Study Guide for Exam 2

American Indians/Alaska Natives

"American Indian or Alaskan Native" (AIAN) refers to people who have origins of North and South America (including Central America) and who maintain tribal affiliation or community attachment (Humes et al., 2011). Native Americans lived in America for thousands of years before the arrival of Europeans. AIANs are the original people of the land now occupied mainly by the Europeans. Evidence shows that AIANs have settled in North America for more than 75,000 years (Josephy, 1991). Native Americans came to be known as Indians, a label given by Columbus when he encountered the native peoples in the West Indies that he mistook for the East Indies. This label was then extended to all the native peoples of North and South America, from the Arctic to Tierra del Fuego. Before 1492 there were an estimated 5 million Native Americans. Columbus' discovery brought colonization and settlement by various European groups (Snipp, 2000). Thus, the ancestral lands of the Native Americans were usurped, and the people were forced to labor on farms and in mines. Thousands died from disease and hard labor or were killed in attempts to escape from slavery. Other events, such as the removal of the Southeastern tribes in 1830, the Navajos' Long March to Fort Sumner in 1864, and the massacre at Wounded Knee in 1890, caused the Native American population to dwindle to 250,000 by 1890 (Fixico et al., 2001). In 2010, 5.2 million people in the United States were identified as American Indian and Alaska Native, about 1.7% of the total U.S. population (U.S. Census Bureau, 2012d). Native Americans are concentrated in Oklahoma, California, Arizona, New Mexico, Alaska, Washington, North Carolina, Texas, New York, and Michigan. Of the total Native American population, 22% live on reservations or other trust lands and about 60% live in metropolitan areas (The Office of Minority Health, 2012a). There are 565 federally recognized AIAN tribes, and more than 100 state recognized tribes (The Office of Minority Health, 2012a). The Cherokees make up the largest tribe (Ogunwole, 2006). Native American percentages for higher education degrees are low in proportion to their total number. Among American Indians and Alaska Natives who are 25 and older, 13% obtained a bachelor's degree or higher (U.S. Census Bureau, 2012d). Native Americans are making some progress in all levels of college education. However, low continuing educational attainment and low income levels combined with higher rates of poverty are socioeconomic issues that affect health and the quality of life of this population. Native Americans experience the many negative situations that confront poor people both on the reservations and in the larger society. Health Care Issues of Native Americans Many of the health problems of Native Americans can be linked directly to the social and economic conditions described here. These conditions predispose Native Americans to illnesses and health problems that afflict the poor. Some of these problems have been discussed in the section on BAAs. Although Native Americans have responded well to prevention and treatment of infectious diseases, other health problems are closely linked with poverty and harmful lifestyle practices (The Office of Minority Health, 2012a). Cultural barriers, geographic isolation, inadequate sewage disposal, and low income are factors that prevent American Indians/Alaska Natives from receiving quality medical care. Some of the leading diseases and causes of death among American Indians/Alaska Natives are heart disease, cancer, unintentional injuries (accidents), diabetes, and stroke. American Indians/Alaska Natives also have a high prevalence and risk factors for mental health and suicide, obesity, substance abuse, sudden infant death syndrome (SIDS), teenage pregnancy, liver disease, and hepatitis (The Office of Minority Health, 2012a). American Indians and Alaska Natives have an infant death rate 60% higher than the rate for non-Hispanic White Americans (The Office of Minority Health, 2012a). Native American adults are 2.1 times more likely than White adults to have diabetes (The Office of Minority Health, 2012b). AI/ANs have disproportionately high death rates from unintentional injuries and suicide (The Office of Minority Health, 2012a). Many mental health problems also confront Native Americans. Difficult life situations and stresses of daily life contribute to an array of problems, including feelings of hopelessness, desperation, family dissolution, and substance abuse, specifically alcohol. Native Americans are twice as likely to have hepatic cancer and more likely to be obese than White adults. Their AIDS rates are 40% higher compared to non-Hispanic Whites (Centers for Disease Control and Prevention, 2011b). The infant mortality rate is 1.6 times that of non-Hispanic Whites (The Office of Minority Health, 2012a). The health problems of Native Americans are complicated by difficult access to health care. Poor health and limited health care options among urban American Indian and Alaska Native populations have been well documented in many studies (The Office of Minority Health, 2012a). Since 1972, the Indian Health Service (IHS), a government agency in the U.S. Department of Health and Human Services, has stated a series of initiatives to fund health-related activities in off-reservation settings, which make health care services accessible to urban American Indians and Alaska Natives. Federally recognized tribes are provided health and educational assistance through IHS (The Office of Minority Health, 2012a). Approximately 1.9 million American Indians and Alaska Natives receive a health service delivery system operated by the IHS. About 36% of the IHS service area population resides in non-Indian areas, and 600,000 are served in urban clinics (The Office of Minority Health, 2012a). Even though the IHS attempts to provide comprehensive, high-quality health care services to AIAN people, the quality of care and access to health services need to be improved.

