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The free write is not an edited piece of work, but you must use one outside source. Please write down your thoughts, insights, stories, cases, examples, experiences and whatever comes to mind for that particular topic. This free write is meant to help you access your deepest and most powerful feelings about family, as well as building on your past and your developing knowledge of family: academically, professionally, and personally.

Guidelines for the Family Free Writes and Brainstorm

From our course syllabus:

Early in the course, each student will write a 2-page open write on each of the following four topics:

1. Healthy Families

2. Family during Acute Care Experience

3. Family in Crisis or Trauma

4. Chronic Illness Experience

The free write is not an edited piece of work, but you must use one outside source. Please write down your thoughts, insights, stories, cases, examples, experiences and whatever comes to mind for that particular topic. I also encourage you to use the course competencies for thematic elements to your writing. Please upload the paper into the discussion thread posted for that purpose. Please read and respond to one student in your group when ideas are interesting and relate what you have learned from them. These are amazing and I am not satisfied to be the only one reading them! Thanks.

This free write is meant to help you access your deepest and most powerful feelings about family, as well as building on your past and your developing knowledge of family: academically, professionally, and personally.

The 2-page free write on healthy families, (for example, there are four categories) may include ideas gleaned from your text, stories from your childhood, something you read in the newspaper, a novel or poem, or an interaction you witnessed in the grocery story. The objective of the free write is to help you decide what most interests you in family health nursing and what literature you might use for your annotated bibliography and your final research work with a family. Examination of the course topics will organize your thoughts and focus your ideas on the desired outcomes of the learning you are doing.

As stated in the syllabus, this is not an edited piece of work. This material is rich in image, story and insight. The free write is meant in part to get in touch with this material. Thoughts from your readings may also be included and will spark new ideas unique to you. Use at least two references in your work for full points.

Please post your writing to the group discussion link under Family Free Write Brainstorm as indicated. Everyone in your group should have one response to the free write, though no references are necessary for your response.

Rubric for Family Free Writes Brainstorm

40 points total

Requirement


Total possible

Total gained

Completion of all 4 topics

10

Application literature/citations

5

Relevance to principles of family nursing

10

Writing clarity and care

10

Insight and creativity

5

Free Write Example

Posted May 14, 2022 12:01 AM

For patients and their families, acute illness or the exacerbation of chronic illness requiring hospitalization may be unexpected. These experiences often bring out the best or the worst in people and serve as a proving ground for the functionality of the family. Roles are suddenly shifted or reversed (Kaakinen et al., 2018, p. 23). Uncertainty regarding prognosis, timing, and circumstances of recovery creates stress for family members. Those with a host of their own health problems may have difficulty coping with the additional significant emotional and financial burden of their loved one’s illness.  

In my own experience caring for acutely ill patients on an intensive care unit, significant acute illness, such as cardiac arrest, creates an environment in which family members with unresolved relational conflicts are forced to interact around important decisions for a common loved one. Sometimes family members and patient significant others battle for decision-making control. At times, they may attempt to manipulate health care providers to take sides. But acute illness may also strengthen families and provide a platform for long-delayed reconciliation. One member’s acute illness may also result in positive health behavior changes for others.  

Each person’s need for the support of a family is displayed in the context of acute illness. Some people have very little relational support and can function adequately in their daily life, but during acute illness and recovery have very few resources for even basic support. I’ve taken care of numerous patients who were recovering from open-heart surgery and had no one who could stay at home with them for a few days after hospital discharge. Many people have a wealth of family resources and these families serve to spur the patient on toward the best outcomes. Families encourage patients to eat, mobilize, and ask unanswered questions. Families may voice patient concerns or advocate for comfort or pain control.  

It’s important to recognize that most patients live within the context of a family prior to their illness and will eventually return to that context. Considering this, it makes sense that nurses would involve family in most aspects of patient care and teaching as they will continue care during recovery at home. Family members may know the patient well, providing relevant insight on medical and personal history that can help providers with the etiology of the illness and other factors that will provide a more comprehensive and accurate picture of the patient’s presentation.  

When considering the family as the client one might anticipate that families will be struggling with knowledge deficit, anxiety, grief, dysfunctional coping, financial concerns, caregiver burnout, and role strain, among other issues. Some of the ways nursing can assist with these issues are the provision of education, empathetic listening, and recruitment of resources, such as chaplaincy staff and social work/case management for post-hospital care. Simply providing information and answering questions can help families cope (Eggenberger & Nelms, 2007, p. 1623). A shift in nurses’ thinking may need to occur to see family not as a hindrance to nursing care, but as an ally in care and to acknowledge and affirm the significance of the family as context for support and healthy behaviors. The family plays an important role in the patient’s life and the patient plays an important role in the family.  

References 

Eggenberger, S. K., & Nelms, T. P. (2007). Being family: The family experience when an adult member is hospitalized with a critical illness. Journal of Clinical Nursing, 16, 1618–1628. doi: 10.1111/j.1365-2702.2006.01659.x 

Kaakinen, J. R., Coehlo, D. P., Steele, R. & Robinson, M. (2018). Family Health Care Nursing: Theory, Practice, and Research (6th Ed.) [EPUB Version]. Available from 
https://bookshelf.vitalsource.com
 

NURS 362 Summer 2022

Week

Family Topic

Assigned Content/Readings

Thought/Discussion Topic

Written Assignments/

Meetings

Module 1

Week 1

May 16

Introduction

Background Understandings of Family and Societal Care

George Maverick audio

Watch the three video clips in order:

Video 1: Brief with Family Focus

Video 2: Simulation with Family Focus

Video 3: Simulation without Familiy Focus

Kaakinen*, Coehlo, Steele, & Robinson (2018) Ch. 1

Denham*, Eggenberger, Young, & Krumwiede (2015) Ch. 1 & 12

Bell (2011)

*Reading list will just use first author name

Individual, Family and Societal Care

Foundations for Thinking Family

Look for posted orientation video on D2L explaining basics of course syllabus, calendar, and assignments. Please ask if further questions after listening and reading documents thoroughly. Thanks!

Free Write #1 regarding healthy families due

May 22nd

Group Discussion in D2L – Week 1

For each week, your initial posting is due by 11:59 p.m. on Wednesday and 2 responses to your peers by 11:59 p.m. on Sunday. Remember to include citations and references to support your comments.

1. Introduction Thread – Help your classmates to get to know you as a person, nurse, and family member. Share aspects of yourself in a posting–For example, Tell us about your family of origin. Tell us about your current family (remember that if you do not have biologic members present in your life, friends as family may apply to you. Pictures of you and your family? What is the work of family? What are your future family goals? What piques your interest in this course and family focused nursing care?

2. Reflect on an illness experience in your own family or a family you know. Describe the struggles the family experienced with the illness. Consider the biological, social, psychological, or spiritual factors that influenced the management and coping of the family. Based on your experience pose a nursing approach that may have been helpful to the family. Use your readings to support your analysis and response.

3. What is your definition of family and family health?

4. Describe your family health experience utilizing the 3 family health domains (contextual, functional, and structural).

5. Describe your family’s health routines. Identify some barriers or challenges for families not developing or maintaining health routines

6. To introduce family nursing practice and give you a background on how to care for the family unit, please watch video clips of our former nursing students caring for George Maverick in our simulation suite on the Mankato campus. Observe the similarities/differences seen between the individual focus (video 1) vs. family focused care (video 2).

7. Thinking Family – Address the health inequities or health disparities: Does the basic premise of family focused nursing care hold true: When the health of one family is improved, the health of society has also been improved.

Week 2

May 23

Background & Understandings of Family Nursing

Theoretical Foundations for Family Nursing

Family Structure, Function, Process

Aspects of Health

Kaakinen (2018) Ch. 2, 3 & 6

Denham (2015) Ch. 2, 3 & 7

Khalili (2007)

Duhamel, Dupuis, & Wright (2009)

Foundation for ‘Thinking Family’

Family as Unit of Care or Context?

Family Nursing Theory

Denham’s Core Processes

Health Routines

Free Write #2 regarding

family during acute care experience due May 29th

Group Discussion in D2L – Week 2

1. What are the barriers/challenges described in your readings that you also face in your environments as you attempt to provide family focused nursing? (e.g. family as client, family as context, family as barrier, family as caring process, family as resource)

2. Review the power point: “Family Nursing Background and Understandings.” Reflect on nursing practice that views family as the unit of care and nursing practice that views family as contextual to the individual patient. Do you believe that current nursing practice most often views family as the unit of care or family as a context to the situation? How do these two views differ?

3. Develop 5 questions focusing on one of Denham’s Core Processes. Interview a client in your workplace or within your community and describe their answers to your questions. Identify family routines and factors related to family health routines.

4. From the Khalili article, what were the most significant aspects of the illness transition for the family? What resources did the family need/want? What were the barriers and facilitators to obtaining the needed resources or supports? What may have changed in the care situation for the family if the family would have been viewed as the unit of care?

5. Using one of the family theories/frameworks described in the literature reflect on an illness experience in a family. (You can reflect on a family you have cared for in your nursing practice.) Consider how family structure, function, and process influenced the family health experience and outcomes. Analyze the experience from a family theory/framework perspective.

6. Use your reading on a One Question Question by Duhamel et al. (2009) to practice this questioning strategy with a family. Share your reflections and outcomes.

Module 2

Week 3

May 30

Family Construct

Share examples from the book to describe Denham’s Core Processes

Fault in Our Stars (Green, 2012)

Read The book and complete the Family Constructs Grid

Post & Discuss

Fault in Our Stars Book Discussion

Free write # 3 regarding family in crisis or trauma experience due

June 5th

Complete First Family Visit

Family Assessment-this is just a guideline to keep you on track-it is not literally due.

Group Discussion in D2L – Week 3

Read Green (2012) and fill out the family construct grid in relation to Green (2012) located in Module 2. Please note, the grid is only to guide your thinking and discussion posts. Please post your grid and any relevant commentary about which family nursing concepts seem most pertinent.

The focus for this week is the Fault in Our Stars book discussion by John Green. I am providing the following list of questions to jump start the book discussion. You don’t need to answer all of the questions. This is meant to be a free-flowing conversation, and I expect each of you will add your questions throughout the discussion.

Each of you can tell us how you experienced the book and pick one of the questions below to answer if these help focus your thoughts.

1. John Green uses the voice of a teenage girl to tell this story. Why do you think he choose to do this? Was it effective? How would it have been different if he had told the story from a different voice? How does voice relate to family nursing practice?

2. What does the title, Fault in Our Stars, mean?

3. How would you describe the two main characters, Hazel and Gus?

4. How do Hazel and Gus relate to their cancer?

5. At one point in the book, Hazel states, “Cancer books suck.” What is she really meaning?

6. How do Hazel and Gus change, in spirit, over the course of the novel?

7. Why is “An Imperial Affliction” written by Peter Van Houten Hazel’s favorite book?

8. How many of you looked to see if, “An Imperial Affliction” was an actual book?

9. What do you think about the author Peter Van Houten?

10. Why it was so important for Hazel and Gus to learn what happens after the heroine dies in the An Imperial Affliction?

Week 4

June 6

Annotated Bibliography

Read syllabus for assignment instructions. Below are several reputable websites that explain how to prepare an annotated bibliography. https://guides.library.cornell.edu/annotatedbibliography

http://library.ucsc.edu/ref/howto/annotated.html

https://owl.purdue.edu/owl/general_writing/common_writing_assignments/annotated_bibliographies/index.html

Annotated Bibliography

June 12th

Please upload your Annotated Bibliography. 

Review and provide feedback for two individual’s Annotated Bibliography.

Incorporate the feedback you receive from your peers into your final Annotated Bibliography.

Week 5

June 13

Family Chronic Illness Experience

Family Construct

Share examples from the book to describes Denham’s Core Processes

Genetics & Genomics

Genova (2009) Still Alice

Read the book and complete the Family Constructs Grid

Post and Discuss

Kaakinen (2018) Ch. 10 & 11

Denham (2015) Ch. 8, 9 & 13

Svavarsdottir (2006)

Alzheimer’s disease fact sheet:

http://www.nia.nih.gov/alzheimers/publication/alzheimers-disease-genetics-fact-sheet

Bennet (2008) This is a very complex and technical article. Read through it for the general ideas presented about the history and uses of genetic mapping.

Family Coping with Chronic Illness

Family Suffering

Still Alice Book Discussion

Free Write # 4 regarding

family during a chronic illness experience

June 19th

Complete Second Family Visit

Family Intervention – this is just a guideline to keep you on track-it is not literally due.

Group Discussion in D2L – Week 5

1. Svavarsdottir conducted an integrative review about Nordic families with children who are chronically ill. Three exemplar family cases were described. How can nurses be empathetically connected to these families? In Figure 1, Svavarsdottir (2006), shows how family daily activities, family relations and family health are interconnected. Describe how the family’s quality of life is affected if one or more of these 3 factors were hindered. What may be some suggestions to help these families boost their quality of life? Feel free to share any experiences in your career where you were empathetically connected to a family and helped boost their quality of life.

2. From your readings and your own experience, identify and discuss five needs of families during a crisis experience.

3. Develop a three generation pedigree to assess your personal family history information using the following website https://phgkb.cdc.gov/FHH/html/index.html The pedigree should represent three generations (student, parents, grandparents). Complete your family history, save it, and view your history grid and genogram. Share your insights into your family health with your group (you do not need to post the pedigree itself).

4. The Bennet article is a helpful resource for pedigree and genogram symbols when you start diagramming genograms in Module 3.

5. Read the genomics case study and Alzheimer’s fact sheet.

Module 3

Week 6

June 20

Family Assessment & Interview

Denham (2015) Ch. 4 & 5

Review Kaakinen (2018) Ch. 5 & 8

Duhamel, Dupuis, & Wright (2009)

Family System Strengths Stressors Inventory pdf on D2L

Family Assessment

and Interview

Family Assessment and Interventions in Practice

Complete Third Family Visit

Family Evaluation -this is just a guideline to keep you on track-it is not literally due.

Group Discussion in D2L – Week 6

1. What is your perspective on key elements of family assessment, based on your text readings? Develop and post the family interview guide you plan on using for the family interview. What underlying framework supports your interview guide (Calgary Family Assessment Model (CFAM), described in Wright and Leahey A Guide to Family Assessment and Intervention, Family System Strengths Stressors Inventory (FS3I)? See PDF attachment on D2L

2. Discuss family assessment in your groups. Discussion may include why family assessment is important or how assessment approaches and structure may differ across settings. Discuss barriers, personal or institutional, to engaging in family assessment.

3. Create and upload the Family Nursing Tools:  Genogram, Ecomap, Circular Conversation, and Attachment Diagram.  {Make sure the name of your family members are changed to protect their identity. 

Module 4

Week 7

June 27

Family Assessment and Interventions in Practice

Family Interventions

Review Kaakinen (2018) Ch. 10 & 11

Denham (2015) Ch. 11, 14 & 15

Wiegand (2008)

Review Video in Module 1: Simulation SEE Model

Video: Debriefing SEE Model with Family Constructs and Family Nursing Actions

Refer to the following chapters to identify nursing interventions:

Kaakinen (2018) Ch. 12-17

Denham (2015) Ch. 10, 11, 12, 13, & 14

Family Level Nursing Approaches

Upload draft Family Nursing Project into discussion thread this week

Please upload your Family Nursing Project.

Review and provide feedback for two individual’s Family Nursing Project.

Incorporate the feedback you receive from your peers into your final Family Nursing Project paper.

Module 4

Week 8

July 4

Family Nursing Policy

Review Denham (2015) Ch. 12

Family nursing interventions and approaches

Family Nursing Project due July 10th

July 10th is the last day to submit graded assignments.

Group Discussion in D2L – Week 8

1.

2. 1. Based upon your readings and your family interview paper experience, what policies (community, institution, statewide, nationwide, global, unit-based, etc.) would you want to put into practice to support the use of the family nursing interventions?

2.

3. 2, Consider your readings and discussions this semester (textbook, personal annotated bibliography, articles, postings, etc.). What family nursing interventions/approaches do you propose to support the family health and illness experience and advance family nursing practice?  Post at least 5 nursing interventions/approaches (include citations and references).

3.

4. 3. Choose a policy at your institution and review it from a family friendly perspective. What did you see? Are there improvements you could suggest?

4.

5. 4. Contact your risk manager or quality and safety nurse to learn whether or not family is used as an indicator within your institution. If yes, find out why and how the institution is measuring the family indicator. If no, propose why the institution needs to focus on family and how a family focused nursing practice could be implemented.

Health Care Needs for
the 21st Century
Patricia K. Young ● Linda L. Lindeke

C H A P T E R 1

C H A P T E R O B J E C T I V E S

1. Identify global trends linked with nursing practice.
2. Describe changes in global demographics and how they influence health.
3. Define vulnerable population, health disparities, health equity, and social determinants of health.
4. Analyze gaps between current health care trends and individual, family, and societal health and

illness needs.
5. Explain links among individual, family, community, and population health and illness experiences.
6. Explain the role of the nurse in family care coordination.

C H A P T E R C O N C E P T S

● Environments of care
● Globalization
● Health disparities
● Health equity

● Population health and illness
● Social determinants of health
● Urbanization

Introduction

Change is inevitable. Florence Nightingale, the founder of modern nursing practice, was a
nonconformist who challenged a man’s world. In the mid-1850s, nurses were largely drawn
from the poor, were unskilled, and were often viewed as immoral persons. Refined, well-
to-do, and educated women did not put themselves in situations in which their character
might be called into question or do work viewed as beneath their societal class. Nightingale
was willing to forfeit her family’s support, if necessary, in order to do the work she believed
she was called to do. She cared for the social good, and is described as a reformer working
to redesign the way nursing was practiced and a leader who questioned the status quo of
the day. Everywhere she went, change followed. In fact, her work might be viewed as a
fight for change.

Have you ever wondered about the forces that drive nursing practice today? Have
you questioned whether current procedures and methods might in future generations
appear foolish or even wrong? It can be uncomfortable to question tradition. Nursing
has focused on patient needs and built practice around the individual. As care became

1

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more complex, seeing the needs of the whole person became difficult. Individual medical
professionals concentrated on their part of the human system rather than the whole.
Who sees the whole person as they really are? Who tends to the holistic care needs of
the person? Where does family fit into this picture?

Sometimes students and nurses agree that family is important but are not sure how to
approach these connected relationships in their practice. Sometimes families are viewed as
disruptive, in the way, or extra burdens in already too busy days. Throughout this book
the ideas of thinking family and family-focused care are explored and some new ways of
thinking are introduced. This first chapter provides background to help identify some rea-
sons why families need to be respected and included in the care of individuals.

Understanding Global Trends and Their Health Effects

Because the care of individuals and families does not occur in a vacuum, nurses need to
be informed about the bigger world systems that influence where they work and the ways
health care costs get paid. For instance, nurses often lack clear understandings about the
costs of health care services and about the laws and guidelines that influence reimburse-
ment or payments. They seldom consider the limits of various health care payment sys-
tems (e.g., Medicare, Medicaid, private insurance, universal health care) as a student or
in practice.

Nurses must fundamentally understand—at their nursing core—that health and illness
are a family affair and that where individuals live and who they live with influence health
status and illness or disease management. Unique sets of individual circumstances give
meanings to every situation. Individuals are situated in families that provide background,
history, and lived stories that reflect their lives. Families are situated in social groups or
networks that make up communities—these provide the lenses for understanding the larger
world’s similarities and differences. These provide individuals with ways to view their
health and illness. Health professionals are learning more about ways in which these larger
contexts or worlds or environments influence wellness and disease. Things that shape or
impinge on the family (e.g., resources, time, relationships, culture) affect health and illness
of individual members. Nurses have unique opportunities to help others understand these
global influences on local life.

Science and Technology

Science and technology are huge drivers of global change and have greatly developed our
understanding of health and illness. Health professions science, including nursing science,
has generated multiple perspectives about health and illness. Florence Nightingale was the
original champion of nursing science, focusing on the effects of environment on health.
Box 1.1 provides a brief biography of Florence Nightingale. Starting with Nightingale’s
work, research has shown us that health is determined not only genetically but also by
the environment, which has considerable influence. Her work greatly revolutionized ideas
about the ways nursing should be practiced. Maybe we should ask: What would Florence
Nightingale do if she faced the science and technology of this time? Would she accept things
as they are or would she challenge those in leadership and suggest some innovative
approaches to the care needs of today’s populations?

Health care–related knowledge has greatly influenced health care professionals’
education—shifting the focus from memorization and merely becoming informed to being

2 CHAPTER 1 ● Health Care Needs for the 21st Century

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able to access information, analyze it, and make critical decisions about its use (Frenk
et al., 2010). Nurses need skills to search for scientific evidence about the effectiveness of
care or interventions and identify the best ways to alleviate problems. Evidence-based
practice is the language used as nurses and others determine the best course of action to
care for a particular disease. Table 1.1 provides the progression of steps used in imple-
menting evidence-based practice.

CHAPTER 1 ● Health Care Needs for the 21st Century 3

BOX 1-1

Florence Nightingale

Florence Nightingale (1820–1910) is considered to be the founder of the nursing profession and
sets a fine example for nurses and all who wish to improve world conditions. She used scientific
thinking to lead changes in health and illness care. Unusual in Victorian times, she considered the
environmental effects on health and emphasized hygiene and good nutrition. During her long life
she looked at poverty and disease scientifically and holistically, laying the foundation for modern
methods of education and practice. She used statistics to prove her theories and was highly skilled
in working with community and political leaders for social reform and public policy advocacy. In
her day much of the sick care took place at home and she wrote letters, articles, and books
containing detailed instructions for creating nutrition and healing environments. She continues to
be a powerful role model, especially because of her effective ways of promoting the empowerment
of women to activism for the poor and neglected in society.

TABLE 1-1 Moving Forward in Evidence-Based Practice

The first step is always to develop a clear question about what you want to know. Without a question
to clearly guide your investigation, you will not be able to secure the forms of evidence needed to
identify the best nursing practices. A search must consider differences between good and bad
information and identify the highest level of evidence.

1. Define and clearly articulate the information needed to answer a specific question. If your question
pertains to family nursing, then you must be sure to include the word family in your search.

2. Identify and choose appropriate sources of information relevant to the identified question. You may
limit your search by years, journals, language, or other factors. A reference librarian can assist you.

3. Develop and use clear and effective search strategies using predetermined terms. These terms
need to be linked with your question.

4. Locate and retrieve all information that appears relevant to your question. At first you gather
everything that seems connected to the question you have asked.

5. Appraise the information retrieved and evaluate its usefulness. You will usually want the latest
information that comes from the most credible sources.

