Family Focused Nursing Practice

Sharon A. Denham, PhD, RNProfessor Emeritus, Ohio University School of Nursing

Houston J. & Florence A. Doswell Endowed Chair in Nursing for Teaching Excellence, Texas Woman’s University, Dallas Campus

Objectives

At the conclusion of this webinar, participants will be able to:

Discuss today’s changing landscape & needs for care delivery

Identify usefulness of the Family Health Model (Denham, 2003) Identify essential aspects of “thinking family” in nursing practice Characterize the nursing practices needed for relationship based care delivery Describe how a family lens can be used to drive care delivery across multiple contexts

Implications of Changing Health

Care System Landscape

∗Affordable Health Care Act∗Technology∗Growth in Knowledge∗Roles of Health Practitioners∗Consumers∗Chronic Illness Care Needs∗Aging Populations∗Increasing Diversity of the U.S. Population∗$$$$$$$

Health Care

Since 2005, 2,000-4,000 articles added daily to Medline database

Physicians Desk Reference grown from 77 pages in 1942 to 3,250 pages in 2012 edition

Explosive growth of health websites on the internet

Billions in medical research (we spend thousands $$$$ for single person to implement treatments)

divorc

e

Shared

commitm

enta loose affiliation

people descended from a common

ancestorFundamental social

group

blood

wedloc

k shared genetics

arranged

co-

habitation

group

foster care

a person having kinship with another or

others

aunts & uncles

adoptio

n

household

living under one

roof

basic unit of society

association of people who share common beliefs or activities

step-

families

chosen

blended families

kinship parents

children

biological classificationcommon ancestry

extended

relativesprocreation

family of orientation

economics

conjuga

l

nuclear

a social unit living

together

matriloca

lspouse

groups linked through descent

partner

consanguinal

Same Sex

grandparents

patriarchal

Illness Care System

Exceptional almost miraculous

Billions wasted on unnecessary & inefficient services

Millions get too much or too little

Quality of care vs. volume of care services

Questions about the quality, adequacy, equity, value & satisfaction with care

Health vs. Illness

Acute illness: short duration, but usually severe

Chronic illness: persistent illness for >6 months, can worsen or get better

Health: “State of complete physical, mental and social well-being, not merely the absence of disease…”

www.diabetesfamily.net/family

see: Family Health Model

“An Ethnographic Study of Family Health in Appalachian Microsystems” (1995 -1996)

8 Appalachian families/4 interviews with each

Family Health During Transitional Change (funded by the American Nurses Foundation, 1996)

Family Health in a Disadvantaged Population (funded by the College of Health and Human Sciences, 1997)

Nurturing & emotionally supportive

A caring unit for its members

Meets individual needs, celebrates, and values members

Dynamic changes are likely to occur over the life course

HEALTHY FAMILY

Family Health

An adaptive state that occurs across the life course as the family unit serves as a major resource for the day-to-day living and wellbeing of its members.

A household phenomenon that effectively uses available resources to maximize the wellbeing of its members and the family unit through supportive interactions with their embedded systems, dynamic relationships, and member routines.

It is experienced when individuals fulfill personal goals, enjoy a meaningful life, and experience full capacity of wellbeing.

“Think Family”

Every time you see an individual...

Even when others are not physically present...

Note similar care needs in families with children & those with adult members

Family Theory (Domains)

Family Structure

Family Function

Family Process

Family Systems Theories Family Health Model

• Contextual Domain

• Functional Domain

• Structural Domain

Contextual Domain

Microsystem

Mesosystem

Exosystem

Macrosystem

Contextual Domain

Household niche

Immediate neighborhood

Family members & close links to others that are like family

Characteristics, genetics, race, age, spirituality, culture, and other family traits

Microsystem

My Family Microsystem

Contextual Domain

Mesosystem: Multiple influences as individuals interact within member sub-systems within & outside the household niche.

Exosystem: Systems that do not directly involve individuals as active participants, but events still effect the family.

Macrosystem: Policy (e.g., social, health, public); larger environments

Chronosystem Timing of events. Number of events in a given time. Length of time of events. Perceptions of time over time. Social life course. Time and place. Human agency. Timing of lives. Interdependent lives. Actual passage of time. Special moments in time. Age differences. Intergenerational transmission. Historical past. Experienced and inexperienced present. Desired futures.

Normative & Non-Normative Events

Normative Events

* Events that developing persons and families anticipate; culturally bound events; have shared meanings (e.g., birth, puberty, graduation, marriage, retirement, etc.).

Non-Normative Events

* Events that appear unexpectedly; families ill-prepared; may be viewed as crisis; linked to historical contexts (e.g., genetic disorder, divorce, losing job, premature death, chronic illness, etc.)