Chapter 2: Emerging Populations and Health (Edelman et al., 2014, pp. 22-34)

* Health Disparities and Health Equality ○Many magnitudes of disparity, particularly in health, exist in the United States. There has been a growing awareness that racial and ethnic minority groups experienced poorer health compared to the general population in the United States. Various factors such as race or ethnicity, gender, age, disability, and socioeconomic status contribute to an individual's capability to attain good health. Healthy People 2020 endeavors to improve the health of all groups (Hansen, 2011). "Health disparities" is an umbrella term that includes disparities in health and in health care. It was defined by Healthy People 2020 as "a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage," and "health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion" (U.S. Department of Health and Human Services, 2011). Health disparities represent a lack of efficiency within the health care system and account for unnecessary costs and diminish the quality of life for persons seeking care (Hansen, 2011). "Health equity" is the accomplishment of the highest level of health for all people. Attaining health equity requires valuing everyone equally with focused and ongoing societal efforts to deal with preventable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities (U.S. Department of Health and Human Services, 2011). Although the diversity of the American population is one of the best assets for this country, one of the greatest challenges is reducing the disparity in health status of America's racial and ethnic minorities and other health disparity populations. The U.S. Department of Health and Human Services (2011) and the Institute of Medicine (IOM, 2008) have well documented that racial and ethnic minorities, compared to Whites, have less access to health care, receive lower-quality health care, and have higher rates of illness, injury, and premature death. The issue of racial and ethnic health disparities has become one of the most urgent problems to plague the U.S. health care system. Efforts to eliminate disparities and achieve health equity have focused primarily on diseases or illnesses and on health care services. However, the absence of disease does not automatically equate to good health. An individual's ability to achieve good health could be affected because of race or ethnicity, gender, sexual identity, age, disability, socioeconomic status, and geographic location. * Emerging Populations in the United States ○Currently, emerging populations include ethnic minorities and persons who are homeless. Ethnic minority populations could include Asian Americans/Pacific Islanders, Blacks/African Americans, Latinos/Hispanic Americans, Native Americans, and Arab Americans (Box 2-1: Healthy People 2020). The increasing population of immigrants has been a significant contributor to the presence of increasing numbers of major ethnic groups in the United States. Between 2000 and 2010, the immigrant population in the United States increased by 8.8 million (Migration Policy Institute, 2012). In 2009 the U.S. immigrant population accounted for about 12.5% of the total U.S. population (Batalova & Terrazas, 2010). One in three Americans in the United States identifies himself/herself as African American, American Indian/Alaska Native, Asian, Native Hawaiian/Pacific Islander, Hispanic/Latino, or multiracial. It was estimated that this number is expected to increase to one in two Americans by 2050 (Kaiser Family Foundation, 2008). The increasing populations of ethnic groups are one of many factors producing disparities in health status and access to the health care system in the United States. The disparities in the health care system may cause increases of social costs attributable to the lost productivity or use of health care services among the ethnic minority populations.

Chapter 10: Health Education (Edelman et al., 2014, pp. 214-218 & 221)

* Healthy People 2020 and Box 10-1 Healthy People 2020: Selected Health Promotion... *Nursing and Health Education *Goals - Health Literacy and Box 10-2: Quality and Safety Scenario... * Diversity and Health Teaching (p. 221)

Health Care Issues and Selected Health-Related Cultural Aspects, of:

* Latino/Hispanic Americans ○The terms Hispanic or Latino are used interchangeably because the Office of Management and Budget (OMB) demands federal agencies to use a "Hispanic or Latino" category to identify individuals from specific national origin. The OMB definition of Hispanic or Latino origin "refers to a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race." The largest Hispanic American subgroups are Mexicans, Puerto Ricans, and Cubans. Most Hispanics live in Texas, New York, Florida, and California (The Office of Minority Health, 2012d). ○Data from U.S. Census 2010 showed that the 50.5 million Latino/Hispanic people of the United States accounted for 16.3% of the total U.S. population, making this population the nation's largest ethnic or racial minority (U.S. Census Bureau, 2012c). A 43% increase in the Hispanic population between 2000 and 2010 makes Hispanics the fastest-growing minority group in the United States. It was estimated that the Hispanic population of the United States will constitute 30% of the nation's population by 2050 (U.S. Census Bureau, 2012c). The large size of the Hispanic population makes Mexico the only country worldwide that has a larger Hispanic population than the United States, and 63% of people of Hispanic descent in the United States were from Mexico (U.S. Census Bureau, 2012c). About 76% of Hispanics age 5 years and older speak Spanish at home, and more than half of these Spanish speakers speak English "very well" (U.S. Census Bureau, 2012c). The poverty rate among Hispanics increased from 23.2% in 2008 to 25.3% in 2009, and the percentage of Hispanics who lacked health insurance also increased from 30.7% in 2008 to 32.4% in 2009. Among the Hispanic population 25 years and older, 14% of them had a bachelor's degree or higher level of education in 2010. Hispanic Americans' health is often associated with factors such as language/cultural barriers, lack of access to preventive care, and lack of health insurance. Latinos/Hispanic Americans (LHAs) have many health issues complicated by multiple cultural, economic, political, and social factors. Hispanics are the highest uninsured racial or ethnic group within the United States (U.S. Census Bureau, 2012c). The leading causes of illness and death among Hispanics include heart disease, cancer, HIV/AIDS, stroke, and diabetes. Hispanic men and women have higher incidence and mortality rates for stomach cancer (U.S. Department of Health and Human Services, CDC, 2012a). Mexican American adults are almost 2 times more likely than non-Hispanic Whites to have diabetes and 1.5 times as likely to die from this disease (U.S. Department of Health and Human Services, CDC, 2012b). Although cardiovascular disease (U.S. Department of Health and Human Services, 2011) and cancer are the first and second causes of morbidity and mortality among LHAs, their incidence in the general population is higher (U.S. Department of Health and Human Services, CDC, 2012a). Hispanic women were less likely to have a mammogram within the past 2 years; however, they were slightly more likely to have a Pap smear during the past 3 years when compared to non-Hispanic White women (U.S. Department of Health and Human Services, CDC, 2012a). In addition, Hispanic adults age 50 and over were 34% less likely to report having colonoscopy, sigmoidoscopy, or proctoscopy as non-Hispanic Whites (Agency for Healthcare Research and Quality [AHRQ], 2011). Hispanic adults living in the United States generally have lower rates of prostate and breast cancer as compared to non-Hispanic White adults (U.S. Department of Health and Human Services, CDC, 2012a). Some other health conditions and risk factors that significantly affect Hispanics include asthma, chronic obstructive pulmonary disease, HIV/AIDS, obesity, suicide, and liver disease. LHAs had the second-largest numbers of persons with HIV/AIDS at the close of 2005 (Centers for Disease Control and Prevention, 2011b). The difficulties experienced by LHAs in receiving appropriate health care services are comparable to those of the poor and other ethnic minorities. Other barriers include the lack of racial and ethnic diversity in the leadership and workforce of the health care system, lack of interpreter services for Spanish-speaking people, and lack of or inadequate culturally appropriate health care resources. Many Hispanic Americans may not readily seek care because they have continued reliance on their folk system of healing. Their preference for this is logical given their lack of health insurance and perceived difficulties negotiating the health care system because of language and other sociocultural barriers. * Blacks/African Americans ○The "Black or African American" (BAA) refers to people having origins in any of the Black racial groups of Africa (Humes et al., 2011). According to the 2010 Census, the 4.2 million people of the Black/African American population made up 13.6% of the total U.S. population, and it is estimated that this population would constitute 15% of the total population of the United States (U.S. Census Bureau, 2012b). African Americans are the second largest minority population, following the Hispanic/Latino population (U.S. Census Bureau, 2012b). As one of the largest ethnic groups in the United States, Blacks/African Americans are considered a minority group, a label originating from their slavery roots. Therefore, they continue, in many ways, to experience extreme segregation and exclusion from mainstream society, and discrimination by the majority group. The majority of Blacks in the United States lived in the Southern states with the largest Black population in 2010 found in New York, Florida, Texas, Georgia, California, North Carolina, Illinois, Maryland, Virginia, and Ohio (The Office of Minority Health, 2012e). BAAs that lived outside of the South have a tendency to be more concentrated in metropolitan areas. The places with the largest Black population were New York, Chicago, and Detroit, and Michigan was the state with the greatest proportion of BAAs (Rastogi et al., 2011). BAAs have made substantial progress in many areas in the past century. However, there are still inequities in many areas such as business, education, political participation, and leadership. The reports of the 2010 U.S. Census indicated that the rate of living at the poverty level for African Americans was three times that for non-Hispanic Whites (The Office of Minority Health, 2012e). Educationally, BAAs have made substantial gains; 18% of Black/African Americans who were 25 or older had a bachelor's degree or more in 2010 (U.S. Census Bureau, 2012b). A complex set of social, economic, and environmental factors can be identified as contributors to the current health status of Blacks/African Americans. However, poverty may be the most profound and pervasive determinant of health status. Individuals and families who are below the poverty level or lack adequate resources have limited access to health care services such as prenatal and maternal care, childhood immunizations, dental checkups, well-child care, and a wide range of other health promoting and preventive services. In 2010 the poverty rate in this population was reported as 27.4%; 20.8% of this population was reported without health insurance during all or part of 2010 (U.S. Census Bureau, 2012b). Two indices of the effects of poverty can be seen in the high rates of infant mortality and maternal mortality. Despite changes in living conditions, advances in infection control, and improved standards in neonatal care, BAAs still experience high infant and maternal mortality rates. In 2007 the infant mortality rate for BAAs was 2.4 times higher than that of non-Hispanic Whites (The Office of Minority Health, 2011b). BAAs have the second-highest percentage of women who lack prenatal care in the first trimester of pregnancy (The Office of Minority Health, 2011b). African Americans have lower life expectancies than other races at age 65. In 2010 life expectancy for African American males was 79 years compared to 82 for all American males. For BAA females, life expectancy was 83 years compared to 85 in all female Americans (U.S. Social Security Administration, 2012). Black American children living below the poverty level also experience numerous health problems, including malnutrition, anemia, and lead poisoning. These problems and the lack of immunizations combine to inhibit normal growth and development and affect school performance. Poverty-stricken families usually live in depressed socioeconomic areas where housing conditions are unsafe and unhygienic. Unsafe buildings and other environmental structures cause accidents and injuries among young children. Young children have fallen to their deaths from windows that were unprotected by metal railings. Older people have suffered falls and other injuries from poorly lit stairways and hallways. Other hazards include uncollected garbage and abandoned buildings that are used as dumpsites or as meeting places for a variety of illegal activities. African Americans are affected disproportionately by the leading causes of death in the United States, including cancer, HIV/AIDS, obesity, diabetes, heart disease, and hypertension. The incidence of cancer and mortality rates for BAAs is higher than that for White Americans. In 2007 the death rate for African Americans was higher than that of Whites for heart diseases, stroke, cancer, asthma, influenza and pneumonia, diabetes, HIV/AIDS, and homicide. African American women are 36% more likely to die from breast cancer, and they are 2.2 times more likely to die from stomach cancer (The Office of Minority Health and Health Disparities, 2007). Although African Americans are only 13% of the U.S. population, they account for 48% of HIV/AIDS cases in 2008. African American males have 8 times the AIDS rate as White males. African American females have 20 times the AIDS rate as White females (The Office of Minority Health, 2011c). Severe high blood pressure is more common for Black Americans in both men and women. African American adults are 40% more likely to have high blood pressure but 10% less likely to have blood pressure under control than their non-Hispanic White counterparts, and African Americans are 30% more likely to die from heart disease compared to non-Hispanic White men (The Office of Minority Health, 2012f). BAA adults are 60% more likely to have a stroke and males are 60% more likely to die from a stroke (The Office of Minority Health, 2012g). Other health issues including obesity and its contributing factors are also receiving attention. BAAs are twice more likely to be diagnosed with diabetes than non-Hispanic Whites, and they are more likely to suffer complications from diabetes (The Office of Minority Health, 2012h). This higher rate of diabetes may be related to higher obesity rates among African Americans. BAAs had the greatest prevalence of obesity compared with other races in the United States (Flegal et al., 2012; U.S. Department of Health and Human Services, 2009).