6. Organize and analyze the information pertinent to your specific question.
7. Determine if any important facts relevant to the question asked are still missing (e.g., economics,

legal, social, policy). If important aspects are missing, then you will need to do additional searches.
8. Synthesize or combine all of your findings in ways that best answer the initial question asked.
9. Determine the strength of the evidence used to answer the question asked. The strength of

evidence rests in the quality and type of research efforts used.
10. Decide whether evidence identified is strong enough to alter practice or if more information is still

needed.

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Today nurses cannot simply know the steps of a procedure or intervention; they
also need to know the intended effects and outcomes. Advances in communication,
technologies, and global knowledge can help nurses consider the best ways to use
evidence to solve problems. They need to consider several factors that can influence
health:

• Environmental or geographical influences
• Where care is delivered (e.g., home, hospital, nursing home, health department)
• The places where individuals and families live

The knowledge and information explosion has not only advanced science and technol-
ogy, but also influenced the ways individuals and families seek health care services and in-
teract with health care professionals. Medical knowledge is no longer isolated, but is readily
available to all persons through the Internet. Some people are very knowledgeable about
health and illness, but others are clueless. Many know their rights, ask questions, make
demands, have high expectations, and want to be partners in their health care experiences.
Nurses need effective communication, collaboration, and advocacy skills to partner effec-
tively with those seeking care (Hook, 2006; McCloughen, Gillies, & O’Brien, 2011;
Mitchell, Chaboyer, Burmeister, & Foster, 2009).

Natural Resources and Environment

Environmental changes, whether natural or produced by civilization, are increasingly
being linked with health and illness. A new awareness of humankind’s effect on the
planet’s food, water, energy, and environmental resources is emerging. According to the
Natural Resources Defense Council (NRDC, 2011), a nonprofit environmental action
group, climate change affects health in six ways: air pollution, extreme heat, infectious
disease, drought, flooding, and extreme weather. Children, the elderly, and the poor are
most vulnerable to health problems due to climate change (United States Global Change
Research Program, 2009). Where people live matters! For example, air pollution is wors-
ened in rising heat. When the number and intensity of “bad air” days are increased,
threats for persons with asthma and other respiratory tract conditions are also increased.
Box 1.2 provides information about ways families can protect themselves against air pol-
lution health threats.

4 CHAPTER 1 ● Health Care Needs for the 21st Century

BOX 1-2

Tips to Protect Against Air Pollution Health Threats

● Check news reports on the radio, TV, or online for pollen reports or daily air quality conditions.
Or visit the Environmental Protection Agency’s Air Now Web site [http://www.airnow.gov/] for
air quality information.

● If you or someone in your family has allergies or asthma, on days when pollen or ozone smog
levels are high, minimize outdoor activity and keep your windows closed.

● Shower after spending time outdoors to wash off pollen that may have collected on your skin
or hair.

● Wash bedding and vacuum frequently to remove pollen that may settle in sheets and carpets.

Source: Natural Resources Defense Council (n.d., Air pollution). Adapted from Hunter, A., & Crabtree, K. 2011.
Global health and international opportunities. In J. M. Stanley (Ed.), Advanced practice nursing: Emphasizing
common roles (3rd ed., pp 327–350). Philadelphia: F. A. Davis.

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Global Infectious Disease Threats

According to the World Health Organization (WHO, 2011), in 2008, 4 of the top 10 causes
of death in low- and middle-income countries were infectious diseases compared to 1 of the
top 10 in high-income countries. New and reemerging infectious diseases pose threats to human
health globally and cause costly periodic disruptions in trade and commerce, political instability
in developing nations, and tensions in developed nations (National Intelligence Council [NIC],
2000). The threat of increased infectious diseases is influenced by several factors:

• Food contamination, potentially from worldwide importation of food products
• Infections acquired while hospitalized (nosocomial infections)
• Increased use of antibiotics causing resistant organisms
• Increases in international travel
• Immigration
• Return of military or other personnel from overseas assignments (NIC, 2000)

Infectious Illness

The most common infectious illness to affect travelers is diarrhea from foodborne or wa-
terborne organisms (WHO, 2012a). Some vaccines are available that can be taken before
travel to prevent an infection. In the past decade, increased travel resulted in national con-
cerns about epidemic bedbug infestations at low-budget and upscale hotels. However, bed-
bugs are found everywhere (e.g., airplanes, subways, movie theaters, locker rooms, stores,
even hospitals). They reproduce quickly, can live for a long while without feeding, and
even the cleanest persons are susceptible. These bugs can be transported into households
in luggage and then affect entire families.

New strains of influenza get introduced through exposure to infected individuals. Those
with severe influenza and coexisting chronic illnesses may require admission to the intensive
care unit and are at increased risk of dying. Nurses need to be prepared to identify and in-
tervene with those at greatest risk for poor health outcomes and consider implications for
family, household, and community risks.

Use of Antibiotics

A longtime concern is the inappropriate use of antibiotics to treat infections that have re-
sulted in the growth of microorganisms resistant to drug therapy (Lehne, 2013). One ex-
ample is multidrug-resistant tuberculosis (TB). According to the WHO (2012b) Tuberculosis
Fact Sheet, about 8.8 million new and relapsed cases of TB were reported in 2010. In 2010,
an estimated 1.4 million people died from TB. Dr. Paul Farmer details his experience of the
TB epidemic among the people of Haiti in the book Mountains Beyond Mountains (Kidder,
2003). Rather than base his treatment of drug-resistant TB on the approach of utilitarianism
(i.e., what is good for the many outweighs what is good for the one), he focused on treating
TB one case at a time—working with the individual and the family living with the infected
person. Evidence showed that caring for the one person and those sharing the dwelling,
rather than the many, positively influenced health outcomes. His results altered conventional
thinking about the best way to treat TB when resources are limited.

Proper use of antibiotics includes the following recommendations:

• Use antibiotics when prescribed.
• Complete the full prescription.
• Throw away unused drugs.

CHAPTER 1 ● Health Care Needs for the 21st Century 5

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• Do not share medicines.
• Use antibiotics only for bacterial illnesses, not viral infections.

It is estimated that as many as 50% of prescriptions written for antibiotic use may
be unnecessary (Hicks, 2013) and that antibiotics are so widely prescribed because
patients demand them. The result is the growth of antibiotic-resistant bacteria. For
example, infection with MRSA (methicillin-resistant Staphylococcus aureus) has long
been known to be a threat to the sick and the elderly and continues to be a growing
problem. A new form of superbacteria known as CRE (carbapenem-resistant Enterobac-
teriaceae), a life-threatening bacterium resistant to most antibiotics, is also a growing
problem (Centers for Disease Control and Prevention, 2013). CRE appears to have the
capacity to transfer resistance to other bacteria that normally would not be much of a
threat. This bacterium is easily transferred through physical contact, is often found in
hospitals and long-term care facilities, and is a risk for those in compromised physical
conditions. Family members can introduce infectious diseases to each other if they are
not aware of good hand washing and isolation techniques.

The spread of infectious diseases results from changes in human behavior—lifestyle
changes, such as those occurring at the individual and family level. Nurses, as educators,
can play huge roles in facilitating lifestyle changes linked with wellness and prevention.

The Global Economy, Globalization, and Health Care

We often hear the term global economy in the world of business and learn about its influ-
ence on the daily lives of people from various nations. The term globalization refers to the
increasing commercial trade among countries and includes exchange of ideas, language,
peoples, and popular culture. Globalization implies that human exchanges occur in ways
that are increasingly more integrated, open, and without borders.

Global threats from infectious diseases are serious world health concerns. For example,
ebola has been known since the 1970s but recent outbreaks have spread and have had high
mortality in low-resourced countries. However, in countries with good health care systems,
early identification, tracking contacts, targeted isolation precautions, and excellent care of
infected individuals has produced good results. Disease spread is no longer just confined
to small communities, but presents global and international challenges.

Globalization and the Medical Workforce

Globalization in health care is also occurring. The U.S. Bureau of Labor Statistics recently
reported that the job growth in the health care sector accounts for one out of every five jobs
created. In 2010, about 209,000 primary care physicians or about one third of all U.S. physi-
cians managed 51.3% of all clinical visits (Agency for Healthcare Research and Quality
[AHRQ], 2011). About half the business went to one third of the physicians—those in pri-
mary care. According to the American Academy of Family Physicians, primary care is defined
as the care provided by physicians specifically trained for and skilled in comprehensive first
contact and continuing care for those with undiagnosed symptoms, signs, or concerns. This
care form includes health promotion or maintenance, disease prevention, education, diag-
nosis, and treatment of acute and chronic illness. Primary care occurs in a variety of settings
(e.g., physician office, inpatient care, long-term care, ambulatory care). Others also provide
primary care (i.e., nurse practitioners, physician assistants). The need for registered nurses is
expected to grow from 2.74 million in 2010 to 3.45 million by 2020 (Squires, 2012). In
2011, the number of nurse practitioners reached 180,233 and some projections expect that

6 CHAPTER 1 ● Health Care Needs for the 21st Century

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number will double by 2025 (Pearson Report, 2011). Likewise, the number of physician as-
sistants is likely to continue to grow, with projections reaching 127,821 by 2025 (Hooker,
Cawley, & Everett, 2011). Geographical distribution of primary care providers is uneven,
with far more of these primary care professionals practicing in urban than rural regions.

Nurses share similar educational standards, but such factors as educational preparation,
regulation, credentials, licenses, entry into practice, and clinical practice vary considerably
among nations. Across nations, pathways for becoming a nurse, practice expectations, and
care delivery vary. For example, midwifery is viewed as a separate profession in Australia,
but it is a nursing specialty in the United States. Foreign-educated nurses often face huge
challenges as they transition into U.S. health care employment settings (e.g., differences in
practice, language barriers, procedures for medication administration, use of technology).

Levels of Nursing Education

Interest in having nurses attain higher levels of education continues to grow with the aim
that the nursing force’s knowledge and skill level will keep increasing. Dr. Catherine Gilliss
was one of the first nurse leaders to sound the alarm that nursing practice should include
the family unit and not just the individual (Box 1.3). Yet, little research has been done to
determine the presence of family nursing in nursing programs. An older U.S. study of Bach-
elor of Science in Nursing (BSN) programs found that students were inclined to study some
things about family nursing, but the amount, type, and content varied widely (Hanson,
Heims, & Julian, 1992). A Canadian study (Wright & Bell, 1989) had similar findings
with gaps found in family intervention and interview skills. A more recent study of graduate
education for family nurse practitioners found that while these students obtained some ed-
ucation about family in their core courses, students were not usually expected to complete
family assessments or plan interventions for the family unit when taking clinical practicum
courses (Nyirati, Denham, Raffle, & Ware, 2012).

CHAPTER 1 ● Health Care Needs for the 21st Century 7

BOX 1-3

Family Tree

Catherine Gilliss, DNSc, RN, FAAN (United States)

Catherine Gilliss is the Helene Fuld Health Trust Professor, Dean of Duke University School of Nursing,
and Vice Chancellor for Nursing Affairs at Durham, North Carolina. She is a graduate of Duke’s
undergraduate nursing program and is the first alumna from the School of Nursing to hold the position
of Dean. Dr. Gilliss earned a Bachelor of Science in Nursing degree from Duke and a Master of Science in
Nursing degree from the Catholic University of America. After earning an adult nurse practitioner (ANP)
certificate from the University of Rochester, she went on to the University of California at San Francisco,
where she earned a Doctor of Nursing Science (DNSc) degree and completed a postdoctoral fellowship.
Dr. Gilliss also holds honorary degrees from Yale University and the University of Portland. Her illustrious
career has been devoted to graduate nursing education, with a scientific focus on the family and
chronic illness. Her research has investigated the experience of family members in the context of illness;
the impact of innovative models of nursing intervention on situations that affect the family and its
members; and the development and synthesis of scientific work in this area of nursing science. She has
received many awards, including the Yale School of Nursing Medal, and has been recognized by the
International Society for Family Nursing with its Lifetime Achievement in Research Award. Dr. Gilliss’s
contributions to the science of family nursing have revolutionized research in this field and have strongly
influenced care for chronically ill patients and their families. Her scholarly works are considered
groundbreaking and several are preeminent resources for junior and senior nurse scientists.

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Global Spending for Health Care Costs

Worldwide health care costs continue to accelerate, and the distribution of resources is
not always equitable. But how much money is truly spent, what goods and services are
bought, and what characterizes the real quality or value of what is bought are not easy
to determine. In economics, usually scarce quantities produce high demands and high
costs, but adequate or abundant supplies decrease demand and cost. These principles do
not work when it comes to health care costs. Even though the health market keeps
increasing availability, costs have not been reduced. Health care spending and costs are
a result of millions of private, corporate, employer, and government decisions. The cost-
benefit ratios of medical expense compared to clinical outcomes are difficult to evaluate.
The supply and use of diagnostic imaging devices are important, but the cost and use of
technologies vary greatly (Squires, 2012). Table 1.2 provides a view of the use and cost
for two machines.

Growing evidence shows that well-educated nurses have an impact on health care out-
comes and costs, but nurses are often at risk for being cut during an economic downturn
(Kavanagh, Cimiotti, Abusalem, & Coty, 2012). Hospital care is a large part of the U.S.
health care system and nurses are the largest direct care providers. Adequate nurse staffing
improves safety and quality, decreases infection rates, lowers mortality rates, and decreases
adverse events, length of stay, and other things. Despite these savings, nurses are a large
expense to hospitals. Models that demonstrate the value of nursing care as a financial in-
centive need to be implemented and effectiveness of nursing care made visible to society
(Kavanagh et al., 2012).

Global Changes in Demographics

Major demographic changes are occurring worldwide, especially in the more advanced
nations. Population growth is slowing, numbers of youth are decreasing as a result of lower
fertility rates, and numbers of elderly are rising as people live longer. Migration, immigra-
tion, and global travel are part of this picture. Families are moving away from the villages
and cultures of their youth. Global changes not only affect the workforce, economics, and
politics of individuals living in different geographical regions, but they also influence the
health and illness concerns of families and the larger society.

8 CHAPTER 1 ● Health Care Needs for the 21st Century

TABLE 1-2 Diagnostic Imaging Device Use and Cost for Selected Countries

COUNTRY

United States

France

United States

Canada

CT, computed tomography; MRI, magnetic resonance imaging.
Source: Adapted from Squires, D. A. (2012, May). Explaining high health spending in the United States: An international
comparison of supply, utilization, prices, and quality. Issues in international health. The Commonwealth Fund pub. 1595,
Vol. 10. Retrieved May 6, 2012 from http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/
2012/May/1595_Squires_explaining_high_hlt_care_spending_intl_brief.pdf

NUMBER OF MACHINES
PER 1 MILLION
POPULATION

25.9 MRI machines

6.5 MRI machines

34.3 CT scanners

13.9 CT scanners

NUMBER OF
EXAMINATIONS PER
1,000 POPULATION

91.2

55.2

227.9

125.4

AVERAGE COST
PER EXAMINATION

$1,080

$281

$510

$122

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Changing World Demographics

Trends in birth, death, migration, and immigration patterns point toward population growth
in Asia and Africa that will result in those places becoming the “youthful” areas of the world.
The population in developed parts of the world (e.g., United States, Canada, European coun-
tries) will effectively age so that people under age 30 will make up less than one third of the
population (NIC, 2008). Populations of India, China, and countries in sub-Saharan Africa
are expected to grow the most (NIC, 2008). Countries such as the United States, Canada, and
Australia, with high immigration rates, will also grow, but at lesser rates. Generally, life
expectancy at birth has increased steadily over past decades so that, in 2009, the average
life expectancy at birth for the global population was 68 (WHO, 2011). In 2009, the lowest
life expectancy at birth was 47 years (in Malawi) while the highest was 83 years (Japan and
San Marino). Aging populations can also mean decreased family incomes as huge numbers of
people retire (NIC, 2008). More resources will likely be needed to support pensions and health
care costs of the elderly. This expense could mean fewer dollars are available for education,
care of the environment, and national defense. Furthermore, an implication of a “youth bulge”
in many parts of the undeveloped world is increased risk for the emergence of political violence
and civil conflict (NIC, 2008). The World Health Organization (2009) predicts that men
between the ages of 15 and 60 years have much higher risks of dying from injuries, violence,
conflict, and heart disease than women in this age category.

Effects of Place on Health and Illness

Where people live matters. Living and working conditions such as overcrowded housing,
lack of adequate sanitation, and unsafe working conditions are called social determinants
of health. These factors arise from the social or physical environment and can lead to health
problems. Living conditions influence not only individual health and illness but also health
of the family unit. Young adults from rural communities keep moving into urban dwellings.
Small rural communities are often populated with the very old and very young, groups
more susceptible to ill health and identified as vulnerable populations.

Urbanization partly contributes to a widening gap between the rich and the poor. Poverty
is extensive throughout the world with major concerns still linked with Africa, Asia, and other
places. Over half the world’s people live on $2.50 or less per day, and 27% to 28% of children
in southern Asia or sub-Saharan Africa are underweight or stunted in growth (Shah, 2010).
According to the WHO (2011c), around the world, 33 countries have more than 80% of their
people living in urban areas. Worldwide, one in three urban dwellers lives in slums or poor
settlements that can lead to increased health inequities and broad health disparities. As pop-
ulation demographics change, the risks for various health problems affecting individuals and
families also change. For instance, morbidity and mortality rates from infectious diseases (e.g.,
pneumonia, diarrhea) are higher in undeveloped countries. As countries develop, more
improvements in medical care, fewer deaths from easily curable diseases, and public health
interventions (e.g., immunizations, clean water, sanitation) occur (WHO, 2009). This change
often means that morbidity and mortality statistics in developed countries are most likely the
result of noncommunicable diseases (e.g., cardiovascular disease, cancers).

Traditional risks for disease tend to affect low-income populations and are linked with
poverty, inadequate nutrition, unsafe water, poor sanitation and hygiene, unsafe sex, and
indoor smoke from solid fuels (WHO, 2009). These risks are in sharp contrast to problems
that threaten health in higher-income countries, where modern disease risks include over-
weight, obesity, physical inactivity, tobacco, and substance abuse. Some nations are fighting
both traditional and modern disease risks as length of life increases and noncommunicable

CHAPTER 1 ● Health Care Needs for the 21st Century 9

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10 CHAPTER 1 ● Health Care Needs for the 21st Century

BOX 1-4

Family Tree

Shirley Hanson, PhD, RN, ARNP/PMHP (United States)

Dr. Shirley Hanson is professor emeritus from Oregon Health Sciences University, School of Nursing.
Dr. Hanson has written, coauthored, and edited more than 150 books, chapters, articles, CDs, and
various other reports pertaining to families and nursing. Her work centers on fathers/fatherhood,
single-parent families, and family assessment and intervention. Her work on the future of family
nursing in the United States has been critical to the development of family nursing as a discipline
and has contributed to the body of knowledge in family social science. Dr. Hanson’s co-authored
textbook for undergraduate and graduate nursing students, Family Health Care Nursing: Theory,
Practice and Research, first published in 1996, is now in its fifth edition. The text has been translated
into Japanese and Portuguese and has been adapted by a group of family nurses in Scotland.
Dr. Hanson’s many contributions to nursing in the area of family were recognized when she was
inducted in 1984 as a fellow in the American Academy of Nursing (FAAN), one of the highest honors
for nursing leaders in the United States. In 2001, Dr. Hanson was inducted as a fellow of the National
Council on Family Relations in recognition of her many contributions in service, publications,
research, and practice with families and family social science. In 2007, Dr. Hanson was recognized by
the International Family Nursing Conference in Bangkok, Thailand, with the Lifetime Achievement
Award for her distinguished contribution to family nursing.

diseases become a major cause of death (WHO, 2009). Risks exposure can be addressed
with public health interventions. For example, enacting strong tobacco-control policies or
air pollution public health policies helps avoid high levels of disease. Nurses who under-
stand large environmental and place-linked risk factors are prepared to improve popula-
tion, family, and individual health. Dr. Shirley Hanson authored one of the leading nursing
textbooks used by students around the world to study family nursing (Box 1.4).

Changing Family Demographics

Observing diverse families provides insight into the ways families and relationships change
over time. Some changes are now seen in mother and extended family roles, the time children
spend in school, the age at which retirement is expected, and the years lived alone. Issues such
as fewer two-parent families, high divorce rates, cohabitation, remarriage, mixed-race
marriages, and civil unions have altered some family foundations that stood for generations.
Family alterations could cause both negative and positive results. New ideas about family
households, intergenerational care forms, housing and living arrangements, more integrated
family values, benefits of intergenerational households, and wider sustainable networks arising
from different partnerships could arise. Societal changes often evolve from the needs of indi-
viduals and families. Family responses to societal trends influence social and public policies.
Factors such as taxation, education, social institutions, travel, and housing are linked with
families. A nation’s health is solidly vested in its people and families.

Presently, a definition of the family from an international perspective is not available. This
inability to define family in global terms presents problems in terms of immigration, migra-
tion, and even health care. Understanding family offers a way to understand the larger units
of societies. Today, many family units do not live under the same roof. Growing numbers of
people are living alone (e.g., single room occupancy hotels, assisted living facilities, nursing
homes). Social isolation for those who are frail, elderly, poor, and vulnerable presents con-
cerns. In the United States, more adult children currently live with their parents than at any

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time since the 1950s. The term accordion families is used to describe the ways members move
in and out of households. The 2010 census data found that 27% of people live in one-person
households compared to 25% in 2000 and only 13% in 1960, trends not seen in less devel-
oped countries with families that are primarily traditional extended family households.

Racial, ethnic, gender, and other factors linked with family types are important consid-
erations when considering demographics. In 2012, in the United States, Child Trends
(2013) reports that 33% of black children lived with two parents as compared to 85% of
Asian children, 75% of white children, and 60% of Hispanic children. However, 2010 cen-
sus data indicate that 66% of all children under 18 years are living with two parents, down
from 69% in 2000. Data show that 40.4% of co-resident grandparents had primary care
responsibility for grandchildren with 20.2% of these grandparents living in poverty and
about 14% having English language challenges (Murphey, Cooper, & Moore, 2012). The
2010 census identified that the median age at first marriage for men was 28.2 and women
26.1, a long-time upward trend noted since the mid-1950s. Additionally, the overall per-
centage of those married was 48.4% in 2010 compared with 51.7% in 2000. Finally,
recorded same-sex households increased from 0.3% in 2000 to 0.6% in 2010, a small per-
centage increase, but this growing sector raises questions about the ways people identify
family. In the United States, family type often has profound effects on the family’s income
and each member’s access to health insurance.