Functional Domain

Individual factors (e.g., values, attitudes, beliefs, abilities, & roles)

Member processes (e.g., communication, leadership, decision making, problem solving, etc.).... dyads & triads

Family unit processes (e.g., cohesiveness, individuation, identity, boundaries, resilience, etc.)

Functional Domain

Relationships with others

Relationships with social systems and larger society Member development, health, and well-being Ways family resources are used Influences family health potentials and how they are met or unmet

Core Family Processes

Caregiving

Cathexis

Celebration

Change

Communication

Connectedness

Coordination

Caregiving

Health maintenance Disease prevention Risk reduction Health promotion Illness care Rehabilitation Acute episodic needs Chronic care concerns

Cathexis

Attachment Commitment Affiliation Loss Grief and mourning Normative life processes Complicated life processes

Celebration

Culture Family fun Traditions Rituals Religion/faith practices Hobbies Shared activities

Change

Control Meeting expressed needs Meanings of change Contextual influences Compare and contrast Similarities and differences Diversity

Communication Language Symbolic interactions Information access Coaching Cheerleading Teaching Counseling Knowledge and skills Emotional needs Affective care Spiritual needs

Connectedness Partnering relationships Kin networks Household labor Cooperation Member roles Family rules Boundaries Tolerance for ambiguity Marginalization

Coordination

Family tasks Forgiveness Problem solving Decision making Valuing Coping Resilience Respect Reconciliation Stress Management

Structural Domain

Rituals, traditions, & routines

Family health routines

Structural Domain

Ways members use beliefs, values, attitudes, information, knowledge, resources, & experience to construct behaviors that impact health & illness.

Provides insight into individual & collective behaviors lifestyle & health behaviors.

Useful for assessment, intervention, & evaluation of the complex patterns affecting individual & family health or illness.

Structural Domain

Prior research suggests that family routines have potential for conceptualization, planning and implementation of interventions to promote healthy lifestyles & manage chronic diseases.

(Denham, 2002a; Denham, 2002b)

Family Health Routines

Self-care Safety and precautions Mental health behaviors Family care Illness care Member care-taking

Complex Family Health Interactions

Household Niche

Individuals & Others

RoutinesResources

Personal Traits

Interactions

Community

Transform Nursing Practices

Household member behaviors

Meet individual Assess Family Needs

Tailor care One size does not fit all

No quick single fixes

Chronic care needs change over time

Family behaviors matter

Should not have to be on “our own”

Change Care Delivery

✦ Move beyond visiting hour debates

✦ Think outside of the acute care settings

✦ What is collaborate care? How do we become partners in care?

✦ What are the implications of continuously coordinated care?

✦ How do we best support the lived experience linked with health & illness?

✦ See family, the household, & community as integral... PLACE MATTERS!!!!

✦ Focus on population needs & quality of life years

✦ Medical errors, safety, infection control, costs of care, etc.

Moving from Patient to Family Focused Care

∗Patient focused (dependent role)∗Individual focused (empowered role)∗Patient-centered & family-centered terms

∗Family physicians & family nurse practitioners

Family Focused Care

∗Nursing is an art & science∗Evidence based practice∗See individuals - Always “think

family”∗ Identify care needs of people in

context∗Holistic care

Family as the Unit of Care

∗Family is in the forefront∗Members are perpetually connected∗Even when members are not present, they are still

important∗Shared lives, resources, & identities

“Thinking Family”

∗An attitude & mindset∗Approach for all care ∗Value deeply connected & interdependent

lives∗Respect expertise of family units’

experiences

Traits of Family Focused Care

Needed by young & old

Intentionally focused

Communication (crisis, conflict, multiple members)

Identify household needs for individual members

Reflection

Individual-Nurse-Family Partnerships

∗Family is ALWAYS present, even when not physically present

∗Hear the family story∗Value the expertise of family members∗Not an extra task, but usual practice in every

situation∗Safe care (think home & community)

Family Communication

∗Who do I communicate with?∗What things need to be discussed?∗How do I conduct private conversations?∗How do I best use time to build trust & deliver care?∗What are the most important things to do?

Continuity of Care

∗Care coordination∗Address care fragmentation∗Self & family care management∗Family needs to know ways to support members care needs∗Health promotion, wellness, risk reduction & prevention∗Resources, barriers & needs∗Family strengths∗ Interprofessional care needs

Family Focused Nursing Practices

∗Assessment: Gather, analyze & synthesize information from a variety of sources

∗Clear communication∗Provide information, education, & support∗Care for acute, chronic, population care needs & wellness

“Doing For” & “Being With”

∗“Doing For” – Task orientation (actions, busyness)∗“Being With” – Sharing emotional presence (listen, hear

story, value other, learn)∗Both important∗Do together

Family Focused Care

∗ Intentionally focused∗Use reflection regularly∗Communicate effectively∗Trust & respect∗Build self-confidence

Questions

sdenham@twu.edu