Nursing Process

*Assessment: Collect data about patient's physical, psychological, social, cultural, developmental, and spiritual needs from patient, family, diagnostic tests, medical record, nursing history, and literature. *Teaching Process: Gather data about patient's learning needs, motivation, ability to learn, health literacy, and teaching resources from patient, family, learning environment, medical record, nursing history, and literature. *Nursing Diagnosis: Identify appropriate nursing diagnoses on basis of assessment findings. *Teaching Process: -Identify patient's learning needs on basis of three domains of learning. -Identify conditions that may interfere with learning. *Planning : -Develop an individualized care plan. Set diagnosis priorities on basis of patient's immediate needs, expected outcomes, and patient-centered goals. -Collaborate with patient on care plan. *Teaching Process: -Establish learning objectives stated in behavioral terms. -Identify priorities regarding learning needs. -Collaborate with patient about teaching plan. -Identify type of teaching method to use. *Implementation: -Perform nursing care therapies. Include patient as active participant in care. -Involve family/significant other in care as appropriate. *Teaching Process: -Implement teaching methods. -Actively involve patient in learning activities. -Include family caregiver as appropriate. *Evaluation: -Identify success in meeting desired outcomes and goals of nursing care. -Alter interventions as indicated when goals are not met. *Teaching Process: -Determine outcomes of teaching-learning process. -Measure patient's achievement of learning objectives. -Reinforce information as needed.