Family Migration

Families have always migrated in one sense or another. Today’s families often relocate for
similar reasons as in the past. Employment opportunities, income, and the need to care for
an ill family member are often leading reasons. Migration may vary based upon personal
factors, but most people move where increased opportunity seems likely. It is common to
find committed couples or families that live apart from each other. The geographical prox-
imity of family has implications across the family life cycle, as nearness and distance are im-
portant factors for child and elder care. An interesting factor linked with parental and elder
care has to do with siblings; siblings are more likely to live further away from parents than
only children (Rainer & Siedler, 2010). This factor could influence parental caregiving roles.

International Families

Changes in international families suggest trends to be considered. For example, fertility
rates are a key aspect of family structures and are declining worldwide (Central Intelligence
Agency [CIA], 2012). Birth rates indicate that total population is increasing to more than
replace the parental generation. Births range from an estimated high of 7.5 children per
woman in the country of Niger to a low of 0.78 births per woman in Singapore. The United
States has an estimated fertility rate of 2.06 children per woman (CIA, 2012). Many
humanitarian projects aim to support child spacing to improve maternal and child health
outcomes and potentially create more stable families. Marriage rates, cohabitation, and
divorce can affect their adequacy in meeting member health and illness needs. Population
customs and characteristics influence unique family needs. Religious beliefs, personal
values, and international traditions also affect families (Fig. 1.1).

Wealth and Health

Growing evidence suggests that wealth and health go together (Braveman, Egerter, & Barclay,
2011), and it is widely accepted that higher incomes mean longer lives. Therefore, families

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with greater economic resources are most likely to have greater health and a higher quality
of life. For example, in 2009, persons in families living in the poorest communities had 1,420
hospitalizations per 10,000 population for all ages combined, compared with 1,189 of those
living in wealthier communities (Healthcare Cost and Utilization Project [HCUP], 2011).
Being able to afford health insurance and medical care is not the only factor that influences
health and well-being. Family income influences the neighborhoods where families live, level
of safety in daily lives, access to good education, availability of nutritious food, access to
various forms of leisure activities, and member health. Standards of living vary from place
to place across the globe. In 2012, the Department of Health and Human Services Poverty
Guidelines identified that an annual income below $23,050 for a U.S. family of four is
below the poverty level. In 2007, the richest 1% of U.S. households held one-third of the
nation’s total wealth and the richest 5% held more than half (Kennickell, 2009). Links
between wealth and health begin early in life. Low birth weight is linked to developmental
delays and challenges and chronic conditions. Children born in lower income families have
higher rates of asthma, heart conditions, hearing problems, and digestive disorders (Braveman
et al. 2011). Health equity is a concern when some have so much and others so little. Thus, it
is important to realize that equality can be more of a myth than a reality for many individuals
and families.

Health Care Trend Influences on Nursing Practice

Current health care trends have critical implications for individuals and families; those
of concern to the larger society or population also affect individuals and families. Trends
also shape the ways in which health care services are made available, how these services
are provided, and the clinical practices of the workforce. Even without being aware
of personal connections, we are all more closely related than we realize. People in
small towns or rural communities easily recognize these connections as extended family
lives nearby, but those living in urban settings may not. In today’s global society, the
lives of all people and places are interconnected, interdependent, and complex. Nurses
need to be aware of these relationships and identify the health and illness implications
of an intricately linked world even when things do not appear directly related at a
point in time.

12 CHAPTER 1 ● Health Care Needs for the 21st Century

FIGURE 1-1 An international
family.

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Gender and Health Risks

Gender is an issue of concern when it comes to health. Women’s rights are an important
way to understand personal well-being. In the United States, women’s suffrage fought for
and only gained the right to vote in 1920. An affirmative action policy that covered
discrimination based on gender was added to a previous 1964 Civil Rights Act in 1967.
This policy ensured American women and minorities the same educational and employment
opportunities as white males. During the 1960s and 1970s, the feminist movement waged
war for women’s rights in the workplace. By the late 20th century and early 21st century,
greater equality has spread with pay for men and women becoming more equal. In the
United States, the American Civil Liberties Union continues to fight for equal opportunity
for women in areas of education, the workplace, gender-based violence, and harms to
women in the criminal justice system. Nursing, a largely female discipline, has also been
affected by these long and continued battles.

It is now widely understood that when nations lack health care infrastructure and op-
portunities for a full education, the poor and women suffer the most. For thousands of
years, gender roles have been socially constructed and beliefs aligned with biology have
driven religious and traditional practices. Gender inequality often means that women are
unable to overcome poverty and have less ability to raise healthy and well-educated sons
and daughters. Women worldwide are often the targets of physical and sexual violence,
genital mutilation, and many other forms of cruelty. Poverty is often the fate of women,
who represent two thirds of the world’s poor. Across the globe, gender equality is a battle
still being fought in many places. The battle to improve women’s rights to live full and pro-
ductive lives, decrease maternal health risks, increase choice in family planning, and combat
issues linked with HIV/AIDS and other diseases is still being fought. Nurses can advocate
for gender equality.

Noncommunicable Disease

The focus for many nursing students and nurses has largely been acute care, in which they
attend to patient problems or diseases. In addition, the Hollywood depiction of a nurse as
rescuer in times of critical need doesn’t address the complex family stories linked with
health and illness. According to the United Nations (2012), noncommunicable diseases
cause 36 million deaths worldwide in a decade, a number that accounts for 63% of all
deaths. These conditions often result from cumulative lifestyle factors (e.g., tobacco use,
lack of adequate nutrition, physical inactivity, substance abuse). When individuals and
family units have unhealthy lifestyles, then it is likely that they will have a disproportionate
number of deaths from noncommunicable diseases. Growing numbers of elderly persons
are at risk, 20% or more of the population in developed countries is 60 years of age or
over, and 80% of all deaths are currently attributed to noncommunicable diseases (United
Nations, 2012). If nurses fail to focus on individual and family lifestyles, then the care
needed to support their health and wellness will likely be neglected.

Taking a Proactive Stance

Nurses can take action before something goes wrong. A proactive nurse is concerned about
wellness, health promotion, and prevention, which are strong predictors of health and
illness outcomes, and can help influence the daily lives of individuals and family members.
Proactive nurses can use nursing actions to not only address critical acute needs, but think
beyond the present and help individuals and families prevent future problems. They ask
questions and think outside the box of usual care to address family household, adequacy

CHAPTER 1 ● Health Care Needs for the 21st Century 13

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of supports, availability of needed resources, and access to needed information during care
delivery and they use evidence and competencies to satisfy patient and family needs. Nurses
can help individuals and families by listening, answering questions, becoming partners in
care, and addressing home and community needs.

Noncommunicable diseases should challenge the way nurses think about how nursing
care is organized and delivered. These diseases are linked with lifestyle changes, urbaniza-
tion, and globalization. Costs of these diseases pose economic burdens for individuals,
families, and larger societies related to absenteeism, disability, lost income, and even bank-
ruptcy. Medication costs for some conditions can be equivalent to several days’ wages.
Those without health insurance or with inadequate finances might forfeit the medications
and increase their risks for catastrophic illness or even early death. Thoughtful nurses see
beyond the acute phase, note possible causative factors, and weigh potential needs and
risks linked with discharge. Proactive nurses know that families can greatly influence the
ways individual members manage needed lifestyles at home.

Practicing Nursing and Thinking Family

Nursing practice applies science and art to everyday real-life problems that influence health,
wellness, illness, and disease. It is more than just identifying problems and fixing them; it
is also recognizing that problems exist in larger systems (e.g., households, worksites, social
domains). Nurses help those seeking care find ways to prevent, manage, and resolve prob-
lems. Nurses treat, educate, counsel, coach, minister to, advocate for, direct, assist, and
support. Some of the work of skilled nurses can get done without requiring much critical
thought. However, other nursing actions must be intentional and should include reflection
that evaluates whether what was accomplished is most desirable. Holistic nursing care
considers unique needs and values. Nurses help those seeking care find ways to prevent,
manage, and resolve problems (Box 1.5).

Families as Allies

To communicate effectively with multiple family persons about the needs of a member,
nurses need skills that prepare them to facilitate care that involves the whole of indi-
viduals’ lives. Too often, family support persons are merely handed a patient handbook
with a reading level too high for them to understand or information is given in imper-
sonal ways without considering specific recipient needs. Family members do not always
know what they should ask or expect as they may have never experienced this situation
before. Families do not expect errors or mistakes because they want to believe things
are under control and everyone knows what they are doing. However, family members
are often fearful, extremely stressed, unclear about the complexities linked with a con-
dition, and unclear about what should happen or when. Telling individuals and families
what to expect and when things will happen can create allies who may be helpful in
preventing mistakes along the way and delivering care that better meets needs.

Throughout this textbook, you will find the idea of thinking family is continually used
as a form of reference for caring for every individual met in a health care delivery setting
or system. Nurses who think family understand ways in which the larger social context
and current trends affect individuals, family lives, and family health. These relationships
can be used to inquire about needs, connect with persons, listen, and respond in valued
ways as care is received (Doane & Varcoe, 2005). An important aspect of nursing care is
the time given to hear the voiced needs. Nurses who think family seek the voices of others
and take time to listen.

14 CHAPTER 1 ● Health Care Needs for the 21st Century

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Individuals Are Family Members

When nurses isolate individuals from families, it is like taking an amputee’s prosthesis and
asking him to walk. As students, nurses spend much time learning the science of nursing and
ways to use evidence and become experts at delivering nursing care. But they need to guard
against believing that they are also the experts on what individuals and families perceive that
they need. Nurses need to be willing to hear from individuals and families about their bodies,
lives, and experiences. Great inequities exist and not everyone, even those with the same
diagnosis, seeks or needs care in the same way. Expectations differ and if all care is delivered
in uniform ways without respect for unique needs then critical concerns can be overlooked.

CHAPTER 1 ● Health Care Needs for the 21st Century 15

BOX 1-5

Evidence-Based Family Nursing Practice

Illness Beliefs Model

Creating a context for changing beliefs about illness can be difficult, and these concerns constitute
the foundation of the Illness Beliefs Model. The first thing to consider is the way in which the nurse
meets an individual and the impression formed within the first few minutes of the meeting. Show
genuine interest and desire to collaborate by taking the temperature of the relationship while
preparing for a therapeutic conversation. Knowing the diagnosis alone is not enough; the nurse
must also understand the ways illness has affected lives. It is useful to learn about illness suffering,
beliefs about diagnosis, causative factors, and beliefs about healing and prognosis. Many things can
enter into the experience of living with an illness. An important role of the nurse is to ask questions
that identify actions to be taken. Nurses can also speak the unspeakable, offer alternative ideas, and
offer commendations. If it is possible to use a reflective clinical team, they may offer additional ideas
for families to consider. The family can then respond to the new ideas and identification of any new
beliefs that emerge can be recognized. Recognizing family strengths and acknowledging their
suffering can invite new energy and a positive direction. Immersion in practice with families needs
to be observable. Two things stand out about family practice:

● Expert practice with families needs to be visible, measured, synthesized, and mentored.
● Processes and outcomes of family nursing practice are messy and complicated.

Through intensive immersion at the Family Nursing Unit at the University of Calgary, clinical
scholarship allowed many nurse researchers to examine and describe the family practice. Over
the years, many masters and doctoral students completed practicums in the family unit and
seven doctoral students, one post-doctoral fellow, and two visiting scholars working with faculty
conducted research about family nursing practice. Study findings, in turn, reflected changes in
practice. The term family systems nursing was coined to signify care for the family unit as
opposed to the term family nursing, which had mainly focused on individuals.

The Illness Beliefs Model strongly identifies the strength of beliefs to influence behaviors and
responses to them when it comes to suffering. Beliefs of individuals, family members, health
providers, and society all come into play when an illness diagnosis occurs. Knowledge creation
and knowledge transfer for family nursing practice are still needed. Recommendations for change
require action in several areas: create innovative opportunities for systems changes from the top
down, create family nursing teams and harness their energy for practice changes, learn from the
practice knowledge already identified, and keep your eye on what you as a nurse bring to nursing
practice. Family nursing is first about change in nurses as they become more curious, less
judgmental, and more open to others’ realities.

Source: Bell, J. M., & Wright, L. M. (2011). The Illness Beliefs Model creating practice knowledge in family systems
nursing for families experiencing illness. In E. K. Svavarsdottir & H. Jonsdottir (Eds.), Family nursing in action (pp 15–
51). Reykjavik, Iceland: University of Iceland Press.

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Health and illness occur within the context of daily life, lives that are outside the view
of nurses and other health care providers. A brief visit of 10 to 15 minutes with health care
providers is often inadequate to ascertain all the issues linked with complicated lives and
problems. When nurses think family, they reflect about the connections between individuals
and families. They realize that any health alteration of a member, young or old, affects the
family unit. Nurses who think family recognize that people live connected and interde-
pendent lives and support by family members can vary. Nurses’ attitudes and actions have
potential to shape experiences in negative and positive ways. Families require skills, infor-
mation, and answers to questions to successfully care for individual needs.

Recognizing Family and Community Links in Nursing Care

The culture, tradition, and history of a geographical place influence the lives of those living
there in health and illness. Nurses living or employed in particular geographical areas must
be attuned to the benefits and risks of place that might impinge on health and create risks.

Coordinated Care: An Important Family Nursing Role

Care coordination ensures that individual needs and preferences for health services and in-
formation are met (National Quality Forum, 2010). While not the same, care is sometimes
used interchangeably with terms such as case management and disease management. Table
1.3 shows the differences in these terms and nurses’ roles. Nurses who think family assume
important roles with individuals and families and can take leadership in three important
caregiving areas:

• Care management
• Disease management
• Care coordination

16 CHAPTER 1 ● Health Care Needs for the 21st Century

BOX 1-6

Family Circle

While working as a care coordinator in an inner city community clinic, Nurse Jones has been caring
for Maria and her 2-year-old daughter Natalie for more than a year. Natalie has been admitted to the
hospital three times in the past 6 months because of asthma that did not resolve with ongoing
medications and nebulization treatments at home. These hospitalizations are very costly for Maria,
who has to miss work when Natalie is ill. They are also very frightening for both mother and child.
Nurse Jones has worked with Maria and Natalie to be sure that the medications are correct. Nurse
Jones decides to arrange for a home visit to assist this family in preventing further episodes. When
Nurse Jones arrives at Maria and Natalie’s apartment, she sees that a city bus stop is located right
outside. When looking around the windows in the apartment, Nurse Jones observes that Natalie’s
room is at street level. Maria explains that the noise of the busy street sometimes disturbs their sleep.

1. What do you notice in this situation?
2. Provide two or three alternative explanations for Natalie’s current situation of frequent

admissions.
3. Discuss the case with a peer and compare interpretations. Discuss actions Nurse Jones can

take as she works with this family. Decide on next steps to be taken by the care coordinator.

What resources are available in your community for Maria and Natalie?

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As they navigate health care systems to locate and obtain needed care, individuals and
families can become frustrated with the barriers they meet. Nurses who think family are
able to anticipate these needs and provide guidance about needed resources that might be
in the community. Review the Family Circle case study and use it as an opportunity to
begin thinking about the ways you can include families in your nursing care (Box 1.6).”

Care coordination makes sure that individuals in health care settings get the right care, at
the right time, by the right persons. Care coordination involves assessment, planning, imple-
mentation, evaluation, monitoring, support, and advocacy so that care is not duplicated, safety
is promoted, and medical errors are prevented (Lindeke, Leonard, Presler, & Garwick, 2002).
Coordinated care, which includes physician support, health literacy, prevention, and emotional
and social support, is most widely used in work with children, especially those with chronic
conditions and special care needs, and to a lesser degree with older adults. However, family
needs to be included in the care of all sick members, regardless of age. Coordinated care is
important to families for all chronic conditions, advanced illness, and end-of-life care and can
promote planning, improve satisfaction, and lower costs (Englehardt et al., 2006).

Family-Centered Care Coordination

Models and guidelines to specifically describe cycles of care coordination activities that en-
sure appropriate and well-coordinated health care have been developed (WHO, 2000).
The WHO proposes that a family health nurse, who works with individuals and families
in primary health care and public health, be a key contributor to a multidisciplinary health
care professional team for the 21st century. The project, called HEALTH21, has three
basic values:

1. Health as a fundamental right
2. Equity in health and solidarity in action between countries, between groups of people

within countries, and between genders
3. Participation by and accountability of individuals, groups, and communities and of

institutions, organizations, and sectors in health development

CHAPTER 1 ● Health Care Needs for the 21st Century 17

TABLE 1-3 Comparing Nurse Roles for Care Coordination, Case Management,
and Disease Management

NURSING ROLE

Focus

Typical
techniques

Examples

CASE MANAGEMENT

Care planning,
monitoring referrals,
resources, risks

Episodic oversight of
care related to illness
or disability

Hospital-based
discharge planning

CARE COORDINATION

Assess, connect, educate,
communicate

Comprehensive ongoing
integrated care
planning

Patient/family-centered
medical or health
home

DISEASE
MANAGEMENT

Engage individuals in
appropriate symptom
management

Disease-specific clinical
guidelines, formularies,
focused patient
education programs,
symptom monitoring

Immunization education
and tracking; smoking
prevention and
treatment

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The Institute for Healthcare Improvement (IHI) is a vast, multifaceted health care
organization improving systems worldwide through a creative range of projects and
coalitions. They have established what they broadly refer to as the Triple Aim initiative to
pursue three critical objectives for health care design:

• Improve the health of the population.
• Enhance the patient experience (i.e., quality, access, and reliability).
• Reduce or control the per capita cost of care.

Nurses who think family ensure that individuals and families are told about the types
of support they will need, attend to specific coordinated health care needs, and assist with
personal care decisions as needed. The Presler Model of Family-Based Care Coordination
(Box 1.7) was tested with 83 families whose children received specialty care for complex
health conditions (Nolan, Orlando, & Liptak, 2007). Findings indicated that parents given
this form of care greatly appreciated it, became responsible for most aspects of care coor-
dination, and were very satisfied. Nurses who think family realize that adults offered similar
care would likely respond positively as well.

18 CHAPTER 1 ● Health Care Needs for the 21st Century

BOX 1-7

Presler Model of Family-Based Care Coordination

Step 1. Identifying and engaging families that lack care or experience fragmented care
Step 2. Assessing families regarding:

● Needs, concerns, priorities
● Strengths and resources
● Current health/functional status, including health records review
● Need for symptom management, services or resources to improve quality of life
● Access to primary and specialty health services
● Access to health care insurance (public or private)
● Access to therapies, nursing services, durable medical equipment or supplies
● Technology or environmental supports or modifications currently used or needed
● Access to basic resources such as food, housing, transportation, respite
● School/employment placement and satisfaction
● Community inclusion and satisfaction
● Perceived need for care coordination services and desired role of the care coordinator

Step 3. Developing family-centered interdisciplinary/interagency plan of care

● Identifying family preference for care coordinator activities and roles
● Identifying current and future goals and priorities
● Developing comprehensive health services plan that includes:

● Medical/health care home
● Specialty care referrals and integration
● Home health care needs and services
● School/daycare/employment health services needs
● Emergency services

Step 4. Implementing the plan of care

● Teaching the family about the importance of health promotion, health condition
management and prevention of secondary disabilities

● Teaching the family essential skills for self-advocacy, self-management and care coordination
● Providing resource information

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Families are usually interested in and willing to take part in care delivery but they often
lack the knowledge of what to do. Too often, nurses and other health care providers assume
they will do what is needed. In the case of both children and adults, if families aren’t in-
formed about what needs to be done, the individual and family are inadequately prepared
to manage the illness or prevent complications. Rethinking the ways individuals and families
are included in care situations should improve service delivery, reduce complications and
errors, save money, and increase satisfaction. Family and friends are usually primary care
providers for young and old individuals and need nurses prepared to think family (Fig. 1.2).

CHAPTER 1 ● Health Care Needs for the 21st Century 19

BOX 1-7

Presler Model of Family-Based Care Coordination—cont’d

● Facilitating interdisciplinary and interagency referrals
● Arranging for and coordinating services
● Advocating for and with the family as needed
● Working with third party payers to ensure appropriate access and payment
● Promoting information exchange with community agencies, schools/employers and health

systems providers including appropriate health care providers at times of transition
● Preparing for and facilitating transition to systems of care, roles and responsibilities as

developmentally appropriate at each encounter

Step 5. Monitoring and evaluating the plan of care

● Assessing individual and family outcomes
● Assessing systems-related outcomes
● Advocating for systems change to improve outcomes
● Providing resource information

Step 6. Disengaging from active care coordination

● Determine individual and family desires and abilities to coordinate care
● Maintain care coordination records
● Periodically assess individual and family’s desires or needs for care coordination

If care coordination services are needed, return to Step 2.

Source: Used with permission of B. Presler, PhD, RN, CPNP, APRN.

FIGURE 1-2 Nurses include
individuals and families in care
situations.

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Shared Decision Making

Nurses often have competing demands with many decision points during a single workday
or shift. Some tasks are purely administrative and others are process decisions about care
needs. Nurses who think family thoughtfully decide what are the most efficient and optimal
ways to spend their time. Nurses who think family form therapeutic relationships and ad-
vocate for policies and practices that can best address needs of the family unit. For example,
policy says an assessment must be completed on every new admission. This generally means
a form must be completed that details assessment findings and observations. Nurses who
think family will effectively use this time to listen to find out the greatest needs of the in-
dividuals and families, to see that questions are answered, to give needed support as care
is delivered, and to set priorities.

This shared decision making with the families occurs within therapeutic relationships
that honor unique individual and family preferences and circumstances. Care options
use “decision aids” based on the best available evidence that is presented in clear
language so the best choices can be made. An international collection of high-quality
decision aids is now available for nurses and others to use, thanks to collaboration
between stakeholders from 14 countries in the International Patient Decision Aids
Standards Collaboration (IPDAS). IPDAS goals guide individuals and families as they
engage in “values clarification” around health, a process integral to the Presler Model
of Family-Based Care Coordination and consistent with a family-focused nursing care
approach.

When nurses think family, multiple members are included in the discussions. The intent
is to reach a conclusion whereby individual rights are weighted highly, but consensus from
family members who individuals regard as important are included. A number of organi-
zations and agencies offer Web sites and tools for use in shared decision making (e.g.,
Agency for Healthcare Research and Quality, Cochrane Collaboration, Center for Shared
Decision Making, Choosing Wisely, Health News Review, Informed Medical Decisions
Foundation, Kaiser Health News, U.S. Preventive Services Task Force). Use of decision-
making aids can be helpful for making decisions and helping families make difficult
choices.

