The extended
family consists of those members of the nuclear family and other
blood-related persons such as grandparents, aunts, uncles, and
cousins. A blended or stepfamily occurs when a divorced, widowed,
or never-married single parent forms a household with a new
partner; both partners or only one may have children. FAMILY
STRUCTURE Single parent family occurs by means of divorce,
separation, death of a spouse, or choice. 90% of them are comprised
of single mothers and their children. Gay and lesbian families are
increasing in numbers. Because homosexuality is stigmatized in our
society, many of these parents are not open about their sexual
orientation. Working with Gay and Lesbian Families
When working with families, do not assume that all parents are
heterosexual. In obtaining the family history, the following
questions may be asked: (1) Who makes up your family? (2) Do you
have a partner? (3) Do you share parenting responsibilities with
anyone else? (4) Who else is responsible for the child's care if
you are not available? Culturally Sensitive Care
Is care provided with awareness of child's and familys own values
and beliefs and recognize how they influence their attitudes and
actions. Cultural sensitivity means having an awareness and
appreciation of cultural influences in health care and being
respectful of differences in cultural belief systems and values. A
multicultural perspective means using appropriate aspects of the
family's cultural orientation to develop health care interventions.
PARENTING Parenting is a dynamic process that evolves over time as
parents acquire experience and mature as individuals. The social
goal of parenting is to guide and nurture children so that they
become productive members of society. The personal goal is a desire
to raise a child, see aspects of oneself continue to exist such as
perpetuating the family line. Parenting by Developmental Stage
Parenting by Developmental Stage Parenting by Developmental Stage
Parenting Styles (1) authoritarian or autocratic,
(2) authoritative or democratic, (3) indulgent or permissive, (4)
indifferent or uninvolved. Socialization Socialization is a process
of learning the rules and expected behaviors of a society. One goal
of parenting is to socialize children, which includes teaching
which behaviors are expected and appropriate, and fostering the
development of self-control. This is also the goal of discipline,
which comes from the root word disciplinare to teach or instruct.
Effective discipline should include three components:
(1) a positive, supportive, nurturing caregiverchild relationship,
(2) positive reinforcement techniques to increase desirable
behaviors, (3) removal of reinforcement or use of punishment to
reduce or eliminate undesirable behaviors. SPECIAL PARENTING
SITUATIONS
adolescent parents, adoption, grandparents as parents, foster
parents. IMPLICATIONS FOR NURSING
Nurses can play a vital role in supporting parenting as they work
with families. This work must be done in collaboration with parents
if positive results are to be achieved. Assessment of
parenting
The parent's views on parenting Clarifying cultural and social
expectations for parenting Identifying issues or children's
behaviors that are of concern to parents Evaluating the
interactions between children and their parents during health care
encounters The identified problems should:
Be confirmed or clarified with parents Be mutually agreed upon as
the priority issues parents wish to address Collaboration with
parents
Identifying: Resources for implementing the plan Strategies that
are congruent with parental beliefs Outcomes for determining
effectiveness of the plan Family-centered Care Family-centered care
is an approach to the planning, delivery, and evaluation of health
care that is governed by mutually beneficial partnerships between
health care providers, patients, and families. Family-centered vs.
Patient-centered pediatric vs. adult care
Family-centered vs. Family-focused collaborative vs. expert and
unit of intervention In family-focused care, professionals provide
care from the position of the expertthey tell families what to
do.They consider the family the unit of intervention.
Family-centered care is characterized by a collaborative approach
to caregiving and decision-making.Each party respects the
knowledge, skills, and experience the other brings to the health
care encounter. Clarification The definition of family (and degree
of family involvement in health care) is controlled by the patient,
provided he/she is developmentally mature and competent to do so.In
pediatrics, families define for themselves who their family members
are. Family-centered vs. family-focused: Both approaches
acknowledge involvement with the family.In family-focused care,
professionals provide care from the position of the expertthey tell
families what to do.They consider the family the unit of
intervention.Family-centered care is characterized by a
collaborative approach to caregiving and decision-making.Each party
respects the knowledge, skills, and experience the other brings to
the health care encounter. Languagehow are your words
interpreted?