*Changing Economic Status, Homelessness, and Domestic Violence

*Changing Economic Status ○For some families, making ends meet is a daily concern because of their declining economic status. Economics affects families at the lower end of the economic scale, and single-parent families are especially vulnerable. As a result, many families have inadequate health insurance coverage. Because of recent economic trends, adult children are often faced with moving back home after college because they cannot find employment or in some cases lose their jobs. The number of American children living below the poverty level continues to rise. There are 16.4 million children living below the poverty level; and approximately 8 million children are uninsured (Children's Defense Fund [CDF], 2014). Although the Affordable Care Act (ACA) aims to improve access to affordable health insurance, the challenge to access appropriate health care continues (USDHHS, 2014). When caring for these families, be sensitive to their need for independence and help them obtain appropriate financial and health care resources. For example, help a family by providing information about resources within the community to obtain assistance with energy bills, dental and health care, and school supplies. *Homelessness ○Homelessness is a major public health issue. According to public health organizations, absolute homelessness describes people without physical shelter who sleep outdoors, in vehicles, in abandoned buildings, or in other places not intended for human habitation. Relative homelessness describes those who have a physical shelter but one that does not meet the standards of health and safety (National Coalition for the Homeless, 2014). The fastest growing section of the homeless population is families with children. This includes complete nuclear families and single-parent families. It is expected that 3.5 million people are homeless and 1.35 million are families with children. Poverty, mental and physical illness, and lack of affordable housing are primary causes of homelessness (National Coalition for the Homeless, 2014). Homelessness severely affects the functioning, health, and well-being of the family and its members (CDF, 2014). Children of homeless families are often in fair or poor health and have higher rates of asthma, ear infections, stomach problems, and mental illness (see Chapter 3). As a result, usually the only access to health care for these children is through an emergency department. Children who are homeless face difficulties such as meeting residency requirements for public schools, inability to obtain previous enrollment records, and enrolling in and attending school. As a result, they are more likely to drop out of school and become unemployable (National Coalition for the Homeless, 2014). Homeless families and their children are at serious risk for developing long-term health, psychological, and socioeconomic problems. For example, children are frequently under immunized and at risk for childhood illnesses; they may fall behind in school and are at risk of dropping out; or they can develop risky behaviors (CDF, 2014). *Domestic Violence ○Domestic violence includes not only intimate-partner relationships of spousal, live-in partners, and dating relationships, but also familial, elder, and child abuse. Abuse includes emotional, physical, and sexual abuse, which occurs across all social classes (Futures without Violence, 2014). Factors associated with family violence are complex and include stress, poverty, social isolation, psychopathology, and learned family behavior. Other factors such as alcohol and drug abuse, pregnancy, sexual orientation, and mental illness increase the incidence of abuse within a family (Futures without Violence, 2014). Although abuse sometimes ends when one leaves a specific family environment, negative long-term physical and emotional consequences often linger. One of the consequences includes moving from one abusive situation to another. For example, an adolescent girl sees marriage as a way to leave her parents' abusive home and in turn marries a person who continues the abuse in her marriage.

Cultural Competency

*Culture may have an impact on people's health, healing, wellness belief systems, perceived causes of illness and disease, behaviors of seeking health care, and attitudes toward health care providers. Culture may also have influence on the delivery of health care services by the providers who use their own limited set of values to view the world. *Every culture has diverse illustrative models of illness and belief systems regarding health and healing. These models and wellness belief systems include views about the pathophysiology of diseases, the cause and the onset of symptoms, the natural history of illnesses, and the appropriate treatments for various health issues. *Cultural competency is one of the major elements in eliminating health disparities; it starts with an honest desire to disregard personal biases and to treat every person with respect. Although the number of racial and ethnic populations is growing in the United States, it has produced a challenge to the system of health care delivery services. Health care providers and persons seeking care bring their individual cultures and health beliefs and values to the health care experience. Hence, understanding the cultural underpinning of care is a challenging task because of the complexity and interaction between the person seeking care and the health care provider's cultural beliefs (Salman et al., 2007). In addition, providing health care services that are respectful of and responsive to diverse individuals' health beliefs, practices, and cultural needs is believed to contribute to fewer negative health outcomes (Management Sciences for Health, n.d.; The Office of Minority Health, 2005). It is very important for health care providers to be aware of how persons interpret their health issues or illnesses and to be capable of providing culturally competent care (Box 2-3: Hot Topics). Simply recognizing and accepting cultural diversity is insufficient to attain cultural competency in health care. Culturally competent health care professionals should be able to consistently and thoroughly recognize and understand the differences in their culture and the culture of others; to respect others' values, beliefs, and expectations; to understand the disease-specific epidemiology and treatment efficacy of different population groups; and to adjust the approach of delivering care to meet each person's needs and expectations (Management Sciences for Health, n.d.). Cultural competency is usually reflected in a health care provider's attitude and his or her communication style.