Chapter Summary

Health care is driven by many factors. Natural disasters, economic disparities, political
upheavals, and many other things affect health. Social issues such as poverty, housing,
and education along with growing scientific evidence and technology are just a few
things that affect health and illness treatment. In a continually changing world picture,
nurses are challenged to stay abreast of global influences on current trends. The rela-
tionships and interdependence of many factors, social determinants of health, influence
health and illness. Individuals live in families and are part of communities. Health care
delivery is not always equitable. The places people live have implications for nurses to
consider as care is given. Where families live, learn, work, play, and pray influences
health needs and illness risks. This chapter introduces some initial ideas about thinking
family and why a family-focused approach in nursing is needed. Proactive nurses identify
ways to coordinate care between acute care settings, homes, and communities. Florence
Nightingale responded to the concerns of her time; what would she do if she were
here now?

20 CHAPTER 1 ● Health Care Needs for the 21st Century

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professionals for a new century: Transforming education to strengthen health care systems in an
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Moving to Family-
Focused Care
Sharon A. Denham

C H A P T E R 2

C H A P T E R O B J E C T I V E S

1. Differentiate between individual care and family-focused care.
2. Define key terms involved in family-focused care.
3. Describe differences between family as the context of care and family as the unit of care.
4. Compare and contrast a systems model and an ecological model.
5. Discuss some of the ecological dimensions of family health.
6. Introduce some ways in which family-focused care influences individual and family health.

C H A P T E R C O N C E P T S

● Ecological model
● Family
● Family as the context of care
● Family as the unit of care
● Family-centered care
● Family-focused care
● Family health

● Family Health Model
● Healthy family
● Individual care
● Patient
● Patient-centered care
● Systems Model

Introduction

Nursing practice is large in scope and often considered both an art and a science. Through-
out this chapter you will see how ideas linked with thinking family and family-focused
nursing care can improve the ways you care for patients. Those ideas outlined here will be
more fully explained in following chapters. The term thinking family is an attitude or way
to approach nursing and use a family-focused perspective. Some of the literature introduced
in this chapter has served as a foundation for family nursing.

Understanding Family Health Terminology

Concepts are ideas that persons in a shared culture understand. Terms and concepts can
be familiar and have specific meanings; however, because everyone does not share the same

25

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vocabulary, ideas are often understood differently. This section focuses on the art of nursing
and provides terms and definitions related to family-focused care.

Individuals and Their Health

Nurses mostly attend to individuals in clinical practice. The word individual suggests ideas
of separateness, distinct needs, and differences. The word person is also used to refer to an
individual. Nurses care for people; some share characteristics, values, beliefs, attitudes, and
actions, but all have unique, distinct qualities, and diverse behavioral patterns.

Patient V ersus Person

In health care, the term patient is used to refer to those looking for and receiving medical
and nursing care. For some, the word suggests dependence, lack of individuality, and even
anonymity. Nurses and other health care professionals often view patients as dependent
with needs to be fixed, repaired, or healed. When a person becomes a patient, he sometimes
loses individuality and unique needs may be overlooked or ignored. Being a patient often
means inability to be a free agent. Patients are often acted upon by others, by professionals
they usually do not know. Nurses say “my patient” or “our patient,” suggesting ownership.
But people seeking care do not belong to nurses, other health professionals, agencies, or
institutions. Sometimes the term client is used to describe those seeking medical care. This
word has some similar connotations to patient, but it also refers to a customer or consumer
of care. This term might imply choice and the right to have a voice in care, and in the busi-
ness world “the customer is always right.” Some health care providers like the idea of
client, but some say it sounds too business-like and prefer the word patient. Regardless of
the terminology used, these persons are care seekers needing professional help. They enter
a care delivery setting like foreigners going to an unfamiliar country.

D if f erentiating Among Individuals

People want to be seen as individuals who are different and unique even though most still
see themselves as parts of groups. People get classified based on many qualities: gender,
age, race, sexuality, culture, ethnicity, economics, education, vocation, and social network.
Personality, motivation, wisdom, values, beliefs, character, and attitudes are other differ-
ences. Yet, they also want to show their uniqueness with clothing, hairstyles, tattoos, and
piercings. In addition, most want to determine their own fate and be treated with respect.
They want personalized, not generic, health care. Failure to see persons as part of a family
and household unit can create unintentional barriers to optimal care (Table 2.1).

Family

Family is the basic unit of society. The word family refers to two or more people related
biologically, legally, or emotionally. For generations, families followed what was considered
a traditional pattern—two parents who reared and launched children, a nuclear family.
Some argue that families should never have been characterized this way (Coontz, 1992,
1997), that this ideal comes from white middle-class American families and is not repre-
sentative of the diversity that defines families (Coontz, 2006). Current marriage and co-
habitation patterns seem radically different from those of the past.

The term family is prone to misinterpretation. Authors, policy makers, educators, and
health care providers use the word, but may fail to describe what they mean. Terms such
as family values, family health, family practice, and family care mean various things to

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different people. Religious activists, local politicians, physicians, and even nurses have ideas
about families. These ideas may not match the thinking of peers, teachers, or those to
whom they provide care. “No traditional [family] arrangement provides a workable model
for how we organize family relations in the modern world” (Coontz, 1992, p 5). Marriage
definitions have been hotly debated and are viewed in divergent ways by ethnic and cultural
groups (Coontz, 2006). Shared ancestry, who lives under a single roof, or a common head
of household may provide instructive guides. However, these distinctions are just guides
and do not exhaust the ways family is defined.

Family has long been identified as “a group of people, connected emotionally and/or by
blood, who have lived together long enough to have developed patterns of interaction and
stories that justify and explain these patterns” (Minuchin, Lee, & Simon, 1996, p 29).
Dr. Suzanne Feetham has contributed greatly to our understandings about family as the
‘unit of care’ needing nurses’ attention (Box 2.1). In this textbook, family is loosely defined
as a collection of persons who call themselves family and have a general commitment to
the care and well-being of one another. Although this is not a legal definition, it allows
nurses to identify persons who see themselves connected as a family unit. This imprecise
definition also offers flexibility in characterizing family units.

CHAPTER 2 ● Moving to Family-Focused Care 27

TABLE 2-1 Ch anging Patient Roles

OLD PATIENT ROLE

Defer to authority of others.

Expectations of medical practitioners are
primary concern in care.

Respect the expertise of the medical
practitioner.

Seek solutions of problems or get “ fixed” by
medical practitioners.

Depend upon the expertise of others.

Accept information as provided and not ask
questions.

Answer questions when asked.

Give only information asked for by others.

Adhere to instructions of others or become
labeled noncompliant.

Rely upon medical experts to solve problems.

Expect the health care practitioner to tell you
everything you need to know.

Assume medical practitioners to tell you how
you are doing.

Expect others to prescribe medicine and
treatments needed.

NEW PATIENT ROLE

Become a partner in health and illness care.

Expectations of individual seeking care and
medical practitioner should be mutually shared.

Respect is mutually shared between medical
practitioner and person seeking care.

Be actively engaged in self-management and
personal care of health or illness.

Identify different medical choices or diverse care
options and participate in choosing.

Expect to have information presented to you in
clear, easily understood language.

Come prepared with own questions and receive
answers.

Share beliefs, values, and preferences.

Choose plan of care based upon wisdom of expert
and personal preferences.

Seek expert medical support and actively engage
in solutions to personal care needs.

Obtain additional information from a variety of
external sources.

Assume responsibility for own care and monitor
progress between care visits.

Consult with others and take personal
responsibility for knowing whether what is
prescribed is what is needed.

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Thinking Family

Thinking family is an attitude nurses use in clinical practice situations. Nurses who think
family know that individuals value members of their family unit, and even when members
are not present in the care delivery setting, they still need to be considered. Nurses who
think family know individuals are influenced by a family point of view. Nurses often lack
the time needed to clarify relationships of linked persons. But nurses can ask who are the
important persons the individuals connect with in daily life. Some family members give
important support; some create conflicts and burdens.

The Family Household

Family is a context that links members over the life course. Families have different expec-
tations of their members. Some encourage individuation and originality, and others insist
upon conformity. Some have tight boundaries. Others have no boundaries. The family
household has many implications (e.g., a structure, shelter, neighborhood, tangible or in-
tangible resources) for unique family units (Denham, 2003). The household is more than

28 CHAPTER 2 ● Moving to Family-Focused Care

BOX 2-1

Family Tree

Suz anne Feetham, PhD (United States)

Dr. Suzanne Feetham, RN, PhD, FAAN, has held clinical, research, and leadership positions in
academia, health systems (Children’s National Medical Center, Washington, D.C.), the federal
government (U.S. Department of Health and Human Services [DHHS], National Institutes of Health
(NIH), National Institute of Nursing Research (Deputy Director and Chief of the Office of Science
Policy, Planning and Analysis), and Health Resources and Services Administration (HRSA). Her work
has focused on health care for families, underserved populations, and health policy. She is
recognized nationally and internationally for her research and scholarship in nursing research of
families and the integration of genetics and genomics in national education, practice, and policy.
Dr. Feetham has a program of research in the care of children with health problems and their
families. She has numerous publications on nursing research about families, using research to effect
change in practice, families and health policy, health and urban families, genetics education, and
genetics and families. In 1977, she developed the Feetham Family Functioning Survey (FFFS).
Currently, this survey instrument is used in research of families across disciplines and has been
translated into several languages including American Sign Language, Spanish, Russian, Bosnian,
Chinese, and Japanese and has reported application in more than 70 research publications. She was
co-editor of the first state of the science Handb ook of Clinical Nursing Research in 1999, and in 2001,
she edited a volume of Nursing and G enetics— L eadership for G lob al Health for the International
Council of Nurses, Geneva, Switzerland. From 1996 to 2001 at the University of Illinois at Chicago, she
was co-investigator on federally funded family studies, including a family intervention for Bosnian
torture survivors, and was principal investigator for a funded interdisciplinary project to develop a
Web-based course on clinical genomics for health professionals. As holder of the H. H. Werley
Endowed Research Chair at the University of Illinois at Chicago, she was principal investigator on a
study of families considering genetic testing for cancer susceptibility; she was also co-investigator on
four family studies funded by the NIH. She has also served as a Visiting Professor at University of
Wisconsin–Milwaukee, a research consultant at Children’s National Medical Center, Washington, D.C.,
and a board member for the International Family Nursing Association. In August 2011, the American
Academy of Nursing announced that Dr. Feetham was a recipient of the Living Legends Award for
her notable accomplishments.

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just the space the family inhabits; it is linked to place and social networks, things that
affects members’ lives (e.g., power of one’s name, finances, access to health). Understanding
the difference between the healthy family and family health concepts is useful for nurses.

H ealth y Family

Individuals initially learn about health and illness in their family households. The household
is where people first deal with the basic facts of life, such as conflict, comfort, care, adver-
sity, and suffering. Early experiences of health and illness (e.g., injuries, accidents, illness,
disease, disabilities) occur at home. Many household experiences become health and illness
determinants, because the household is the place where habits, routines, and responses to
health and illness are learned.

The term healthy family has been identified with nurture and care that members offer
one another; healthy family traits (e.g., good communication, respect, shared responsibility,
balance of interactions, shared religious core) have long been described (Curran, 1984).
Healthy family suggests that members come together for the common good and that they
support one another’s growth and maturity. They share time, interests, traditions, and re-
sources. A healthy family is vibrant, has a sense of stability, has access to needed supports,
provides its members emotional support, and balances individual needs against those of
the family unit (Denham, 2003). A healthy family is one that effectively balances competing
aspects of the household that have health and illness consequences for its members’ well-
being and is successful at accomplishing needed tasks. Members care for one another’s
needs as resources are acquired and equitably distributed to individuals. The idea of healthy
family does not always include a health-illness perspective or factors relevant to biomedical
concerns.

B eing an U nh ealth y Family

An unhealthy family is one in which pain, biophysical symptoms, or emotional problems
prevent or limit an individual’s self-efficacy and the family unit is unable to perform
needed tasks linked with concerns. An inability to effectively complete needed tasks, fulfill
roles, or meet social obligations might indicate a family is unorganized. Even though this
situation could lead to being less healthy, the family might not see their circumstances as
unhealthy. Judgments from the outside are not always aligned with what families view as
reality. When physical pain, symptoms, or emotional suffering interfere with abilities to
complete self-care or family care, an unhealthy situation might exist. If members are unable
to perform roles, fulfill obligations, or complete duties, outsiders might call them un-
healthy. When social expectation are unfulfilled, one might be tempted to place an
unhealthy label. For example, a family using or dealing illegal substances or a home where
neglect or abuse occurs might be labeled an unhealthy family. Social values often influence
what is or is not viewed as healthy. Thus, labeling a family healthy or unhealthy should
occur with great caution.

Making H ealth J udgments

Nurses need to be careful about making judgments about what is and is not healthy. Some
health care providers use the terms dysfunctional and noncompliant, referring to individ-
uals or families that do not follow what is prescribed. To ensure a therapeutic relationship,
nurses need to avoid judgmental attitudes. Families have ideas about what they need, and
these ideas can differ from what nurses think.

For example, a nurse might meet a person with type 1 diabetes based upon laboratory
results. A 36-year-old man presents with a blood glucose level of 198 mg/dL on a routine

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physician visit. The high blood glucose level might mean this person has failed to follow
doctor’s orders, lacks personal motivation, or is irresponsible. However, before lecturing
this man about the problem, be sure that fact finding is complete. The nurse may only
know part of the story. He may think that he is working very hard on daily management
efforts. He might lack family support. Maybe he has inadequate health insurance coverage
and can’t afford the medical supplies. Maybe he doesn’t know how to manage his diet or
has not been adequately instructed about needs for physical activity. The high cost of test
strips might prevent regular daily glucose checks. He might be focused on pressing personal
problems. A family assessment might reveal that he has great emotional and financial stress
about a child with a serious and worsening disability. Nurses who think family know that
individuals seldom have one problem at a time. They learn about holistic needs before
making judgments.

Family H ealth

When terms like family as a system, family system, and family nursing practice are
not defined, confusion about what is implied can occur. Medical professionals often
focus on medical care for single persons. Implications for the family unit are largely
ignored. A lack of conceptual clarity about family health contributes to this neglect.
Nursing students often learn about family care needs when infants or children are
involved. Families are largely ignored when adults need care unless they are disabled or
need end-of-life care.

The term healthy family speaks to attributes of interacting members. It refers to ways
members support and care for one another. The idea of family health is somewhat fuzzy.
It is often referred to in the literature and identified as a goal of nursing, but it is seldom
defined (Loveland-Cherry, 1996). Family health is a phenomenon that explains the com-
plex interactions and relationships of a family household unit as they collaborate to
maximize individual abilities for wellness and maintain what they view as healthful
(Denham, 2003). Family health is connected to the whole family unit. Family health
aims to maximize potentials of member actions (e.g., resilience, organization, adapta-
tion, stability, support, caregiving) that contribute to the family unit’s health and well-
being. Family health occurs when household resources are used to enhance member and
unit well-being.

Families uniquely organize their lives. Some live in disorganized fray. It is useful to con-
sider ways members relate and possible implications on health and illness. Family health
refers to the health status of the whole family unit and how well the group is functioning.
How well do members use their actions, abilities, and resources for the good of the whole,
but also meet unique individual needs? A family focused on wellness will likely instill ideas
about good nutrition and physical activity from cradle to grave. At the same time, individ-
ual factors can alter the family unit. Early work on addictions demonstrates that an indi-
vidual member can radically alter the family health of the entire unit by using enabling
behaviors (Steinglass, Bennett, Wolin, & Reiss, 1987). A child born with a severe disability
places great demands on family resources over a lifetime. Thus, family health is strength-
ened or damaged based upon the family unit’s abilities and willingness to satisfy the needs
for its members (Fig. 2.1).

Family Health Patterns

The family household is where members’ shared lifestyles produce uniquely constructed
health patterns and routines. It is where health behaviors are taught, learned, and practiced
(Denham, 2003.) Households are the basic units of analysis for collecting U.S. census data.

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The census defines a family household as: where two or more persons related by birth,
marriage, or adoption, but unrelated people live. Non-family households are places where
people live alone or share the place with unrelated individuals. Members of non-family
households are connected to other households where they are still viewed as immediate or
extended family members. Less than half of Americans are currently married, and similar
reductions have been noted in other advanced postindustrial societies. Social class, culture,
age, and race often influence family forms. Households members experience a continuum
of wellness-illness care needs. This continuum is influenced by many things (e.g., genetics,
culture, religion, peers, beliefs, values, attitudes, available resources). Developing individ-
uals respond to things that threaten or support health and care management daily. The
scale and forms of family influence upon individuals differ. Nurses can ask individuals
about family priorities in caring for health and illness.

Individual Health

Research about family health identified that being healthy is more than merely the absence
of disease (Denham, 1999a, 1999b, 1999c). Health is often described as holistic, but it is
often viewed in terms of the presence or absence of disease or illness. Ask someone you
know about her health. She might tell you about an illness or disease or say that she is not
sick. She might describe her inability to be active, complete activities, care for basic needs,
or do things for herself. Few will answer the question in terms of well-being.

Health could be described as the ability to have an active life. It might include things
like taking part in family life, having emotional strength, feeling spiritually connected, or
doing meaningful tasks. Some might think of health in terms of routines (e.g., eating a
nutritious diet, being physically active, refraining from risky behaviors). Those living with
a serious disease or a terminal illness might see themselves as healthy if basic self-care needs
(e.g., take part in valued daily living activities, fulfill usual roles, do meaningful things) can
be completed. Health is an adaptive state experienced as persons seek meaningful ways of
being and wrestle with personal, family, household, and environmental liabilities across
the lifespan (Denham, 2003). Family nurses help persons and family units clarify their
expectations and engage in healthful activities they value.

CHAPTER 2 ● Moving to Family-Focused Care 31

FIGURE 2-1 Nurses think family
health and individual health.

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Models for Understanding Family Nursing

Ideas about family nursing have been evolving for decades. Many nursing scholars have
contributed to a growing body of evidence about the value of family nursing. Yet, the ques-
tion remains: How should family nursing be defined? In this textbook, we define family
nursing as clinical practice approaches that address the person and family unit even when
only one individual is present for care. Family nurses focus on families and their home set-
tings where health problems are addressed and endeavors to create a healthy family are
targeted (World Health Organization, 2000). Family nurses assist individuals and families
to manage all aspects of wellness, health, illness, disease, and chronic disabilities. Family
nurses realize that care needs exist beyond health care settings and aim to deliver coordi-
nated care to family households.

In nursing, the application of a variety of theories and models offers different ways to
define and deliver nursing care. Some grand nursing theories (e.g., Orem, Roy, Neuman)
have been generated by nurses to guide nursing practice. Many of these frameworks have
had several revisions and were updated so family perspectives were better addressed. The-
ory can help nurses understand different approaches to clinical care. Theories directly
linked with family nursing have emerged over the past several decades. These family the-
ories offer distinct ways to think about how individual health is influenced by the family
unit and household. Ideas about family systems nursing have been advanced through the
Calgary Family Assessment Model and the Calgary Family Intervention Model (Wright &
Leahey, 2013). These models are discussed later in this textbook. In many of the following
chapters, a variety of middle-range theories useful in family-focused nursing practice are
introduced.

A Systems Perspective

A non-nursing theory often used by nurses is general systems theory (von Bertalanffy,
1950). It can be used to think about care of individuals and families and encourages the
nurse to consider the whole as more than the sum of its parts. Systems thinking provides
ways to understand the connectedness and feedback responses as individuals interact with
family members and their environment. Systems theory suggests that too much focus on
the whole can result in overlooking the importance of the parts and too much attention to
the parts risks the possibility of overlooking the whole.

Systems theory has been influential, but critics say it tends to emphasize some perspec-
tives and ignore others. Systems theory can help one understand some aspects of family
member interactions, but influential historical, cultural, and political factors are often ig-
nored. Understanding about equilibrium might cause one to assume that individuals and
families seek balance, but this assumption is not always true. Using systems theory, one
might think that experiences or conditions are linear or circular in progressing from cau-
sation to outcomes, but life more often is random and chaotic. Systems thinking can help
nurses understand that multiple interacting forces are in play when an illness occurs or
when needs to promote wellness arise. However, nurses might find some implications vague
or difficult to apply in a practical way.

No clear-cut rules govern the ways family members interact with each other. The family
is more than the sum of its members. How can one explain family health without taking
into consideration the complexity of multiple member interactions outside the family unit?
Is the family even fully explained by the members? Do other things also need to be taken
into account? The uniqueness of family units, their discrete traits, and the roles of members
need consideration. Systems theory aims to explore the whole, but the number, type, and

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magnitude of multiple member interactions and their implications for individual and family
health can be overlooked. In systems thinking, ideas about environment are often vague
and clear distinctions about values and relationships ignored.

An Ecological Perspective: The Family Health Model

There are different ways to consider individual and family health. Research findings about
family health suggested that an ecological perspective could be a better model to describe
family health, one with a household and community lens to better understand the family
unit (Denham, 2003). The Family Health Model moves the focus away from acute episodic
clinical care to more mindful thoughts about an individual’s relationships with the family
unit, household, lived spaces, and the needs posed by daily life. An ecological model is a
good way to think about multiple factors relevant to health such as:

• Relationships of shared and separate events and contexts
• Individual and collective experiences
• Interactive behaviors within and outside the family household
• Effects of social networks, larger communities, and environmental circumstances
• Perceived meanings, beliefs, values, or interpretations tied to health and illness
• Multiple personal and family interdependent factors linked with health or illness

The Family Health Model suggests ways to identify interconnecting events and circum-
stances. Nurses can use these interrelated ideas to complete assessments and complete nurs-
ing actions or interventions. This model views family health as a socially constructed
phenomenon. The Family Health Model has three domains: context, function, and struc-
ture. Each domain provides a way to understand factors linked with individual and family
health and to identify nursing practice actions (Fig. 2.2).

The Family Health Model provides a framework for thinking about nursing practice that
includes relationships, needs, connectedness, and environment (Fig. 2.3). It is a way to think
about the many obscure, interacting, and conflicting factors associated with health and ill-
ness. Family health is influenced by the family’s internal and external environments. Box 2.2
provides some explicit points about the Family Health Model. This model includes ways
individuals view themselves in connection to their family unit and household, but also offers
ways to consider how these and other relationships or environments influence health and
illness. This model suggest that things be considered over time and place. The lived shared
experiences of multiple household members and their shared internal and external environ-
ments have potential to affect their well-being, life quality, and illness or disease potentials.

Ecological thinking implies that multiple interacting, dynamic, and enduring factors
across the life span are important. Family nurses can use these varied factors to see that
intrinsic and extrinsic factors are assessed. When first using ecological thinking, one can
be overwhelmed. New terminology is introduced. This thinking offers many different areas
to assess—so many ways care might be delivered. Keep in mind that nurses do not address
all factors with every person. Instead, these ideas can be used in conjunction with presenting
clinical problems. Consider the following questions: What is most important at this time?
Are there other factors that should be considered? What features about this person’s family
unit and household might be relevant to this situation? Answers to these questions give
directions for assessment areas that might lead to needed nursing actions.