Family unavailable for interview Compliance is poor Presented the
Chinese food summary, but dad claims the suggestions dont apply One
of my cases is a 5-year old Downs kid Another thing to think about
is family-centered language.These are examples of professionals
statements that are not very family-centered.Think about how they
might be interpreted by the family or by other professionals: This
was in a hospital chart 4 days in a row, at 1 pm. What the
professional did not know was that the family spent most days (and
nights) in the room, but left between 12:30 pm and 2 pm for lunch
at the individuals request. The family was trying, blood glucose
levels were improving, butnot ideal. This was a posting on a
listserve; it turned out that the family was from Japan. Think
about how you would react if this statement was made about your
child. Family-centered Language
When we recognize that people with disabilities are people first,
we can begin to see how people with disabilities are more like
people without disabilities than they are different. Kathie Snow,
1998 Kathie Snow has written about using People-First Language.Some
of her writing is in your handout material. Does anybody have any
thoughts about this statement?What do you think it means? Some
people view it as, I am defined by who I am, not by what my
disability is. Kathy Snow says: My son Benjamin, is 11 years old.He
loves the Lone Ranger, ice cream, and playing on the computer.He
has blonde hair, blue eyes, and cerebral palsy.His disability is
only one small piece of his life. Family-centered Language:
People-first language
Focus on the individual, not the disability; do not refer to the
disability unless its relevant Avoid labeling people: a Downs kid
vs. a child who has Down syndrome Emphasize abilities not
limitations: confined to a wheelchair vs. uses a wheelchair Avoid
negative or sensational descriptions (achieved a near-normal life
despite suffering from) Avoid using normal to describe people
without disabilities 1. When I introduce myself to people, I dont
tell them Ill never be a prima ballerina.I focus on my strengths,
not on what I cant do. 2. Labeling is demeaning and doesnt reflect
a persons individuality or equalityand does not convey respect.
Other examples from Kathie Snow: A parent of a child who wears
glasses doesnt say, My child is myopic.A person with a medical
diagnosis of cancer doesnt say I am cancerous. 3. I dont say, My
son cant write with a pencil, I say, My son uses a computer to
write. 4. Keep the disability in perspective.Avoid making somebody
a victim (e.g., avoid she suffers from Down syndrome or he is a
tragic victim of blindness.)Avoid making people superheros. 5.
Instead of normal use typical or without disability or without
diabetes etc. Arguments against person-first language (& some
rebuttal) [these discussion points may or may not come up; use them
as time allows and depending on the audience] But we use non-person
first language for things that arent related to disabilityyou
wouldnt say the person who provides nutrition services or the
person who grandmothers. It is appropriate for society to
categorize people without person-first language in some cases, but
not when referring to disabilities.Disabilities are not defining
characteristics in which a profession (e.g., the nutritionist v.
the person who provides nutrition services) or a role in society
(the grandmother v. the person who grandmothers). We call people
patients all the timebut thats what they are when they are in the
hospital, right? This is often a judgment call.If you are working
in a hospital, the people who are receiving the medical care are
indeed patients.For some people, this okays the use of the term
patient.Other people prefer to use a different term (the clients
name?) when referring to an individual, reserving the use of
patient to refer to a general group of people. But this is how weve
always said it; nobody else uses that kind of language. stereotypes
die slowly People-first Language
Change the following from language to avoid to people-first
language the handicapped normal kid he is autistic hes one of my
cases a quadriplegic she is learning disabled a victim of epilepsy
Ask participants to fix the terms on this slide.Suggested
responses: People with disabilities Child who is developing
typically He has autism I see him in clinic Person with
quadriplegia Person with a learning disability Person with epilepsy
HIPPA and the Privacy Rule
Patients must have access to their medical information A written
consent must be completed before medical information is released
More information: Can you think of how this might have an impact on
your practice? Sharing information with other health care providers
Sharing information with school staff, other people involved in a
childs life Q&A?