*Ability to Learn: Developmental Capability and Learning in Children o Box 25-3: Teaching Methods Based on Patient's Developmental Capacity

*Developmental Capability. -Cognitive development influences a patient's ability to learn. You can be a competent educator, but if you do not consider a patient's intellectual abilities, teaching is unsuccessful. Learning, like developmental growth, is an evolving process. You need to know a patient's level of knowledge and intellectual skills before beginning a teaching plan. Learning occurs more readily when new information complements existing knowledge. For example, measuring liquid or solid food portions requires the ability to perform mathematical calculations. Reading a medication label or discharge instructions requires reading and comprehension skills. Learning to regulate insulin dosages requires problem-solving skills. *Learning in Children. -The capability for learning and the type of behaviors that children are able to learn depend on the child's maturation. Without proper physiological, motor, language, and social development, many types of learning cannot take place. However, learning occurs in children of all ages. Intellectual growth moves from the concrete to the abstract as the child matures. Therefore information presented to children needs to be understandable, and the expected outcomes must be realistic based on the child's developmental stage (Box 25-3). Use teaching aids that are developmentally appropriate (Figure 25-1). Learning occurs when behavior changes as a result of experience or growth (Hockenberry and Wilson, 2015). ****Teaching Methods Based on Patient's Developmental Capacity**** *Infant • Keep routines (e.g., feeding, bathing) consistent. • Hold infant firmly while smiling and speaking softly to convey sense of trust. • Have infant touch different textures (e.g., soft fabric, hard plastic). *Toddler • Use play to teach procedure or activity (e.g., handling examination equipment, applying bandage to doll). • Offer picture books that describe story of children in hospital or clinic. • Use simple words such as cut instead of laceration to promote understanding. *Preschooler • Use role play, imitation, and play to make learning fun. • Encourage questions and offer explanations. Use simple explanations and demonstrations. • Encourage children to learn together through pictures and short stories about how to perform hygiene. *School-Age Child • Teach psychomotor skills needed to maintain health. (Complicated skills such as learning to use a syringe take considerable practice.) • Offer opportunities to discuss health problems and answer questions. *Adolescent • Help adolescent learn about feelings and need for self-expression. • Use teaching as collaborative activity. • Allow adolescents to make decisions about health and health promotion (safety, sex education, substance abuse). • Use problem solving to help adolescents make choices. *Young or Middle Adult • Encourage participation in teaching plan by setting mutual goals. • Encourage independent learning. • Offer information so adult understands effects of health problem. *Older Adult • Teach when patient is alert and rested. • Involve adult in discussion or activity. • Focus on wellness and person's strength. • Use approaches that enhance patient's reception of stimuli when they have a sensory impairment (see Chapter 49). • Keep teaching sessions short.

Chapter 7: Health Promotion and the Family (Edelman et al., 2014, pp. 149-153)

*Family, Nursing Process and the Family The nursing process with families is a two-level process that includes the family as a group and the interactions among family members (Ward & Hisley, 2009). The entire family is viewed as the care recipient that guides assessment from a holistic framework (Ward & Hisley, 2009). Home is a natural environment for health-promotion encounters, although the process may occur in other settings as well. Different age groups (infants, children, and older adults) are likely to be available in the home. Nurses observe physical surroundings firsthand during home visits. For example, household safety hazards are observed directly. Nurses also monitor family unit rituals, roles, and interpersonal interactions. Generally the nurse contacts the family and establishes an appointment time for visiting. Including each family member in the visit provides a broad perspective. During visits, the nursing process occurs mutually with families, not for families. Families collaborate with nursing in all phases of the process. Guidelines for home visits are presented in Box 7-1. Comprehensive family assessment provides the foundation to promote family health (Kaakinen et al., 2010; Lundy & Janes, 2010; Ward & Hisley, 2009). Several factors influence family assessment, such as nurses' perceptions about family constitution; theoretical knowledge; norms; standards; and communication abilities during visits. In addition to factors that pertain to the nurse, familial factors also influence assessments, such as family cooperation, mutual agreement to work toward goals, and family ability to recognize the relevance of health-promotion plans. Useful health-promotion family assessments involve listening to families, engaging in participatory dialogue, recognizing patterns, and assessing family potential for active, positive change (Kaakinen et al., 2010; Lundy & Janes, 2010; Ward & Hisley, 2009). *The Nurse's Roles Nurses collaborate with families using a systems perspective to understand family interaction, family norms, family expectations, effectiveness of family communication, family decision-making, and family coping mechanisms. The nurse's role in health promotion and disease prevention includes the following tasks: •Become aware of family attitudes and behaviors toward health promotion and disease prevention. •Act as a role model for the family. •Collaborate with the family to assess, improve, enhance, and evaluate family health practices. •Assist the family in growth and development behaviors. •Assist the family in identifying risk-taking behaviors. •Assist the family in decision-making about lifestyle choices. •Provide reinforcement for positive health-behavior practices. •Provide health information to the family. •Assist the family in learning behaviors to promote health and prevent disease. •Assist the family in problem-solving and decision-making about health promotion. •Serve as a liaison for referral or collaboration between community resources and the family. Nurses use family theoretical frameworks to guide, observe, and classify situations. Nursing roles for families in various stages of development are presented in Table 7-3 on p.173.