Family C ontex t

The Family Health Model also suggests that health and illness are influenced by the family
context, which is the first domain to consider when conducting an assessment. The term

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family context explains the deeply connected experiences that family unit members share
over a lifetime. While the family unit is the context for its members, this unit is embedded
into other complex systems (e.g., neighborhoods, communities, nations). These larger
systems have other factors that influence health and illness (e.g., institutions, organizations,
political milieu). Family members have discrete and shared viewpoints and often experience
things differently. It is paradoxical that while families are somewhat predictable, they are
also dynamic. Members and families evolve; they change over time. Nurses who think fam-
ily know that family socialization and experience are critical factors when it comes to health
and illness. The larger cultural, social, and physical environment exerts negative and
positive potentials.

Family context mirrors some aspects of the larger societal systems. It is the stage for
relationships and social discourse. The household is the place internal and external
environments meet and exchange ideas that influence behaviors. The household is where
many unique identities, values, beliefs, and attitudes are formed. It is where genetics,
religion, culture, traditions, history, and behaviors, among other things, are shared. Care

34 CHAPTER 2 ● Moving to Family-Focused Care

Contextual Domain
• Individuals
• Extended family members
• Genetics, culture, ethnicity
• Family household(s)
• Friends, peers, co-workers
• Neighborhood, community,

nation
• Larger social context

(history, policy, time orientation)
• Available resources
• Time

Functional Domain
• Developing individuals
• Developing and maturing family
• Roles and expectations
• Core processes
• Member interactions with each other
• Member interactions with outsiders
• External influences on family

members
• Immediate and latent conditions

Structural Domain
• Individual and family

routines
• Routine meanings
• Routine types
• Routine characteristics
• Routine purposes
• Routine participants
• Timing of routines conditions

Factors
Influencing

Individual and
Family Health

FIGURE 2-2 Factors influencing individual and family health.

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CHAPTER 2 ● Moving to Family-Focused Care 35

FIGURE 2-3 Ecological influences on individual and family health.

Individual
and

Family
Members

Family
Household

Household
Neighborhood

Household
Community

Multiple Households
Over Time

Multiple Interacting
Environments

Social Influences

Government, State, Local,
and Social Policy

Historical Period

given to individuals in clinical environments seldom reveals the complexities of family
unit and household needs. Nursing assessment findings that take families into consider-
ation help the nurse figure out the best ways to address care needs.

Family Function

In the Family Health Model, the functional domain is used to explain the interactive
processes that occur as family members develop, mature, share time and experiences, and
change within their household (Denham, 2003). The functional domain pertains to ways
members interact, communicate, and relate within and outside the household and it helps
explain roles, processes, and behavioral interactions. Members use many forms of relational
processes to meet personal and collective needs.

Parents and others give social cues to developing children about ways to respond to
health and illness. Family members often test these experiences as they engage the larger
community (i.e., for work, play, school, faith, social or public policy). Ways to respond to
wellness or disease are learned behaviors over time. Some ideas are steadfast, and others
can be altered, but basically those ideas are formed as members interact with family. Some

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families encourage healthy lifestyle behaviors, but others do not. Some factors (e.g., resilience,
identity, adaptation, accommodation) are influenced by family, but peer groups also play
roles. Time alters some behaviors, but others change little. Some life events (e.g., mental ill-
ness, disability, crisis, tragic death) can have dire effects on family units. Nurses who think
family consider how these functional factors pertain to an individual’s health and illness.

Nurses need to know ways to interact with both well-functioning and troubled families. In
clinical practice, nurses meet and aim to help people from all walks of life; some have multiple
troubles that extend beyond the reason for currently seeking care. Nurses often meet people
facing distressful life situations, critical incidents, and long-standing troubling predicaments.
The Family Health Model suggests ways that nurses can use core processes (e.g., communica-
tion, cooperation, coordination, caregiving) to address functional aspects of health and illness
(Denham, 2003). These processes are described in Chapter 14. Each indicates ways nurses can
use caring, treatments, education, counseling, and other nursing actions. Dr. Peri Bomar, in the
late 1980s, published the first book to address health promotion with families (Box 2.3).

Family Structure

The third aspect of the Family Health Model is the structural domain (Denham, 2003).
This domain focuses on patterns of behaviors, which includes habits and family health

36 CHAPTER 2 ● Moving to Family-Focused Care

BOX 2-2

K ey Principles of the Family Health Model

1. Developing persons experience individual and family health in relationship to all aspects of
their lives; both can be either stable or dynamic over time.

2. Individual and family health are inextricably tied to the family household and communities.
These influences can be positive and negative aspects of individual health and the health of
the family unit.

3. Individual and family health are affected by the ecological relationships that connect family
members within the family household to the larger environments with which they directly or
indirectly interact.

4. The family is a microsystem that includes those viewed as part of the family and
encompasses all the interactions occurring among individuals as they interact with external
environments in everyday life.

5. The family and its members interact with multiple external environments (e.g., home, work,
school, peer groups) that have the potential to affect individual and family health both
negatively and positively.

6. The family and its members interact with diverse environments (administrative decisions by
parent’s employer, boards governing school policies, etc.) that have the potential to affect
individual and family health even when members are not direct participants.

7. Larger societal systems that represent the ideologies of the evolving world (e.g., legislation,
social policy, culture, media, history) can potentially affect individual and family health.

8. Time and historical experiences have the potential to influence the family, its members, and
their health in positive and negative ways.

9. Family health results from the complex interactions of the family, its members, and larger
environments over time as the multiple interacting factors have potential to maximize or
minimize the health and illness of individuals and the family unit.

10. Family health routines are important ways to discuss, describe, assess, intervene, and
evaluate interventions and outcomes pertinent to individual and family health.

Source: Adapted from Denham, S. A. (2003). Family health: A framew ork for nursing. Philadelphia: F. A. Davis.

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routines. These patterns develop as members interact within the family household and with
other larger environments. Family health routines have distinct traits: they are recognized
by others, are shared in some instances, and have the potential to affect the health-illness
continuum (Denham, 2003). These patterns, while not static, seem firm or stable over time.
Routines may not be visible or of concern until something conflicts with them. Family
members can often describe each other’s behaviors with great accuracy.

Family health routines are relevant to behaviors with disease risks. Nutrition and dietary
routines are one category with great significance for wellness or disease management. For
example, food consumption has many linked routines (e.g., meal plans, shopping, label
reading, food preparation, meal patterns). Diets often include sugary drinks and chemical-
laden processed foods with large portion sizes and high-calorie snacks. Despite the rele-
vance of habitually shared behaviors in family households, questions about them are rarely
asked. Nurses who think family know that family routines influence individual risks and
can include these concerns when doing assessments and planning nursing actions. A person
diagnosed with type 2 diabetes needs to modify his diet. What needs to be known about
current individual and family dietary routines? How can long-standing family behaviors
be changed? What are the goals or outcomes to measure?

Nurses who think family assess linked individual and family behaviors. They consider
the family unit and household resources in goal setting. Strategies for change identify mean-
ingful, achievable, and measurable outcomes. A dietary assessment (e.g., proximity of gro-
cery store, food costs and availability, preparation time, nutritional knowledge, literacy
level) that considers contextual, functional, and structural factors is an important step to-
ward change. One needs to know what is currently happening before real change can be
planned. Things like mealtime interactions of young children with asthma have been found
to influence the quality of life (Fiese, Winter, & Botti, 2011). Disease management for
young and older persons almost always involves family in some way. Family-focused care
requires collaborative planning and decision making. Deconstructing risky routines and
constructing new ones takes planning and intentionality. Nurses who think family begin
by learning what is valued. They identify members’ cooperative spirit. They evaluate
motivation or readiness for change. Medical care often involves needs for change that are

CHAPTER 2 ● Moving to Family-Focused Care 37

BOX 2-3

Family Tree

Perri Bomar, PhD

Dr. Perri Bomar’s first degree was a nursing diploma from a hospital school in Canton, Ohio.
Subsequently she earned a BSN, MSN, and PhD. Her career took her to various institutions, the U.S.
Department of Health and Human Services, the University of San Diego, and the University of North
Carolina Wilmington (UNCW). At UNCW she served as Associate Dean and was instrumental in
establishing the first master’s degree program in nursing, which began in 1998. Her first edition of
Promoting Health in Families, in 1989, was recognized as the American J ournal of Nursing Book of the
Year and the Nursing Outlook Book of the Year. Two follow-up editions of this text were published.
This book has been used by nurses in the United States, Canada, Japan, Thailand, and other nations.
As an African American nurse, Dr. Bomar has been instrumental in modeling the value of graduate
education and has mentored many students who have sought her guidance and support. A number
of her graduate students have progressed to doctoral studies with a focus on family or health
disparities in underserved populations. Her most recent research is focused on describing and
developing family nursing interventions that incorporate community-participatory research
methods using evidence-based research focusing on self-management, spirituality, and the
rural environment to improve health promotion with African American families.

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not easy. Family-focused care includes multiple members who either support or thwart
behavioral changes.

Nurses who understand the importance of shared routines linked with health and illness
use them during assessment, planning care interventions, and evaluating outcomes. Six
areas of family health routines are identified in the Family Health Model (i.e., self-care,
safety and prevention, mental health behaviors, family care, illness care, family caregiving).
Families organize daily routines in ways viewed as meaningful and replacing old routines
with new ones is difficult. Nurses who think family assist them in identifying goals and ac-
tion steps that are Specific, Measurable, Attainable, Realistic, and Timely (SMART goals).
Changing routines takes planning, strategies for making changes, and steps to evaluate
along the way.

Moving Toward Family-Focused Care

Providing family-focused clinical care takes forethought and reflection. Nurses who think
family plan care that considers the family unit needs. The frantic pace of daily work does
not make it easy to always be thoughtful about what will be done, but taking the time to
consider family needs can pay a big return. This next section describes differences between
family-centered care and family-focused care.

Family as Contex t of Care V ersus Family as Unit of Care

Nurses need to plan the ways in which they approach clinical care. One can see family as
the context of care or the unit of care. These terms were initially coined by Dr. Suzanne
Feetham (1991), an internationally recognized family scholar and researcher (see Box 2.1).
Family as the context of care implies that family is connected to individuals seeking care
but is in the background. Family members might be viewed as directly relevant, but be seen
as visitors, an afterthought, and not essential to immediate care.

On the other hand, when family is viewed as the unit of care, family members are in the
forefront. They are viewed as fundamental to individual care. Individuals and family
members are viewed as perpetually connected or inseparable. Individuals are inherently
tied to others even when they are not physically present. When nurses recognize family as
the unit of care, they understand that shared lives, resources, and identities play active roles
in one another’s health or illness. Family is an abiding presence and not a transitory aspect
of life. Attachments formed in the household are ties that bind even when we wrestle
against them. As the unit of care, nurses think about individual care in terms of deep,
intricate, entangled, and inseparable household member bonds. The family shares re-
sources, provides caring relationships, and gives support for members. Thinking family
means meeting holistic care needs of the individual in ways that include family involvement.
Table 2.2 compares the ideas of family as the context of care and family as the unit of care.

Patient- and Family-Focused Care

The terms patient-centered and family-centered care are not often used consistently and
therefore are poorly understood. Disease-centered care largely uses a biomedical focus with
individual attention mainly given to clinical expertise, diagnostic tests, episodic care, and
medical management. Patient-centered care requires health care providers who think about
patient needs and focus attention on the individual receiving care.

38 CHAPTER 2 ● Moving to Family-Focused Care

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Patient- C entered C are

The Institute of Medicine (2001) suggests that patient-centered care implies that a respect-
ful and responsive partnership among practitioners, care seekers, and their families to ad-
dress patient values, wants, needs, and preferences is available. This model assumes that
individuals actively seek care and take part in identifying needed services. Many people
have limited knowledge about health care systems or the business of medicine. Identifying
needed services in timely ways is not always easy. Individual needs are the target, but fam-
ily involvement needs to be encouraged. Many are uncertain about how care should look
in practice. Care consumers often make quick decisions. Technology and the Internet make
access to medical information easy, but wading through Web sites when you have no med-
ical background is difficult. Medical terminology and explanations are hard to decipher.
The general public is often unsure about what is reliable or accurate. Too often, the first
information accessed can be biased, confusing, incomplete, or not supported by scientific
evidence.

Primary C are

Primary care is recommended whenever treatment is non-life-threatening and choices
exist. Primary care begins when the person meets a health–care professional in a medical
practice setting. Most people seek care infrequently over the life course. When the visit
ends, the care recipient is expected to follow through on the prescribed treatment. Because
care delivered is often limited to 8 to 15 minutes per visit, pertinent questions go unan-
swered. In addition, people seldom receive a follow-up call to ask if everything is going
well. A national study of 1,837 physicians who practiced at least 3 years past residency
found that only 16% communicated via e-mail with patients, only 36% get patient feed-
back, less than 50% use patient reminder systems, and only 14% of those in solo practices
have adopted half of the patient-centered care practices (Audet, Davis, & Schoenbaum,
2006). Technology is available, but links between primary care providers and care con-
sumers is lagging. Box 2.4 provides a list of patient-centered practices that can be used in
primary care.

Questions remain about how much power and control are truly shifted to patients or
families. The quality of care we currently have in the United States might be far from the
quality we could have (Berwick, 2009). Patient-centered care needs to be linked with an
experience in which individuals are informed in ways they desire (Berwick). This care
should be transparent, individualized, and provided in respectful ways in which the dignity
of persons is upheld. Personal choice and family involvement would make this care form
superior to current delivery systems (Box 2.5).

CHAPTER 2 ● Moving to Family-Focused Care 39

TABLE 2-2 Families as th e Contex t of Care or th e Unit of Care

FAMILY AS THE CONTEXT OF CARE

Individual is the care focus

Family is in the background

Family is composed of individuals

Individual data reflect family

Care of solitary persons

FAMILY AS THE UNIT OF CARE

Family is the care focus

Family is in the forefront

Family is a unified whole

Family data also reflect individuals

Care of individuals and family

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Integrative C are

Integrative medicine is defined as patient centered, healing oriented, and a care form that
embraces both conventional and complementary therapies (Maizes, Rakel, & Niemiec,
2009). It is different from the dominant biomedical model in that it is more focused on
holistic needs. It recognizes that high-tech medicine is not always useful in addressing

40 CHAPTER 2 ● Moving to Family-Focused Care

BOX 2-4

Patient-Centered Care Practices

Examples of practices that incorporate actions sensitive to individual needs and evidence-based
practices that can be used effectively in the clinical setting:

● Schedule same-day appointments.
● Exchange e-mail with patients.
● Text appropriate disease management reminders.
● Use reminder notices for preventive or follow-up care.
● Keep registries of individuals with chronic conditions.
● Update patient medication lists regularly.
● Store information in electronic medical records.
● Make information from referral physicians available promptly.
● Ensure that medical records or test results are readily available when needed.
● Feed back patient survey data into practice.
● Be aware that patient ratings of care affect compensation.
● Make information on quality of care about the referral physician available.

BOX 2-5

Providing Patient-Centered Care W ith a Family Focus

Care that is patient centered implies that individuals who are patients have more autonomy, share in
decision making, and have a voice in what, where, when, and how things are done. For this form of
care to truly become family centered, then the following changes need to occur:

● Hospitals would not have visitation restrictions, except those chosen by and under the control
of patients.

● Patients determine the food selected to eat and what clothes they wear in hospitals (to the
extent health status allows).

● Patients and family members participate in rounds and are included in reports.
● Patients and families participate in the design of health care processes and services.
● Medical records belong to patients. Clinicians, rather than patients, would need to gain access

to them.
● Shared decision-making technologies would be used universally.
● Operating room schedules would minimize waiting time for patients rather than follow the

convenience of the clinicians.
● Patients physically capable of self-care would, in all circumstances, have the option to perform

it and have family assist.

Source: Adapted from Berwick, D. M. (2009). What “ patient-centered” care should mean: Confessions of an
extremist. Health Affairs, 2 8 (4), 555–565.

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chronic health problems. Addressing health promotion and disease prevention needs by
including other methods such as nutrition and stress management could be more viable
options but are out-of-pocket costs. Nurses’ education about integrative medicine is often
limited (Box 2.6).

O rigins of Family-Focused Care for Children

Family-centered care was first described by former Surgeon General C. Everett Koop at
an American Academy of Pediatrics conference in 1987. He spoke about care access and
quality of life for children with special care needs. He called for commitment to establish
a national agenda for families and professionals to work together through an initiative
to focus on family-centered, community-based, coordinated care for children and their
families (Box 2.7).

Many children’s hospitals include parents in care delivery. About 15 years ago, it was
suggested that pediatric practice would be improved when nurses and other health profes-
sionals approached care in intentional ways in which needs, cultures, resources, and
strengths were included (Dunst & Trivette, 1996). Care needed to be delivered with effi-
ciency, flexibility, quality, confidentiality, and privacy. Enlisting family members to teach
nursing students and hospital staff about family needs has been suggested. Since 1998,
family advisory councils have been in place in many children’s hospitals to improve
customer service.

Family-centered care assures the health and well-being of children and their families
through respectful family-professional partnerships (National Center for Family-Centered
Care, 1989). This care focuses on the best interests of the child and family respecting the
skills and expertise that each person brings to the care setting. Care hallmarks include
trusting relationships, meaningful communication, cooperative decision making, and

CHAPTER 2 ● Moving to Family-Focused Care 41

BOX 2-6

Principles of Integrative Medicine

● Individuals and practitioners are partners in the healing process.
● All factors that influence health, wellness, and disease are considered (e.g., body, mind, spirit,

community).
● Appropriate uses of conventional and alternative methods are used to assist the body’s innate

healing response.
● Natural and less invasive interventions should be used whenever possible.
● All practice should be based upon the best scientific evidence available, open to inquiry or

questions, and allow for new practice forms.
● Individuals must decide on what treatments to have based on their personal values, beliefs,

and available evidence.
● Treatment alone is not enough; broad ideas of health promotion and prevention must also be

included.
● Integrative medicine practitioners should be exemplars of the practices they suggest and be

committed to self-exploration through reflection and continued development.

Source: Adapted from Maizes, V., Rakel, D., & Niemiec, C. (2009). Integrative medicine and patient-centered
care. Commissioned for the IOM Summit on Integrative Medicine and the Health of the Public. Retrieved
January 29, 2012 from http://www.iom.edu/~ /media/Files/Activity% 20Files/Q uality/IntegrativeMed/
Integrative% 20Medicine% 20and% 20Patient% 20Centered% 20Care.pdf

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willingness to negotiate. Research supports these ideas. For example, highly cohesive fam-
ilies with low internal family conflict and a child with type 1 diabetes respond positively
to a family-centered care approach (Hanson, DeGuire, Schinkel, & Kolterman, 1995).
While family has been included into thinking, planning, and delivery of children’s care,
adult care has been ignored.

The Institute for Patient- and Family-Centered Care (2010), created in 1992, was orig-
inally focused on advancing family-centered care in pediatric, maternity, and newborn care.
Their philosophy is grounded in thinking family members should play important roles on
the care team. Now, because they realize that family is important in all care processes, too,
their mission also includes adult and geriatric care. This vision acknowledges the profound
changes needed in health care delivery. Nurses and other health professionals need to build
on individual and family strengths, enhance their confidence, and build their competence.
Family is indispensable to collaborative partnerships. Empowered relationships matter.
Family can serve as advisors.

O rigins of Family-Focused Care for Adults

Family participation in health care is essential to nursing practice (Williams, 2006). Since
ideas about family participation have primarily targeted children, there is little evidence
of progress in actively including family in the care of all people regardless of age. Family-
centered care for adults has been occurring during end-of-life care (hospice). Yet, while
decades of results indicate positive outcomes of end-of-life care at home, some still die in
institutions where poor communication between family and staff, inadequate support,
and rude treatment still occur (Teno et al., 2004).

42 CHAPTER 2 ● Moving to Family-Focused Care

BOX 2-7

Elements of Family-Centered Care for Children

More than 20 years ago, Surgeon General Koop identified some critical aspects of family-centered
care for children with special health care needs. Ideas suggested then also appear relevant to needs
of adult family members seeking health care services. These ideas include the following:

● Recognize that the family is the constant in a child’s life, while the service systems and
personnel within those systems continually change and fluctuate.

● Share complete and unbiased information with parents about their child’s condition on an
ongoing basis in an appropriate and supportive manner.

● Recognize that families have strengths, individuality, and different methods of coping.
● Encourage and make referrals so parents facing challenging situations with children can gain

support from other parents facing similar concerns.
● Facilitate parent/professional collaboration at all levels of health care (e.g., care of an individual,

program development, implementation, evaluation, policy formation).
● Ensure that health care delivery system design is flexible, accessible, and responsive to

individual needs and families.
● Implement appropriate policies and programs that provide emotional and financial support to

families.
● Understand and incorporate the developmental needs of children and families into health

care delivery systems.

Source: Adapted from Surgeon General Koop (1987).

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Challenges to Family-Focused Care

Clearly, a lack of appreciation for family-centered care by many still exists. Numerous con-
straints continue to occur:

• Overly demanding provider-patient staffing ratios
• Restricted family visitation
• Health care systems focused on a provider-centric model of care
• Unequal distributions of power
• Lack of time to provide adequate information and support
• Communication difficulties
• Limits of fiscal resources

Many providers still restrict family visitation. Family care is ineffectively integrated, and
information and education are provided without regard for unique needs, literacy level, or
culture. Coordinated care still falls short during inpatient stays and is mostly disregarded
when it comes to discharge home and the needs of those self-managing home care. Tech-
nologies keep evolving and conversations about needs for cost reduction continue. Reduced
length of acute care stays and growing numbers of those with chronic illnesses mean care-
givers face greater burdens for longer time periods. Caregiver burden, stress, role fatigue,
spousal burnout, and inadequate access to needed information are growing concerns. The
inability to navigate the breadth of options in an unsystematic health care industry is often
neither family driven nor caring. This evidence points to needs for different forms of care.

Nurses face stress from practice roles that make it difficult to separate professional ex-
pectations and personal values. Nurses still take directions from the institutions, organiza-
tions, and agencies that employ them. They observe the gaps between needed care and what
is provided. They often sense they are powerless to make needed changes. Institution-based
supports, adequate education for individual care needs, empathetic supervision, nonpunitive
workplaces, and safe work environment where nurses can discuss and be included in the
resolution of dilemmas are needed. Nurses need knowledge and abilities to be leaders in
health care delivery and advocate for sensitive and supportive work environments that at-
tend to individual and family unit needs.

Realizing Family-Focused Care

Adding another title to describe nursing care might seem superfluous or unnecessary, but the
term family-focused care is used throughout this textbook to claim caring ideas that nurses can
call theirs. The terms patient-centered and family-centered care are useful terms, but groups
outside nursing largely control them. The term family-focused care is proposed to describe a
care form that uniquely belongs to nursing. This practice is characterized by intentional actions
and deliberate supports aligned with the wishes and needs of individuals and those they identify
as their family unit. Family-focused care uses mindful relationships to meet holistic health and
illness care needs; it is a care attitude conveyed through thinking family that intentionally and
purposely guides nursing actions. This care values and respects the unique needs of individual
and family units. Regardless of the care system or situation, family is always viewed as the unit
of care. Coordinated care identifies needs beyond the immediate ones. Nurses who think family
look beyond episodic care and identify the preventive actions needed to protect health and
encourage wellness for the family unit. Clear communication is a hallmark of every nursing
care encounter. Health education relevant to care management is provided in clear language
and culturally appropriate ways. While providing family care, nurses ensure that adequate

CHAPTER 2 ● Moving to Family-Focused Care 43

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resources are available and interventions respect family household and environmental concerns.
Family nurses use theories and scientific evidence to guide practice.

Implications of Family-Focused Care

In family-focused care, the individual and family are the unit of care. When single persons
are seen in caregiving settings and family members are absent, nurses still identify the family
household unit as the focus of nursing care. Because family-focused care is relationship-
based, it fosters collaboration or partnerships. Nurses bring initiative, authenticity, and
responsiveness to the care situation (Doane & Varcoe, 2005). Nurses who think family
listen and hear the voices of those seeking care as well as those they recognize as family.

The nurse is aware that some ambiguity and uncertainty will always be found in caring
situations. Family nurses avoid biased opinions, assumptions, prescriptive solutions, easy
answers, and quick fixes. These nurses understand that many factors shape experience (e.g.,
culture, ethnicity, language, policy, systems). Family nurses notice personal strengths and use
them in empowering ways. These nurses aim to understand the implications of the family house-
hold on individual care needs. Finally, family-focused nursing allows space for personal reflec-
tion, examination of biases and prejudices, and promotion of self-care and knowing oneself.

Usefulness of Family-Focused Perspective

People are connected to others through family and their social networks and nurses who think
family know that. Even when some family members are not physically present, they have per-
sonal meaning and influence. Those who seek medical care services are still attached to the
values, fears, and stresses linked with their personal lives. Individuals may never give voice to
these concerns unless invited to share them and perceive a caring person willing to listen. In-
fluences beyond the immediate interaction may have great relevance to care. When nurses
think family, they approach individuals judiciously and respect unspoken needs and concerns.
Whenever you are involved in a clinical situation, it is good to take time and reflect about the
skills required to effectively interact with individuals and their family members (Box 2.8).

As nurses deliver care, they are aware that other relevant factors beyond the immediate
situation might need consideration. For example, a middle-aged gentleman is alone in the
hospital room after a surgical procedure and says he is unable to sleep. An immediate
response might be that he is awake from discomfort related to the earlier surgery. A nurse
who thinks family understands that the sleep difficulties might have their foundation in
family or household concerns. He might be worried about missing work and the income it
represents. He could be concerned about the extra burden his wife bears for their disabled
adult child. He could be anxious about his hospital bill and payment without insurance
coverage. Although sleep medicine might resolve the immediate problem, it will not likely
solve the more complex family-related hurdles. Family nurses look beyond the immediate
and inquire about other possiblities.

Nurses’ Roles in Family-Focused Care

Family-focused care addresses young and old, healthy and sick, and dependent and inde-
pendent. Varied needs are treated with sensitivity and the understanding that a larger under-
lying story exists. Family members are seen as tangible supports. On the other hand, nurses
also realize that sometimes families can be barriers. Some even sabotage the needed care.
Family-focused care is used to assess family needs and assets. Outcome evaluation considers
what is possible in a given family situation. Nurses build trusting relationships in which they

44 CHAPTER 2 ● Moving to Family-Focused Care

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can be respectfully curious about things not discussed and experiences not shared. The fused
lives of multiple persons can enhance or threaten quality of life and wellness potentials.

Transforming the Nursing Perspective

A biomedical model is a common way students learn about nursing practice. Students are
taught using biological, anatomical, and physiological aspects of human function and dis-
ease processes. Learning about body systems can be difficult. However, gaining proficiency
in responding to the complex interacting biological and social systems can be even more
challenging. As the science of care is taught, the art of nursing care (e.g., process, emotions,
consciousness, presence) is often relegated to the background. A reductionist perspective,
in which individuals are viewed as separate parts or systems, can be shortsighted. It is like
not seeing the forest for the trees! Wellness, health, disease, and illness situations have un-
derlying stories that are unlikely to be easily or quickly told. Medical diagnosis is important,
but it explains only part of the story connected to personal and family lives.

Nurses are usually taught to relate to single individuals. Education and experience com-
municating with families or groups can be limited for many students. Often a sick model
of care is internalized, with care being sought by an individual only when he senses or ob-
serves a malfunction or problem. Most people report physiological problems. Those of an
emotional, psychological, or social nature are often ignored or discounted. Immediate acute
care needs get the most attention. Chronic disease management, prevention, and lifestyle
behaviors to promote health often get overlooked. Family nurses know that coordinated
care also includes wellness, health promotion, prevention, community, and population-
based care needs. Take some time to review the case presented in Box 2.9 and consider
ways the content of this chapter might fashion your thinking about care needs.

CHAPTER 2 ● Moving to Family-Focused Care 45

BOX 2-8

Evidence-Based Family Nursing Practice: Trilogy Model of Family Systems Nursing

Use of family systems nursing knowledge in clinical practice has been a challenge in the United
States and many other parts of the world. Problems primarily occur in two areas. One is the concerns
of nurses about their relationships with those seeking health care and beliefs about their roles. The
second area of concern has to do with ways to bring nurse educators, researchers, and practitioners
together as partners. These researchers have noted that the prevalent biomedical perspectives may
be at odds with family systems nursing (FSN). Their findings suggest that the FSN approach uses a
partnership perspective and competencies involve creating space for family members to participate
in goal setting and identification of solutions. A study examined different forms and time lengths of
education to prepare for practice in a variety of clinical settings. Findings indicated that nurses
progressively incorporated FSN in practice as they received positive feedback from colleagues and
families. The authors concluded that students and nurses need more time in supervised practicums
to develop needed skills (e.g., family interviewing, therapeutic conversations, fears linked with family
suffering and emotions, uncertainty). It seems that nurses seek the same level of direction and
support for relational skills as they do for technical ones. Findings indicated that educators’
personalities and capacity to comfortably apply FSN skills influenced students use of knowledge.
Messages about the potential use of FSN need to be shared among researchers, educators, and
practitioners to demonstrate ways these three areas are interlinked.

Source: Duhamel, F., & Dupuis, F. (2011). Towards a trilogy model of family systems nursing knowledge utilization:
Fostering circularity between practice, education and research. In E. K. Svavarsdottir & H. Jonsdottir (Eds.), Family
nursing in action (pp 53–68). Reykjavik, Iceland: University of Iceland Press.

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Chapter Summary

This chapter introduces many ideas and terms nurses link with family-focused care. The
idea of thinking family is used to introduce different ways to provide nursing care. An
ecological model—the Family Health Model—is described as a useful way to view the
complex lives of individuals and families. More about ways this model can be used
in delivering nursing care will be discussed throughout this book. The varied places
individuals and family units live influence health and illness. Nurses who think family
acknowledge that influences on health and illness can be assessed and this information
offers opportunities for nursing interventions. Family units and their households give
important clues about resources, supports, strengths, and hurdles to overcome when it
comes to getting healthy or well. Nurse who think family know that family is always
present to individuals, even when members are not physically visible. This presence has
meaning and direct implications for nursing care in all settings. The following chapters
explore many implications of family-focused care and thinking family.

REFERENCES

Audet, A., Davis, K., & Schoenbaum, S. C. (2006). Adoption of patient-centered care practices
by physicians: Results from a national survey. Archives of Internal Medicine, 166, 754–759.

Berwick, D. M. (2009). What “patient-centered” care should mean: Confessions of an extremist.
Health Affairs, 28(4), 555–565.

Coontz, S. (1992). The way we never were. New York: Basic Books.
Coontz, S. (1997). The way we really are. New York: Basic Books.
Coontz, S. (2006). Marriage: A history. New York: Penguin Books.

46 CHAPTER 2 ● Moving to Family-Focused Care

BOX 2-9

Family Circle

As you begin your early morning clinical experience in the medical unit today, you walk into a room
and see Mrs. Cattrell, a frail older woman resting in a rumpled bed. Alongside the bed is a man
who appears to be in his mid-30s; he is sleeping, reclining in a chair about halfway covered with a
blanket. On closer examination, you notice that two IV lines are on one side of the bed. A large bag
of normal saline is dripping steadily into a right arm site and a blood transfusion is dripping slowly
into the left arm. The Foley catheter bagging hanging at the end of the bed looks as if it was recently
emptied. You were told that her diagnosis is adult acute lymphocytic leukemia. She was diagnosed
several months ago, and her condition has steadily declined over the past few weeks. She had
experienced severe symptoms for several months before going to her medical doctor and being
diagnosed. In morning report, you heard that Mrs. Cattrell has not been eating, slept poorly last
night, seems somewhat agitated, and makes frequent demands on the nursing staff. Nothing was
said about the man in the chair beside her. You were instructed to obtain her vital signs and assess
her condition.

1. Using what you have previously been taught about completing traditional assessments,
write a four- to five- sentence summary to describe the approaches you would take and
identify the various things you would consider.

2. Now, use what you have learned from reading this chapter and think about ways a family-
focused approach might be different from a traditional assessment. Write four to five sentences
that describe the different kinds of things to include in a family-focused assessment.

3. Next, compare and contrast your ideas with three to four others in a small-group discussion.
Make a list of the pros and cons of each approach to care.

4. Finally, come to group consensus about the best forms of nursing care for Mrs. Cantrell.

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Craft-Rosenberg, M., & Pehler, S. (2011). Encyclopedia of family health. Thousand Oaks, CA: Sage
Publications.

Curran, D. (1984). Traits of a healthy family. New York: Ballantine Books.
Denham, S. A. (1999a). The definition and practice of family health. Journal of Family Nursing,

5(2), 133–159.
Denham, S. A. (1999b). Family health: During and after death of a family member. Journal of Family

Nursing, 5(2), 160–183.
Denham, S. A. (1999c). Family health in an economically disadvantaged population. Journal of Family

Nursing, 5(2), 184–213.
Denham, S. A. (2003). Family health: A framework for nursing. Philadelphia: F. A. Davis.
Doane, G. H., & Varcoe, C. (2005). Family nursing as relational inquiry. Philadelphia: Lippincott.

Williams & Wilkins.
Duhamel, F., & Dupuis, F. (2011). Towards a trilogy model of family systems nursing knowledge

utilization: Fostering circularity between practice, education and research. In E. K. Svavarsdottir
& H. Jonsdottir (Eds.), Family nursing in action (pp 53–68). Reykjavik, Iceland: University of
Iceland Press.

Dunst, C. J., & Trivette, C. M. (1996). Empowerment, effective helpgiving practices and family-centered
care. Pediatric Nursing, 22(4), 334–337.

Feetham, S. L. (1991). Conceptual and methological issues in research of families. In A. L. Whall &
J. Fawcett (Eds.), Family theory development in nursing: State of the science and art (pp 55–68).
Philadelphia: F. A. Davis.

Fiese, B. H., Winter, M. A., & Botti, J. C. (2011). The ABCs of family mealtimes: Observational
lessons for promoting healthy outcomes for children with persistent asthma. Child Development,
82(1), 133–145.

Hanson, C. L., DeGuire, M. J., Schinkel, A. M., & Kolterman, O. G. (1995). Empirical validation
for a family-centered model of care. Diabetes Care, 18(10), 1347–1356.

Institute of Medicine. (2001). Envisioning the National Health Care Quality Report. Washington,
DC: National Academies Press.

Institute for Patient- and Family-Centered Care. (2010). Institute’s new name. Retrieved July 30,
2011 from http://www.ipfcc.org/about/name-change.html

Loveland-Cherry, C. (1996). Family health promotion and health protection. In P.J. Bomar (Ed.), Nurses
and family health promotion: Concepts, assessment, and interventions (pp 13–25). Baltimore:
Williams & Wilkins.

Maizes, V., Rakel, D., & Niemiec, C. (2009). Integrative medicine and patient-centered care. Commis-
sioned for the IOM Summit on Integrative Medicine and the Health of the Public. Retrieved
January 29, 2012 from http://www.iom.edu/~/media/Files/Activity%20Files/Quality/IntegrativeMed/
Integrative%20Medicine%20and%20Patient%20Centered%20Care.pdf

Minuchin, S., Lee, W. Y., & Simon, G. (1996). Mastering family therapy: Journeys of growth and
transformation. New York: John Wiley.

National Center for Family-Centered Care. (1989). Family-centered care for children with special
health care needs. Bethesda, MD: Association for the Care of Children’s Health.

Nationwide Children’s Hospital. (n.d.). Family-centered care. Retrieved July 30, 2011 from
http://www.nationwidechildrens.org/family-centered-care

Steinglass, P., Bennett, L. A., Wolin, S. J., & Reiss, D. (1987). The alcoholic family. New York: Basic
Books.

Teno, J. M., Clarridge, B. R., Casey, V., Welch, L. C., Wetle, T., Shield, R., & Mor, V. (2004). Family
perspectives on end-of-life care at the last place of care. JAMA, 29(1), 88–93.

von Bertalanffy, L. (1950). The theory of open systems in physics and biology. Science, 111, 23–29.
Williams, W. (2006). Advanced practice nurses in a medical home. Journal for Specialists in Pediatric

Nursing, 11(3), 203–206.
World Health Organization. (2000). The Family Health Nurse: Context, conceptual framework, and

curriculum. Retrieved November 26, 2011 from http://www.see-educoop.net/education_in/pdf/
family_health_nurse-oth-enl-t06.pdf

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

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Thinking Family to
Guide Nursing Actions
Sharon A. Denham

C H A P T E R 3

C H A P T E R O B J E C T I V E S

1. Identify various perspectives linked with health and illness.
2. Differentiate among the terms healthy, unhealthy, and societal health.
3. Describe ways in which nurses think family to deliver family-focused care.
4. Discuss ways in which thinking family improves individual, family, and societal health.

C H A P T E R C O N C E P T S

● Biomedical model
● Health care
● Illness
● Interdisciplinary practice
● Nursing roles

● Public health nursing
● Scope of nursing
● Social Policy Statement
● Societal health
● Theoretical perspectives

Introduction

The world of health care is changing. Health care costs keep rising and many argue about
the best approach for health care reform. The Affordable Health Care Act continues to be
debated. Health care programs based on need rather than ability to pay, as practiced in
Canada and Europe, are continually being reformed as these countries wrestle with the grow-
ing costs. Nursing practice the world over is influenced by each nation’s health care policies.
If nursing is to reach a place where practice can confidently meet societal health care needs,
then changes are needed in some of the care approaches nurses use. Nurses have primarily
been taught to focus on individual care needs. This perspective too often ignores the at-home
family and household experiences and the societal linked health and illness risks. This chapter
provides some ways to consider societal health and its meanings for individuals and families.
New directions for thinking family in care delivery are described (Fig. 3.1).

Differentiating Among Health and Illness Perspectives

Health is a value or a desirable quality that allows a person to be capable of activities
that add worth, quality, and enjoyment to daily life. We all want to avoid illness, health

49

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threats, and injuries that lead to disease. Being healthy allows us to accomplish many
meaningful things. It can be difficult to agree on health norms when a single standard for
evaluation is unavailable. We live in a perplexing time with changes coming rapidly from
every direction, a time of need for radical innovations that offers great opportunity. An
amazing array of health enhancements (e.g., braces, glasses, contact lenses, cataract sur-
gery, plastic surgery, gastric bypass) is available, yet many of these advances were unimag-
inable less than 50 years ago.

Health care is often considered to entail diagnosis, treatments, tests, and drugs. Impor-
tant things that might help avoid being ill, such as sleep, dietary changes, physical activity,
and stress management, are often ignored. We might say that health and disease begin at
a level difficult to see. Are our bodies really like a 3D print of how we live? What does it
mean to live a full, joyful, and authentic life? Some think spirituality and faith are important
for the body and the mind. Some say that being physically able is important but then drive
around a parking lot several times to get the closest parking place. Many engage in risky
behaviors (e.g., tobacco use, overeating, sedentary lifestyle). People often think that disease
or illness can be fixed. Nurses mostly see people with medical problems.

Health allows us to be active and do many things. However, the meaning of normal or
excellent health is not always clear. Health care consumers often hear confusing media
messages. Ideas about norms differ, and it is often difficult to establish a single standard.
In 1947, the World Health Organization (WHO) defined health as a state of complete
physical, mental, and social well-being and not merely the absence of diseases. Capabilities
that have a continuum of function (e.g., vision, sleep, and mobility) are difficult to measure.
Some attributes are naturally altered with age. How does one measure a dynamic quality
such as health? Even wellness has variability—optimal wellness to lower level wellness.
Persons afflicted by the same disease do not suffer in the same ways. People with disabilities
are not equally impaired. Healing and rehabilitation occur at various paces. It is not always
easy to discuss disease rates, mortality, quality of life years, or environment. Persons in one
geographical region may have health advantages not enjoyed by others. Genetic factors
differ. Many health alterations are only identified over time. Some cultural and ethnic
groups have norms viewed as abnormal in other places. We must take care not to confuse
happiness and well-being with longevity and health. Good health does not guarantee a
longer or better life. Living longer does not equal good health.

Rethinking the Ways We Define Health

Health and illness have multiple dimensions. Nurses might ask, Who is healthy? Who is
sick? How do we decide who is and who is not healthy? Advanced technology (e.g., imaging,

50 CHAPTER 3 ● Thinking Family to Guide Nursing Actions

FIGURE 3 -1 Thinking family.

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genetic screenings) is used to identify medical conditions that we cannot always cure. Di-
agnosis confirms that someone is ill, but when did the sickness begin? If a person has a
chronic condition (e.g., diabetes, hypertension, heart disease, cancer), does this mean he is
unhealthy? What factors cause people to see themselves as sick or well? A medical problem
might imply that a special diet is needed, but is this person ill? Someone with a common
cold might say she is sick and unable to attend school, go to work, or complete usual tasks.
Ways in which individuals and family units interpret symptoms differ. These points of view
can be extremely different from those of nurses or other health professionals. Judgments
about who is sick or well differ widely.

Perhaps nurses need to discuss health and illness in different terms. What would happen
if we spoke less about things related to medical care delivery (e.g., hospitals, physicians,
technology, pharmaceuticals) and more about social determinants of health (e.g., environ-
ment, water, sanitation, employment, housing, social justice)? Suppose issues were discussed
in more measurable terms. For example, would it be better to spend less on repairing people
after they are ill and more on keeping people healthy? It is good for nurses to understand
some things about the ways money is spent for health care and its implications for families
(Box 3.1).

Nursing Actions Related to Societal Health

What does health mean to large groups or broad populations? People often attend to their
activities of daily living without giving great thought to health. Yet many actions relate
to individual, family, and societal health. Some needs are basic (e.g., food, shelter, sleep,
mobility). Others are aligned with quality of life (e.g., stress, hope to fulfill dreams,
achievement, self-worth). In the United States, the aging populations have Medicare
hospice benefits for end-of-life care. Growing numbers of aged persons over the next
decade may need long-term care for chronic disorders that meets care needs at home.
Caregivers will be needed more than ever. Older adults have different concerns than
younger ones, and more attention will be needed for geriatric care and alternative care
arrangements that include family (Scitovsky, 2005). Providing for the costs and needs of
family members as they care for dependent family members 24 hours a day, 7 days a week,
might be more critical than payment for brief primary care visits. Eight essential care
dimensions have been identified that primarily relate to acute care settings (Box 3.2). Five

CHAPTER 3 ● Thinking Family to Guide Nursing Actions 51

BOX 3-1

Evidence Ab out Changing Costs for Medical Care

A decade-old study that examined Medicare outlays in the last year of life in 8,000 deaths found that
little change had occurred over the prior 20 years, as 27.4% of medical expenditures were incurred in
the last year of life (Hogan, Lunney, Gabel, & Lynn, 2001). Most persons had at least four significant
health problems in the year of their death. Medicare expenditures largely included persons with
heart disease, cancer, stroke, chronic obstructive pulmonary disease, pneumonia, or dementia. A
surprising finding from this study was that minorities living in high poverty areas or factors viewed as
social determinants of health were likely to have 28% per capita higher Medicare spending costs
than those who did not. In this study, about 50% of those diagnosed with cancer were likely to use
hospice care, yet only 10% of all others used it. However, 40% of the Medicare beneficiaries spent
some of their last life year in a nursing home, where many deaths occurred. These findings indicate
that the high cost of death largely has to do with caring for severe illness, dealing with functional
impairment, and covering nursing home expenditures.

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primary drivers of exceptional family-centered inpatient hospital care experiences are
identified as follows (Bailey, Conway, Zipper, & Watson, 2011):

• Leadership demonstrates a culture focused on patient- and family-centered care.
• Staff and care providers are fully engaged in patient- and family-centered care.
• Respectful partnerships among care providers enable them to anticipate and respond

to needs (e.g., information, comfort, emotional, spiritual).
• Health care delivery is reliable and competent.
• Evidence-based care is practiced.

When physicians discuss end-of-life choices with cancer patients, their health care
costs are much lower in the last week of life (Zhang et al., 2009). Yet, many dying persons
never get referred to hospice. More than a third of those referred spend only 7 days
enrolled, and many would benefit greatly from aspects of care management lasting longer
(Jennings, Ryndes, D’Onofrio, & Baily, 2010). Hospice care offers several things that
families desire:

• Response to human consequences of profound illness (e.g., comfort, safety, support,
choice)

• Continuity of caregiving among settings and providers
• Response to evolving community needs (e.g., multiple diseases, children, prisoners,

rural residents, bereaved)

Dying persons and their families want autonomy and dignity. Things like responses to
suffering, compassion, and vigilance at the end of life are important.