Chapter 9: Cultural Awareness (Culture and Ethnicity) (Potter et al., 2017, pp. 101-105)

*Healthcare Disparities and Health Care Disparities Health disparities are the differences among populations in the incidence, prevalence, and outcomes of health conditions, diseases, and related complications. On the other hand, health care disparities are differences among populations in the availability, accessibility, and quality of health care services (e.g., screening, diagnostic, treatment, management and rehabilitation) aimed at prevention, treatment, and management of diseases and their complications. Poor access to health care is one social determinant of health that contributes to health disparities. Access to primary care is an important indicator of broader access to health care services. A patient who regularly visits a primary care provider is more likely to receive adequate preventive care than a patient who lacks such access. The 2013 National Healthcare Disparities Report (AHRQ, 2013a) revealed that African-Americans, Asians, and Hispanics are less likely than non-Hispanic Whites to see a primary care provider regularly. A similar disparity in access to care exists in other disadvantaged groups. Less care is available or accessible to people in low- and middle-income groups compared with people in high-income groups. Uninsured people ages 0 to 64 are less likely to have a regular primary care provider than those with private or public insurance (AHRQ, 2013a). Research suggests that some subgroups of the LGBT community have more chronic health conditions and a higher prevalence and earlier onset of disabilities than heterosexuals (Ranji et al., 2015). In addition to the poor access to health care, a large body of research shows that health care systems and health care providers can contribute significantly to the problem of health disparities. More than a decade ago, reports by the Institute of Medicine (IOM, 2001, 2010) defined quality health care as care that is safe, effective, patient centered, timely, efficient, and equitable or without variation in outcomes as determined by stratified outcomes data. Although the U.S. health care system has improved in most of these areas since the IOM reports were published, the focus on equity has lagged behind (Mutha et al., 2012). Inadequate resources, poor patient-provider communication, a lack of culturally competent care, fragmented delivery of care, and inadequate access to language services all compromise patient outcomes (NQF, 2012). As a result, many disparities in health care and health outcomes remain. Disparities in access to care, quality of care, preventive health, health education, and available resources to enable self-management when patients are outside of the health care setting contribute to poor population health. Health disparities are also very costly. Recent analysis estimates that 30% of direct medical costs for Blacks, Hispanics, and Asian Americans are excess because of health inequities and that overall the economy loses an estimated $309 billion per year because of the direct and indirect costs of disparities *Culture, Culturally Congruent Care and Cultural Competency Leininger (2002) defines transcultural nursing as a comparative study of cultures to understand their similarities (culture that is universal) and the differences among them (culture that is specific to particular groups). The goal of transcultural nursing is to provide culturally congruent care, or care that fits a person's life patterns, values, and system of meaning. Patterns and meaning are generated by people themselves rather than from predetermined criteria. For example, rather than instructing all patients to always take their medications at the same set times during a day, you learn their lifestyle patterns, eating habits, sleep habits, and beliefs about medications and then try to plan a dosage schedule that fits each patient's needs. Culturally congruent care is sometimes different from the values and meanings of the professional health care system. Discovering patients' cultural values, beliefs, and practices as they relate to nursing and health care requires you to assume the role of learner and to partner with your patients and their families to determine what is needed to provide meaningful and beneficial nursing care (Leininger and McFarland, 2002). Effective nursing care integrates the cultural values and beliefs of individuals, families, and communities with the perspectives of a multidisciplinary team of health care providers. When you provide culturally congruent care, you bridge cultural gaps to provide meaningful and supportive care for all patients. For example, during nursing school you are assigned to care for a female patient who observes Muslim beliefs. You notice the woman's discomfort with several of the male health care providers. You wonder if this discomfort is related to your patient's religious beliefs. While preparing for clinical, you learn that Muslims differ in their adherence to tradition but that modesty is the "overarching Islamic ethic" pertaining to interaction between the sexes (Rabin, 2010). Thus you say to the patient, "I know that for many of our Muslim patients, modesty is very important. Is there some way I can make you more comfortable?" You do not assume that the information will automatically apply to this patient. Instead you combine your knowledge about a cultural group with an attitude of helpfulness and flexibility to provide quality, patient-centered, culturally congruent care. *Five Interrelated Components of Cultural Competence: ASKED • Cultural awareness: An in-depth self-examination of one's own background, recognizing biases, prejudices, and assumptions about other people 105 • Cultural knowledge: Sufficient comparative knowledge of diverse groups, including the values, health beliefs, care practices, world view, and bicultural ecology commonly found within each group • Cultural skills: Ability to assess social, cultural, and biophysical factors that influence patient treatment and care • Cultural encounters: Cross-cultural interactions that provide opportunities to learn about other cultures and develop effective intercultural communication • Cultural desire: The motivation and commitment to caring that moves an individual to learn from others, accept the role as a learner, be open to and accepting of cultural differences, and build on cultural similarities. Cultural Competency Cultural competency is defined by the National Institutes of Health (2015) as the enabling of health care providers to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients. Developing cultural competency allows systems, agencies, and groups of professionals to function effectively to understand the needs of groups accessing health information and health care and thus help eliminate health care disparities and ultimately health disparities (NIH, 2015). It is a developmental process that evolves over time. Both individuals and organizations are at various levels of awareness, knowledge, and skills that affect their ability to effectively function in a multicultural context (National Center for Cultural Competence [NCCC], n.d.). According to the NCCC framework, culturally competent organizations: 104 • Value diversity • Conduct a cultural self-assessment • Manage the dynamics of difference • Institutionalize cultural knowledge • Adapt to diversity A culturally competent organization integrates these principles and capabilities into all aspects of the organization (e.g., policy making, administration, service delivery) and systematically involves consumers, key stakeholders, and communities. In 2000 the Office of Minority Health (OMH) developed the Culturally and Linguistically Appropriate Standards (CLAS). In 2013, after 10 years of successful implementation, the OMH updated the standards to reflect the tremendous growth in the field and the increasing diversity of the nation (Box 9-2). The enhanced national CLAS are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint to help individuals and health care organizations implement culturally and linguistically appropriate services