Concerns about societal health might consider what forms of care delivery are most cost
effective in supporting family needs. What does society need when it comes to such prob-
lems as cognitive dysfunction, mental illness, long-term disability, genetic disorders, or the
homeless? Political leaders’ debates should include pressing family and societal health
needs. For example, the obesity crisis is of great concern. About 33.8% of U.S. adults are

52 CHAPTER 3 ● Thinking Family to Guide Nursing Actions

BOX 3-2

Patient-Centered Care

In the late 1980s, the Picker Commonwealth Program for Patient-Centered Care and the Picker
Institute identified important care dimensions: care access; respect for values and preferences; care
coordination; information, communication, and education; physical comfort; emotional support;
involvement of family and friends; appropriate preparation for discharge and care transition. Care
needed includes the following things:

● Effective treatments provided by trusted staff
● Patient involvement in decisions and respect for their preferences
● Rapid access to reliable health care advice
● Clear and understandable information that supports self-care
● Physical comfort in a safe and clean environment
● Emotional support and empathy
● Involvement of family and friends
● Continuity of care with carefully managed transitions

Source: Gerteis, M., Edgman-Levitan, S., Daley, J., & Delbanco, T. L. (Eds.). (2002). Through the patient’s eyes:
U nderstanding and promoting patient- centered care. San Francisco: Jossey-Bass.

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overweight or obese (Centers for Disease Control and Prevention [CDC], 2011). Obesity
is a growing problem for other countries as well. Growing numbers of young children are
at risk for becoming obese and even morbidly obese. Obesity is linked with heart disease,
stroke, hypertension, type 2 diabetes, and some forms of cancer. Medical costs linked with
obesity are in the billions, with obese persons spending $1,429 more annually for health
care than those of normal weight (Finkelstein, Trogdon, Cohen, & Dietz, 2009). Others
have found that obesity raises medical costs even higher ($2,826 in 2005 dollars), with
estimates that annual treatment costs are about 16.5% of the national spending budget on
medical care (Cawley & Meyerhoefer, 2010). Another study about relationships between
middle-aged individuals, Medicare costs, and mortality found that obese persons at
45 years of age had a smaller chance of surviving to age 65 (Cai, Lubitz, Flegal, & Pamuk,
2010). Obese persons had lifetime Medicare expenditures of $163,000 compared to
$117,000 for those at normal weight. Left unchecked, by 2030, it is predicted that
obesity-related medical costs could rise to $48 billion to $66 billion a year in the United
States (Wang et al., 2011). This is a great deal of money! Increased lifetime costs will sub-
stantially increase the overall Medicare expenditures for today’s middle-age population.
We are still learning about the full magnitude these costs will have on employment,
disability, and health insurance.

In the 1990s, the World Health Organization began warning that the growing burden
of obesity was becoming a global epidemic for industrialized nations and developing coun-
tries. More still needs to be known about a global food system of processed, inexpensive,
and commercially marketed items to children and adults. Nurses and the general public
are often unaware of public health measures that might be used to reverse this still-growing
epidemic. Some solutions rest outside the health care industry, but clinicians might make
important differences. For example, lifestyle choices, the built environment, leadership
capacities, prevention, public policy, and government interventions offer alternative
approaches to the obesity problem. Coordinated actions are needed to solve a problem of
this magnitude. Nurses who think family can help by looking beyond primary care settings
and finding ways to address this concern.

While concerns grow about obesity, malnutrition and starvation are also growing
problems. Inadequate nutrition affects physical, cognitive, and behavioral development.
It can also cause irritability, lead to fatigue, and lessen the ability to concentrate. Not
only is hunger a concern for people who are homeless and unemployed, but it is faced
daily by families with inadequate incomes. Families often must choose between food
and other basic needs (e.g., rent, utilities, and medical care). In 2014, Feed the Children
reports that more than 17 million U.S. households face not having enough food for
everyone in the family. Nurses who think family consider the health and illness of family
units and the larger society, not merely individuals.

Think Family and Improve Societal Health

Health has many points of view. Physical health is usually discussed, but mental and societal
health are often ignored. Societal health includes wealth distribution, equal opportunity,
human rights, and ways people get along with each other. Health can be discussed as moti-
vation, attitude, moral principles, or availability of care providers, systems, or programs.
Societal health has been defined by such terms as employability, marital satisfaction, socia-
bility, and community involvement (Renne, 1974). Evidence shows relationships between
social networks and health status (Haas, Schaefer, & Kornienko, 2010; Song, 2011;
Umberson & Montez, 2010). Societal health has effects on individual and family health.

CHAPTER 3 ● Thinking Family to Guide Nursing Actions 53

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American veterans from the Iraq and Afghanistan wars number 2.3 million; 20% or
more of them suffer from post-traumatic stress syndrome (PTSD) or depression, 19% of
them might have traumatic brain injury (TBI), and perhaps 7% or more have both. Alcohol
and drug abuse are problems for others (U.S. Department of Veterans Affairs, 2014). These
injuries are often accompanied by other physical disabilities. Veteran families from many
wars experience trauma, suffering, and challenges that last a lifetime. Homelessness and
suicide are other factors faced by many veteran families.

Philosophy can provide other ways to consider social aspects of health. For example,
health can imply abilities to adapt to changing environments, social situations, or
surroundings (Dubos, 1987). Health is linked with relationships; it is an adaptive
process, and is a socially constructed reality (Illich, 1975). Social groups attend to things
they prize, things viewed as needed or attainable (e.g., car seat belts, infant seats, drug,
alcohol, or tobacco use). Health can be discussed in terms of suffering and recovery.
Some find individual suffering valuable, others don’t. Health can be medicalized
with prescribed treatments that ignore the potentials of things the human spirit can
accomplish.

People live interdependent lives with connections to social institutions. Do we really act
on our own volition? Or are we continually influenced by household, neighborhood, and
societal factors? So, what health indicators should we measure? What social factors are
linked to family and individual health? Individuals and families are bound to the places
where they live, learn, work, play, and pray. Social determinants influence thinking about
health and are linked with life experiences (e.g., birth, development, live, work, age). Access
to nutritious foods, quality housing, health care services, physical activity, workplace
environment, and educational opportunity are social determinants of health. They affect
everyday lives. An ecological point of view encourages one to see connections between
society, individual, and family health.

Financial Costs of Health Care

Health factors can be influenced by one’s culture or nation. For example, even though
Canada is part of North America some cultural perspectives differ from those in America
(Box 3.3). The United States is one of the wealthiest nations in the world and spends more
money on health care than any other country. Yet, the United States has growing health
disadvantages with higher mortality rates and inferior health from birth (Woolf & Laudan,

54 CHAPTER 3 ● Thinking Family to Guide Nursing Actions

BOX 3-3

Canadian Perspective of Societal Needs for Medical Care

The Royal College of Physicians and Surgeons of Canada (2011) agrees that when it comes to
medicine, societal needs have both quantitative and qualitative perspectives. Q uantitative needs are
addressed by having the appropriate type and mix of physicians. These characteristics largely
represent the public’s interest and role of educational institutions. Q ualitative needs have to do with
the adequacy of the physicians’ knowledge, skills, attitudes, and willingness to assume the roles
needed by diverse societies. Similar observations can also be made about nurses and other health
care professionals. Professional competencies needed by population groups are often culturally
specific responses to societal needs, social determinants of health, and the burden of illness.
Although health systems play roles, policy choices that influence distribution of money, power, and
resources at local, national, and global levels are extremely influential. Social concerns often result in
legislation or laws that greatly influence the health of a society.

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2013). When compared with peer countries, the United States fares worse in nine areas of
health (birth outcomes, injuries and homicides, teen pregnancy and sexually transmitted
infections, HIV and AIDS, drug-related deaths, obesity and diabetes, heart disease, chronic
lung disease, disability) than some other nations. These health problems affect all age
groups until after 75 years and are of particular concern for persons up to 50 years. Several
reasons for the concerns were found:

• Fragmented health care; weak public health and primary care; and a significant
segment of uninsured people

• High-calorie consumption; abuse of prescription and illicit drugs; traffic accidents;
more firearms; more sexual activity (earlier, more partners, riskier practices)

• Higher poverty rates; pace of education is falling behind
• Stark differences in land use (distance from food sources, residential segregation by

socioeconomic status)

Although U.S. health care spending is almost 2.5 times higher than that of other nations,
adoption of health information technology has lagged behind (Organization for Economic
Cooperation and Development, 2011). In the United States, the government plays a large
role in financing health spending and spends more than any other developed country.

Some might say that the United States is an illness profit industry. Health care and hos-
pital cost finances have evolved without clear pricing formulas or attention to wide cost
variations across geographical settings (Reinhart, 2006). Few Americans truly understand
the complex payment systems. Nurses and other professionals are uncertain about the ways
costs are derived and have a difficult time making sense of medical expenses. Some people
pay far more for medical care than others. Health care spending involves more than just
making everybody’s insurance cheaper; it is also pertains to cutting unnecessary spending
and paying for needed things in equitable ways.

Health Care Reform

Health care reform is needed. Dissatisfaction with current processes abound, yet the best
ways to restructure things continue to be argued. The Affordable Health Care Act was
intended to hold insurance companies more accountable, lower health care costs, offer
health care choices, and improve care quality (Box 3.4). The Affordable Health Care Act
is intended to improve quality of care and the population’s health, but also to reduce costs
of quality care. Yet, this reform does little to alter the ways care services are delivered.
Family nurses can lead the change in ways care is provided. Nurses who think family can

CHAPTER 3 ● Thinking Family to Guide Nursing Actions 55

BOX 3-4

Affordab le Health Care Act

The Affordable Health Care Act established a National Strategy for Q uality Improvement in Health
Care (U.S. Department of Health and Human Services, 2011) that has set these priorities:

● Make health care safer by reducing harm caused in care delivery.
● Ensure that patients and families are engaged as partners in their care.
● Promote the most effective prevention and treatment practices for leading causes of death

(e.g., cardiovascular disease).
● Enable communities to promote wide use of best practices to enable healthy living.
● Make quality care more affordable for all by developing and using new health care delivery

models.

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identify needs of family units and plan care to truly satisfy unique care needs. A culture of
health innovation is essential if acute and home care is to support safe practice, health eq-
uity, and comprehensive needs. Nurses who think family can provide leadership in rethink-
ing the ways coordinated care is delivered across care settings.

Nurses’ Roles in Societal Health

Nurses who think family can ask: What forms of health care are most needed to promote
societal health? A compelling body of evidence suggests that some old ideas need to be
reexamined to meet present and future needs. Are biophysical needs the only concern?
How can psychological and emotional needs also be considered? What can be done to
provide better care for families and society? How can nurses use integrative medicine?
What roles can nurses play in partnerships and interprofessional care? How can nurses
better evaluate whether quality care has been delivered? Many things are of great concern,
but which are within the scope of nursing practice? What would society consider effective
nursing practice? In what ways can nurses use critical thinking, clinical judgments, and
moral reasoning to set priorities for nursing care delivery?

As one thinks family, nurses must be able to gather, analyze, and synthesize information
from a variety of sources. Options and implications need to be weighed. What happens if
you act one way instead of another? Thinking family employs intentional actions, evaluates
needs, and weighs costs and benefits of actions taken. Societal health is linked with the
places people live and what they do in their households. Increasing evidence shows that
geography matters and needs are influenced by where people live (Behringer & Friedell,
2006; Cummins, Curtis, Diez-Roux, & Macintyre, 2007). Noting where people live (e.g.,
rural, suburban, urban) and related concerns (e.g., isolated, dangerous, natural disasters)
gives important information.

Reform in moving from a disease management focus to a sustained healing network is
needed. Nurses have long had a social contract with the public (Box 3.5). The Social Policy
Statement suggests that nurses need to lead in some care processes and be therapeutic
collaborators in others (American Nurses Association, 2010). Collaborators can assist
individuals, families, and communities in ways that satisfy care needs outside traditional
medical delivery sites. Nurses who think family might seek answers to these questions:
How can I be prepared to meet individual and family needs? As a nurse, what does society
expect from me? What does the social contract imply about nursing roles? Proactive re-
sponses to these questions can lead in new directions.

56 CHAPTER 3 ● Thinking Family to Guide Nursing Actions

BOX 3-5

American Nurses Association Social Policy Statement

As early as 1995, the American Nurses Association’s Social Policy Statement described family as a
target for nursing care. The Social Policy Statement is a contract that acknowledges the care
mechanisms to be incorporated into practice. Ideas included in this contract are public
accountability, professional social responsibilities, appropriate stewardship, and a valued scope of
practice dedicated to meeting the needs of the society served. The 2010 revision of this contract
reaffirms the importance of social roots and nursing’s societal commitments at all levels of practice
and educational settings. The scope of nursing practice includes concerns about educational
content of nursing programs, clinical practice experiences, varied nursing roles, and population
needs.

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Needs of a Nation’s Families

Well-functioning societies need healthy people. So, a big question is how can the family
units that make up a society be healthier? What do families need most? In what ways do
the needs of individuals and families differ from those of society? What can nurses do bet-
ter? How do we set policy that encourages strong families? How do we provide the kinds
of care that people really need? Family-focused care can address immediate care needs but
it always asks about broader family concerns for now and in the future. Nurses who think
family remember that factors that influence illness and health transcend solitary settings
and single points in time.

As technologies change and information increases, real needs must be in the forefront
of care. Affordability and access to health care services are important, but so are answers
to questions about health equity and fair and just service distribution. For example, difficult
decisions about who gets what care are important. What are the most efficient, effective,
and affordable ways to manage the health of a nation’s families? If families are society’s
building blocks, then shouldn’t they be the focus of nurses’ attention?

A wide cast of health care professionals is needed to fulfill society’s needs. Nurses will
need to address the challenges that best fit within their scope of practice. Are there tradi-
tional practices that need to be questioned? What should stay the same and what must
change? What creative ideas can family nurses bring to practice? Attending to family
units and global perspectives both require some new practice models. How can nurses use
family-focused nursing as an avenue of change? What can nurses do to transform nursing
practice so that it better meets society’s needs?

Individual and Family Health Care Needs

Individuals and family units need clear information, adequate supports, and abilities to
self-manage health and illness at home. Consumers must be able to navigate through health
care systems. Some reorganization of care delivery is needed so individuals and family units
can have more active roles in their care (U.S. Department of Health and Human Services,
2011). Health care systems are discussed as if they existed but little about care delivery is
systematic. Families are rarely informed about what health care services to access. What
is needed? How do people decide when and where to go? How do they choose among
the public health department, a nearby clinic, or a medical practice? When should you
visit urgent care or an emergency department? Care consumers do not always have good
information about what steps to take.

Effective care delivery is not a motto, buzzword, or a mission statement. Effective care
provides what people want, the means to solve real problems and answer their questions.
Satisfaction levels are likely to be low if needs are ignored. Some people might even think
that this is a form of disrespect. We speak of being partners in care. A partner is an asso-
ciate, teammate, or collaborator. Partners have voices in decisions and make choices. Fam-
ilies need voices in the care they receive and need to be at the table where decisions are
made (Box 3.6).

Needed Changes in Acute and Inpatient Care

The Institute for Healthcare Improvement has provided leadership to improve inpatient stays
and hospital experiences (Box 3.7). Rather than being treated paternalistically, as in the past,
families should be considered an essential part of the care team. Nurses who think family do
that. Respectful partnerships equip people to participate in their care. They are encouraged

CHAPTER 3 ● Thinking Family to Guide Nursing Actions 57

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58 CHAPTER 3 ● Thinking Family to Guide Nursing Actions

BOX 3-6

Changes for Meeting Individual and Family Health Care Needs

ORGANIZ ATION PERSPECTIVE

Choices and decisions need to be made by
the persons most affected.

Safety is a concern inside the care setting,
but a critical need for those at home.

Family members are not obstacles in the way
of efficient care delivery, but important
caregivers with responsibilities to the
individual receiving care.

Patient and family satisfaction and outcomes
are likely to be improved when they are
empowered by nurses and other health
care professionals.

Family members are not just people to treat
politely or view as optional to meeting care
needs, but they are necessary and the true
caregivers.

PATIENT/FAMILY PERSPECTIVE

Consumers have choices and rights.

Individuals and family members need full
disclosure and clear explanation about what
is occurring in care settings.

Family members need to be informed about
diagnosis, care needs, ways to best support
unique individuals, and how to care for
themselves.

Individual and family members need
information about care to be given,
decisions that need to be made, problems
that might be encountered, and ways to
access needed supports and resources.

Individuals and family members want to be
involved, know what is expected, and be
prepared to meet the required needs in their
households.

BOX 3-7

Criteria for Ex cellent Acute Care Delivery

The Institute of Medicine (2001) recommends redesign of health care systems and aims for
improvement in six areas:

● Safety
● Effectiveness
● Patient-centeredness
● Timeliness
● Efficiency
● Equity

Care is respectful and responsive to individual needs, preferences, and values; it includes
listening, effective communication, and family presence.

to ask questions so that all aspects of the care delivery are understood. Box 3.8 suggests steps
nurses can use to gather information and use that evidence in nursing practice.

Nursing Care That Individuals Want and Need

What do people want when they enter health care settings? Research indicates that consumers
do not make rational choices based upon high-quality and low-priced care (Lubalin & Harris-
Kohetin, 1999). The weight given to quality-of-care information about health care services
chosen does not indicate how quality-of-care information is used (Faber, Bosch, Wollersheim,
Leatherman, & Grol, 2009). We lack strong evidence about the kinds of care most wanted.

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Persons seeking care find that good manners, kind treatment, friendliness, genuineness,
confidence, and passion of the nurses are important. Some of the best employees are identified
as persons who know their strengths and use them to make contributions. Responses to an
injection can be perceived differently. Those who receive injections from excellent nurses
might report feeling less pain. Differences between the two groups can result from the way
nurses set the stage before giving the injections. They might say something like “This might
hurt, but I will try to be gentle.” A show of empathy and compassion for the pain of the
experience can cause nurses to be higher on a likability scale. Personal skills such as showing
self-confidence, using etiquette, giving compliments, or using humor can help them seem
approachable and encourage conversation. The best nurses get more compliments than com-
plaints. Nurses who enjoy their work and create personal and positive experiences for those
in their care might be viewed as more trustworthy. Nurses often have different beliefs and
values than care recipients, but care experiences are transformed by use of nursing presence.

D elivering E x cellent N ursing C are

Excellent care is more than hospitality. W. Edwards Deming (2000) is widely known for his
work in quality measurement. He said that, if you cannot measure it, you cannot improve it.
He also said that even though care delivery is important, most people want an experience that
meets their unique needs. They want information they can use. Nurses who listen to individ-
uals and family members, provide human touch, and show empathy are valued by most.

Being in a strange bed, sitting alone in the emergency department, waiting to learn of
surgery outcomes, hearing unfamiliar medical jargon, and dealing with technical procedures
and clinical care systems can be stressful. Nurses who think family offer care that puts people
at ease, addresses fears, and answers questions. Dr. Marilyn Friedman was one of the first
nurses to pay careful attention to the need for completing family assessments; her textbooks
have been used by thousands of nursing students since the 1980s (Box 3.9).

H aving Meaningf ul C onversations

Nursing students and some nurses may fear having certain conversations with individuals.
They worry about saying the wrong thing or not knowing all the answers. Sometimes
talking with strangers and the uncertainty of what to discuss can be uncomfortable and
they avoid situations by busying themselves with tasks. But those diversionary tasks are

CHAPTER 3 ● Thinking Family to Guide Nursing Actions 59

BOX 3-8

Ideas for Moving Forw ard in Evidence-Based Practice

1. Define and clearly articulate the information needed to answer specific questions.
2. Identify and choose appropriate sources of information relevant to the question.
3. Develop and use clear and effective search strategies using predetermined terms.
4. Locate and retrieve all information that appears relevant to your question.
5. Evaluate the usefulness of the information retrieved.
6. Organize and analyze the information pertinent to your specific question.
7. Determine if any important facts relevant to the question asked are still missing

(e.g., economics, legal information, social aspects, policy).
8. Synthesize the findings in ways that best answer the question asked.
9. Determine the strength of the evidence used to answer the question asked.

10. Decide whether evidence identified is strong enough to alter practice or if more information
is needed.

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sometimes read as rudeness, disinterest, or not caring. For example, what does it mean if
the nurse has a furrowed brow when telling a person he has “bad veins?”

What is a meaningful conversation? It is not measured by length but by the quality of the
interaction. Maybe it demonstrates empathy. Perhaps it is about sharing what will happen in
a particular experience. What questions do families have as they wait for a surgical outcome?
If someone said it was an invasive surgery, what does that mean? Nurses might see some med-
ical procedures as mundane, but the family waiting might recall hearing about air bubbles
that could kill you, “blowing out” veins, or “bleeding out.” These ideas produce anxiety.

Speaking about death can be an awkward situation and too often these conversations never
occur. Yet it is an experience that all humans will face. When is the right time to speak of
death? Medical providers might be hesitant or sidestep the topic. Facing the end of life is not
a single or simple thing. It is shared with others. It can be a conversation that happens over
time. It might not occur until very late in treatment of stage 4 cancer, maybe only weeks or
even days before death is inevitable. What opportunities might be lost through this delay?

How do nurses gain expertise in conversing about uncomfortable things? How does one
learn the best ways to approach difficult subjects? Nursing students need skills and expe-
rience to be at ease. Sometimes it can be easier to talk with strangers than with those who
are closest. The best conversations are dialogues, involving give and take. The nurse might
say something like “When you think about what is happening, what is of most concern?”
When nurses think family, they realize dialogue means listening. Nurses are not required
to have “the answer” or give advice. Being an active listener is important. Active listeners
ask questions that encourage others to tell their story—it is not your story!

Family Content in Nursing Education

Ideas about nursing education are continually evolving but are based in the biomedical
model that guides medical diagnosis and illness treatment in the Western world. This

60 CHAPTER 3 ● Thinking Family to Guide Nursing Actions

BOX 3-9

Family Tree

Marilyn M. Friedman, PhD (United States)

Marilyn M. Friedman is professor emerita from the California State University School of Nursing in Los
Angeles, California. She is recognized as the author of the first family nursing textbook. In the late 1970s,
while teaching community health nursing to students, she recognized the lack of adequate teaching
materials about family care. She envisioned having a book to use in teaching nursing students that
would conceptually define family nursing practice. She developed a family assessment framework that
has been used by countless thousands of nurses as they have studied family and community health. She
used the sociological literature available at the time to create an assessment tool that could be used to
measure a family’s structural-functional dimensions. Dr. Friedman has made an important contribution
to nursing as she identified that family nursing is distinct and different from ideas of nursing care for
individuals. She has helped us realize the importance of family as the unit of care, differentiate potential
risks and needs of various types of families, understand the developmental stages of families, and
consider behaviors of a well family. Her early work enabled nurses to use theory as they considered the
health care needs of families and stressed the importance of completing a comprehensive family
assessment. In 1981, the first edition of Family Nursing: Theory and Assessment was published. Over the
years the book was revised several times (1986, 1992, 1998), and in 2003, the final version of Family
Nursing: Research, Theory, and Practice was published. In 2005, at the Seventh International Family
Nursing Conference in Victoria, British Columbia, Canada, Dr. Friedman was awarded the Distinguished
Contribution to Family Nursing Award for her important contributions to the field of family nursing.

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focus is on problems, issues that are “not normal.” Nurses learn to do health histories,
physical examination techniques, and observation, and use laboratory findings to
treat and manage illness. They are taught to view people across the life span and holis-
tically, including family and other related factors (e.g., culture, emotions, spirituality,
environment).

Yet nurses are not always well prepared to work with family units (e.g., involve them in
decision making, support caregiver needs, include them in care) in care settings (Institute
of Medicine, 2001) because their education is focused on episodic illness needs. They know
they are to address wellness, health promotion, and disease prevention, but do not always
know how. Nurses know that coordinated care is needed, but they are not always well pre-
pared to ensure that what is needed at home is addressed in the acute care setting. Nurses
who think family learn to organize care to anticipate unique needs that might occur in
different settings.

Preparation to Address Family Health Needs

To address family and societal health, nurses need to learn more about integrated care.
Integrated care is more than cures and treatments. It includes family health history, genetics,
current concerns, availability of support, adequacy of resources, personal goals, individual
values, community, and environments. It involves consultations with interprofessional care-
givers and use of conventional medicine and complementary therapy providers. Integrated
care uses an array of cost-effective therapeutic services and processes.

Changing the approach to nursing care requires changes in what is learned and how
that knowledge is applied in practice. Perhaps concepts of wellness, the power of the brain,
and mind-body relationships need more attention. Letting go of tradition, changing ideas
previously learned, and incorporating new knowledge may not be easy. How can nurses
be leaders in delivery of new care forms? Will nurses lead or will they follow? Dr. Marilyn
McCubbin is an example of a leader; her work has helped nurses around the world under-
stand the problem of stress for individuals and families (Box 3.10).

CHAPTER 3 ● Thinking Family to Guide Nursing Actions 61

BOX 3-10

Family Tree

Marilyn McCub b in, PhD (United States)

Dr. Marilyn McCubbin served as the former faculty director at the University of Wisconsin–Madison
School of Nursing and as the director of the Nursing Center for Research on Health Disparities at the
University of Hawaii at Manoa. Along with her husband, she developed the Resiliency Model of
Family Stress, Adjustment and Adaptation. Her research and scholarship advanced knowledge of
family responses in health and illness and provided important directions to health professionals who
worked to improve family care. Her research underscores the importance of strengthening
individual and family resiliency as a mechanism for improving family adaptation. Dr. McCubbin’s
work was instrumental in changing the ways in which we understand and conduct research about
families with chronic illness. Her important work has moved the focus from family dysfunction and
pathology to family resiliency and adaptation. Her work has been translated into German and
Icelandic and contributed to our understanding about families from Germany, Korea, Japan, Iceland,
Thailand, Taiwan, and the United States. In 1996, Dr. McCubbin was selected as a Fellow in the
American Academy of Nursing in recognition of her significant nursing leadership in the United
States. She has also received an award from the Family Health Research Section of the Midwest
Nursing Research Society and, in 2007, was awarded for her distinguished contribution to family
nursing research at the Eighth International Family Nursing Conference in Thailand.

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To think family, nurses need to include family responses to health and illness, have
greater communication expertise, and be more familiar with family dynamics, health policy,
and ways to do family interventions. Becoming a family nurse requires exposure to the
lived experiences and concerns of those receiving care. It also involves the ability to perceive
things from a different point of view.

Varied clinical experiences that allow nursing students to see broad life experiences
of individuals and their families are needed (Benner, Sutphen, Leonard, & Day, 2009).
These exposures can provide greater insights about larger life experiences. That means
reaching beyond personal knowing and experience and investigating the other—those
different from you. What does health or illness mean personally? Do personal views dif-
fer from those of other family members? Is the family prepared to handle needs related
to an illness, injury, or disability? Clinical situations suggest questions about ways to
think family.

Shifting the Focus to Family

Learning to think family requires some new care orientations and philosophies. How can
societal care and efficient, cost-effective, high-quality, and safe individual care be delivered?
What is the best way to meet needs? How can nursing practice be transformed so that it
meets the unique care needs of particular individuals and families?

Shifting focus from individual to family care will not occur without some battles. Most
health care experiences involve only the individual. Some family members may accompany
the person to the visit or sit in waiting areas, but they are neither addressed nor included
in the care delivery. Unlike in some countries, home care in the United States is mainly for
people with disabilities, those unable to travel, and those who are dying with hospice care.
Most nurses never learn about household experiences because they never see individuals
in their home settings. For example, hospitalized individuals in Malawi are dependent upon
family members to bring food from home daily. Their overcrowded hospitals are just not
prepared to provide for this basic need. Thus, family remains a constant in each individual’s
life and nurses see them and identify their important caring roles.

Learning to think family is a process. Intentionally focusing one’s mind on family as a
critical aspect of individual care might seem tedious at first. Family-focused nursing care
has expectations whether family is present or not. Think about yourself; although your
family is not always physically present, your family is still with you. Human connections
occur in minds and hearts. Family-focused care is more than just comfort care, it includes
intentional nursing involvement to satisfy unique needs presented.

Approaches to Family Care

Being a family nurse cannot be prescriptive. All will not look or act the same. A definition
of a family nurse is one who identifies and attends to family as the unit of care in a breadth
of care situations. Classroom, peer, and clinical experiences help one practice and gain un-
derstandings about the variety and breadth of family experience. Box 3.11 identifies dif-
ferent forms of nursing care, family-friendly care, and family-focused care. Box 3.12
differentiates individual and family care approaches.

Inadequate preparation for thinking family is a roadblock to providing family-focused
care. Being a family nurse means investing time and examining personal assumptions and
biases, incorporating evidence about complex family lives into practice, and honing skills
for working with family units living in diverse community settings.

62 CHAPTER 3 ● Thinking Family to Guide Nursing Actions

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Denham, Sharon, et al. Family Focused Nursing Care, F. A. Davis Company, 2015. ProQuest Ebook Central,
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CHAPTER 3 ● Thinking Family to Guide Nursing Actions 63

BOX 3-11

Diverse Forms of Family Care

Primary focus

Nursing role

Individual’s role

Family role

FAMILY-FOCUSED
CARE

Family as care unit:
Intentionally included
Inclusion
Holistic measures
Support
Empowerment

Collaborator or partner

Care recipient

Care participant

TRADITIONAL
NURSING CARE

Individuals:
Acute or presenting

needs
Cure or “ fixing” the

problem
Treatments
Procedures

Expert

Care seeker

Not involved in care

FAMILY-FRIENDLY
CARE

Aesthetics:
Sitting rooms
Open visiting hours
Private spaces
Comfort measures

Consultant

Care recipient

Care recipient

BOX 3-12

Comparison of Individual and Family Care Focus

AREA

Care settings

Assumptions

Solutions to
concerns

FAMILY CARE FOCUS

Care needs in traditional and other
care settings (e.g., hospice, public
health, community)

Family household
Aware of importance of family roles in

care

Complex interrelated care needs
include family members and
household perspectives

Individuals include family, and
household members are part of
self-management

Individuals are never isolated from
others and needs of multiple
interdependent persons must be met

Assess needs and capacities of multiple
members for needs linked with
education and counseling

Interventions target needs of multiple
family members and household
concerns

INDIVIDUAL CARE FOCUS

Traditional approaches in
diverse health care settings
(e.g., acute care, ambulatory
care, mental health, nursing
home, rehabilitation)

Diagnose and treat
Individuals make decisions and

family might be involved
Individuals act alone and self-

management is tied to
individual

Meet needs of solitary persons

Educate and counsel single
persons

Interventions target single
individuals

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Practical Application of Family Content

Knowledge about families is useful when it can be artfully applied to situations in ways
that meets care recipients’ needs. Nurses who think family act responsively and deliber-
ately to address diverse needs during clinical care situations. That approach requires prior
thought and preplanning to select purposeful actions that satisfy distinct needs. Skillfully
applying what has been learned in deliberate ways to satisfy family unit’s needs is the
backbone of family nursing. Using deliberate actions implies that the nurse performs as
follows:

• Exerts conscious efforts to reflect on assessed and voiced concerns.
• Enters into interactions with individuals about family unit concerns that provide

answers to questions and information or support for identified problems.
• Collaborates with the family unit to identify solutions.
• Assists family units with finding needed resources.
• Evaluates care outcomes.

Thinking family is not just a cognitive experience, it is an attitude that nurses develop
and use. Family nurses know that families have similar needs, but express them in unique
ways. For example, the initial loss of vision in a 48-year-old woman with type 1 diabetes
may result in uncertainty and fear about the future. However, if the nurse doesn’t under-
stand the concerns of family household members, ideas about what is needed are vague.
Asking questions will clarify those needs: Does she have a job and will the vision loss
affect her economic security? Is she the only driver in the family? What safety risks need
to be considered? Is she the caregiver for others? What adaptations need to be made in
her lifestyle? In what ways does she need assistance and who will help her? How will
she spend her time if she cannot see? Is she responsible for cooking and cleaning? How
will she manage daily activities without her vision? As the answers are forthcoming, it is
likely that additional questions will arise. What will this vision loss mean to other family
members? What are their questions and needs? Thinking family recognizes that every
diagnosis not only raises questions for the individual, but also for the family unit. Think-
ing family encourages potential vulnerabilities of the individual and family unit to be
disclosed (Fig. 3.2).

64 CHAPTER 3 ● Thinking Family to Guide Nursing Actions

FIGURE 3 -2 Nurse uses
deliberate actions to collaborate
with a family.

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We tend to connect with what we know and have previously experienced. What do you
know about yourself?

• Do you acknowledge the way things are or the way you want them to be?
• What is it like for you to be vulnerable?
• How do you experience others when they are vulnerable?

Learning new things sometimes means earlier ideas have to be unlearned or modified and
that is not easy. Are you aware of things that you might need to unlearn as you consider
thinking family? For example, does your behavior change in different situations (e.g., in an
elevator, waiting in line, sitting in a waiting room, being with friends)? When we are in
familiar situations, we know how to speak, where to look, and how to behave. In America,
it is customary to walk to the right and let persons pass on the left. Did someone teach this
to us? Or did we learn through observation? Notice how awkward it seems when someone
tries to pass you on the right side. Yet, persons in other cultures might find our ways unnat-
ural. Learning to forfeit what seems natural to learn new approaches takes time and effort.

G aining C onf idence

How is the confidence to interact with individuals and family units gained? Research used
a pre- and post-test design to examine the self-efficacy of nursing students in a family nursing
clinical practicum as they learned about family practice, home visiting, and collaborative
practice (Ford-Gilboe, Laschinger, Laforet-Fliesser, Ward-Griffin, & Foran, 1997). Self-
efficacy is the term used to explain perceptions about abilities to be successful in specific
situations (Bandura, 1971). Perceptions of success are often remembered observations made
over time. Those with high self-efficacy are likely to believe they perform well and often see
difficult tasks as things to be mastered not things to avoid. Students took the pre-tests at
the beginning of the school year and then again at 4 and 8 months later. It was only after
the second post-test that their self-efficacy was noted to demonstrate significant difference.
This study found that performing family nursing skills in a clinical setting was an essential
source for gaining self-efficacy. Another study completed with nursing students in a com-
munity setting yielded similar results (Laschinger, McWilliam, & Weston, 1999). So, learning
and practicing skills in clinical settings can enhance self-confidence and perhaps skill use.

Th inking Family

The idea of thinking family is not new to this textbook. In 1997, a paper published by
Clarissa Green described that concept as a primary building block for nursing care. She
explained that this idea involved “understanding and appreciating the interactive complex-
ity of family life from a systems perspective” (p 231). She suggested that a critical focus of
nursing practice should be aimed at helping families develop skills and confidence in man-
aging illness experiences and adjusting to challenges.

Students had previously completed a course in basic family dynamics. One assignment
involved topics in a fictitious case (e.g., divorce, substance abuse, a caregiving crisis, an
unexpected serious illness, loss associated with death, financial vulnerability). A second
major assignment involved the student development of a fictional family to answer the
question: “What is this family’s experience with difficulty?” Students found these topics
challenging because they did not have much personal experience with conditions in family
lives. The cases caused students to focus on three things: (a) factors contributing to or shap-
ing the situation and related pertinent history, (b) family behaviors exhibited, and (c) what
happens over time as the family members cope with difficulties. Students worked in small

CHAPTER 3 ● Thinking Family to Guide Nursing Actions 65

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groups to consider what would constitute effective discharge planning, ways family health
policies influence caregiving capacity, tools family members need to provide adequate care,
and ways problems affect family roles, decision making, and health practices. Students
were engaged with the ideas, but also evaluated their own thinking. The cases challenged
the students and caused emotional responses and some personal discomfort. Students
learned about strengths in troubled families and found that even big problems can get
resolved without long-term harm to family members. Students were frustrated when they
realized that they were ill-equipped to make their families do anything; it was family mem-
bers and their unique circumstances that guided outcomes. Activities such as these are frus-
trating at times, but learning from them can help one gain the ability to think family.

Putting Family K now ledge into Actions

Critical thinking, decision making, problem solving, and effective communication are essential
skills to master to be an effective family nurse. Varied laboratory and clinical experiences pro-
vide great opportunities to focus on the reading, writing, listening, talking, and reflecting
needed to actively learn these skills. Simulated laboratory experiences can incorporate thinking
family into case scenarios and provide time for shared learning experiences during debriefing.

In those experiences, the nurse begins to learn about family care. What does the family
want to achieve? What things are needed? Even small changes in the right direction can
provide a sense of accomplishment. You might not focus on personal concerns but rather
on the immediate family need. For example, how will I answer questions about turning
off the ventilator and allowing their father to die? Small things count. Listening, being
present, and showing genuine care can make it easier to have difficult conversations once
a trusting relationship is formed. Most people know that easy answers to hard questions
do not exist.

Spending time doing critical analysis of family nursing and how it fits with nursing prac-
tice enhances practice (Hartwick, 1998). Sharing personal stories among peers can affirm
that other families with different experiences can have similar responses. Nurses find other
useful ways to handle problem situations and collaborate with family members by hearing
what their colleagues have done. Nurses who think family are in touch with emotions and
notice ways they respond to others.

O bj ective and Subj ective Asp ects of N ursing Practice

Nursing care is objective because it uses scientific evidence, skills, knowledge, formal poli-
cies, and standard procedures to guide care implementation. This objective work relates
to the science of nursing. However, in the performance of care, the practice of nursing is
also subjective and an art. For example, consider two nurses who perform the same pro-
cedure with a hospitalized person. Both nurses carefully follow the same steps of the pro-
cedure and demonstrate knowledge, skills, and competency. In reviewing the outcomes,
one might find that satisfaction does not rest in nurses’ competency skills. Responses to
the treatment might relate to the nurse’s attitude or behaviors. A business-like nurse might
be seen as less helpful and receive a lower satisfaction score than the outgoing nurse who
engages in conversation and appears genuinely interested. Thinking family has both ob-
jective and subjective aspects in care delivery. See the case study about a family facing many
dilemmas when trying to understand health care (Box 3.13).

Work with families requires emotional balance or what some might call emotional intel-
ligence. One needs to show concern, but not demonstrate extremes. Family nurses are not
without emotion. They respectfully show empathy and compassion, but remain logical and
competent. Nurses are bound to have times when intense emotions are triggered. Also, people
show emotions differently. Critically reflecting on laboratory simulation or clinical experiences

66 CHAPTER 3 ● Thinking Family to Guide Nursing Actions

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allows nurses to safely discuss responses to care situations. Reflection about things that hap-
pened in clinical environments can help one examine alternative ways to approach care.

Interacting w ith Families

Family members can be intimidating. The following situation illustrates this point. A co-
worker came to the nurses’ station and asked if she could be reassigned to a different patient
as she was quite disturbed by the way the patient’s wife acted. It seems she had a notebook
and every time the nurse entered the room, she wrote something down. The nurse complained,
“She makes me nervous, I think she is trying to build a case against me for a lawsuit.” The
nurse manager went to speak with the wife and inquired: “I see that you are writing things
down in a book. . . .” The wife readily answered: “I am trying to keep a record of things, so
I will remember them later. People come and go all day and each one tells me things. My memory
is not as good as it used to be. Things happen one after another all day and it gets confusing.
I am afraid I will forget, so I just write it down. Besides, it gives me something to do.”

Boredom and confusion that come from sitting all day in a hospital room seemed good
reasons to keep a written record. She was not trying to catch anyone doing something
wrong, but merely passing time and ensuring that she could recall things later. A brief con-
versation easily clarified things. The other nurse was informed about reasons for writing.
Later that day, the first nurse reported that she had spoken with the woman and discovered
that they shared a common interest in quilting. Finding ways to relieve anxieties and get
better acquainted with family members is a good way to correct false perceptions.

CHAPTER 3 ● Thinking Family to Guide Nursing Actions 67

BOX 3-13

Family Circle

Larry Hopsen had an excellent job until the recession hit. After a year of fear and frustration as he looked
for work, he found a job. On his first day, he attended an orientation program and received information
about health insurance options. He was told to return the paperwork by the end of the week. He took
the papers home and gave them to his wife. She asked, “What do you want me to do with this?” He
replied, “We have to choose a plan.” The Hopsens are in their early 30s and have two children. David,
their 2-year-old, was born with a form of spina bifida called meningocele. Sandra has just turned 4 and
appears healthy. Larry had asthma as a child, but it was well controlled until they moved into this new
apartment, which seems to have mold. The Hopsens think that they might want another child. Mrs.
Hopsen experienced gestational diabetes with Sandra. Many Americans do not understand their health
insurance plans. They do not know how to choose a plan. If you were to counsel the Hopsen family,
what would you suggest they consider? Consumers need two skills to understand health plans. One is
the ability to read and understand the choices. The second need is numeracy, or the ability to reason
with numbers and use mathematical concepts. Here are some questions to consider:

Traditional approach:

1. What can you afford? What are the monthly, quarterly, or annual payments?
2. How much is the co-pay? Are there any deductibles?
3. Are you or is anyone in your family being treated for any illnesses?

Family-focused approach:

1. What is the best value for your family? Tell me about potential problems in your family that
might lead to health concerns.

2. Do you have any questions about the meanings of terms like co-insurance, annual benefit
limit, out-of-pocket limit, drug tier, or allowed amount?

3. Is anyone in your family taking any specialty drugs? Do you know how much they cost?

It is a good idea to focus on wellness and health. Let us review the health care plans together
and see what each family member needs.

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W orking w ith D if f icult Situations

Some situations can be difficult. For example, one might seem to be an intruder when en-
tering a space that a family seems to claim as theirs. Maintaining privacy is not easy in an
acute care setting. As nurses and others attend to clinical care needs, they often disrupt
conversations. Nurses who think family learn ways to enter a family’s private space. For
example, concerns about genetics and related diseases can be troubling for families.
Dr. Marcia VanRiper has long engaged in research with families with Down syndrome and
has demonstrated many ways nurses can work with these families (Box 3.14). They manage
some common problems, such as setting boundaries, forming relationships, and finding
things to talk about and learn to effectively ask tough questions.

Wondering what you will talk about with a family can be troubling, but recognizing
the family’s strengths and competence can help (Wright & Leahey, 2013). For instance,
the nurse might say: “Today, when the doctor explained the surgical procedure to your
wife, I noticed that you listened carefully and asked several good questions.” This positive
remark might be followed with something like: “I was just wondering if all of your ques-
tions were answered or if there is something else you would like to know.” Entering a
conversation in this manner can seem welcoming and easy conversation can follow. Some-
times it is useful to be silent and just listen, then commend actions or behavior and ask
for further details. Routine use of immediate and delayed affirmative responses can engage
family members in useful conversations.

U sing N arrative Ap p roach es

A narrative approach can encourage family members to tell stories linked with everyday
concerns and suffering; it is a valuable way for nurses to learn ways to take actions (Chesla,
2005). Conversation and stories can put family members at ease. It is good to have a few
general questions that you can use in speaking with any family member, such as, what is
most troubling to you about this situation? What can I do today to put you most at ease?

68 CHAPTER 3 ● Thinking Family to Guide Nursing Actions

BOX 3-14

Evidence-Based Family Nursing Practice

Marcia Van Riper, RN, PhD (United States)

Dr. Van Riper is currently a Professor at University of North Carolina at Chapel Hill, with a joint
appointment in the School of Nursing and the Carolina Center for Genome Sciences. Dr. Van Riper
teaches genetics courses. The main focus of Dr. Van Riper’s research has been the family experience of
being tested for or living with a genetic condition. She has conducted numerous studies with
national and international colleagues concerning families of children with Down syndrome. Dr. Van
Riper completed a Mentored Research Scientist Career Development Award where she examined
how families define and manage the ethical issues that emerge during four types of genetic testing:
maternal serum screening for Down syndrome, carrier testing for cystic fibrosis
(CF), B RCA1 and B RCA2 testing for families at high risk for breast cancer, and mutation analysis for
Huntington disease. As part of this work, she engaged in a 3-year intensive, supervised career
development/training plan that included (a) formal coursework in genetics, bioethics, and qualitative
methods, and (b) interdisciplinary experiences, such as clinic and laboratory rotations, case rounds,
journal clubs, and workshops. She recently completed a study about feeding issues in children with
Down syndrome. Other work includes pilot studies on how minority families make sense of and use
the results of genetic testing. Dr. Van Riper has been active in ISONG and served as the first president
of the International Association for Family Nursing.

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What do you think is the biggest problem your family needs to solve? Who is having the
greatest difficulty? Family members will tell their stories if invited. Family insights offer
the best guidance for nursing intervention. Meaningful conversations with family members
create a therapeutic context for healing changes. Stories can help nurses gather information,
organize it, make sense of it, and use it to plan nursing actions or interventions.

Chapter Summary

Nurses need to understand the ways health and illness are defined and regarded by the
larger society. Not everyone sees these conditions in the same ways. Families are the
building blocks of a society. Some health care services may not be what the family needs
most Nurses have a social contract. this encourages them to think about what society
needs and apply this understanding to the nation’s families. The family household has
great sway in determining individuals’ needs and resources. Much about health and
illness is learned first from family and then influenced by larger societal forces. Individ-
uals stay healthy or get sick in the presence of family members. Nurses who think family
can take the reins in modifying clinical practice so that it better addresses family and
societal needs. These nurses are keenly aware of the complex factors that influence
health and illness.

Providing family care does not always come naturally. Practicing skills in class, in clinical
situations, and with peers can be useful for determining the best ways to provide family-
focused nursing care. This chapter introduces many topics that will be explored more
deeply later in this book.

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