Chapter 25: Patient Education (Potter et al., 2017, pp. 336-355)

*Standards for Patient Education Patient education has long been a standard for professional nursing practice. All state Nurse Practice Acts recognize that patient teaching falls within the scope of nursing practice (Bastable, 2014). In addition, various accrediting agencies set guidelines for providing patient education in health care institutions. For example, The Joint Commission (TJC, 2015a) sets standards for patient and family education. These standards require nurses and all health care providers to assess patients' learning needs and provide education on a variety of topics, including medications, nutrition, use of medical equipment, pain management, and the patient's plan of care. Successful fulfillment of the standards requires collaboration among health care professionals and enhances patient safety. Ensure that your educational efforts are patient centered by taking into consideration your patients' own education and experience; their desire to actively participate in the educational process; and their psychosocial, spiritual, and cultural values. It is important to document patient education interventions and a patient's response to teaching in the medical record. Standards such as these help to direct patient education and ensure best possible outcomes. 337 *Purposes of Patient Education The goal of educating others about their health is to help individuals, families, or communities achieve optimal levels of health (Edelman et al., 2014). Patient education is an essential component of providing safe, patient-centered care (QSEN, 2014). In addition, providing education about preventive health care helps reduce health care costs and hardships on individuals and those surrounding them. Patients now know more about health and want to be actively involved in their health maintenance. Comprehensive patient education includes three important purposes, each involving a separate phase of health care: health promotion and illness prevention, health restoration, and coping. Maintenance and Promotion of Health and Illness Prevention As a nurse you are a visible, competent resource for patients who want to improve their physical and psychological well-being. In the school, home, clinic, or workplace you provide information and skills to help patients adopt healthier behaviors. For example, in childbearing classes you teach expectant parents about physical and psychological changes in a woman. After learning about normal childbearing, the mother who applies new knowledge is more likely to eat healthy foods, engage in physical exercise, and avoid substances that can harm the fetus. Promoting healthy behavior through education allows patients to assume more responsibility for their own health (Thom et al., 2013). Greater knowledge results in better health maintenance habits. In addition, when patients become more health conscious, they are more likely to seek early diagnosis of health problems (Hawkins et al., 2011). Restoration of Health Injured or ill patients need information and skills to help them regain or maintain their levels of health. Patients recovering from and adapting to changes resulting from illness or injury often seek information about their conditions. However, some patients find it difficult to adapt to illness and become passive and disinterested in learning. As the nurse you learn to identify patients' willingness to learn and motivate interest in learning (Bastable, 2014). The family often is a vital part of a patient's return to health. Family caregivers usually require as much education as the patient, including information on how to perform skills within the home. If you exclude a family from a teaching plan, conflicts can occur. However, do not assume that a family should be involved; assess the patient-family relationship before providing education for family caregivers. Coping with Impaired Functions Not all patients fully recover from illness or injury. In addition, patients with preexisting mental illness are also challenged during recovery (Lorig et al., 2014b). Many have to learn to cope with permanent health alterations. New knowledge and skills are often necessary for patients to continue activities of daily living. For example, a patient loses the ability to speak after larynx surgery and has to learn new ways of communicating. Changes in function are physical or psychosocial. In the case of serious disability such as following a stroke or a spinal cord injury, the patient's family needs to understand and accept many changes in his or her physical capabilities. The family's ability to provide support results in part from education, which begins as soon as you identify the patient's needs and the family displays a willingness to help. Teach family members to help the patient with health care management (e.g., giving medications through gastric tubes and doing passive range-of-motion exercises). Families of patients with alterations such as alcoholism, mental retardation, or drug dependence learn to adapt to the emotional effects of these chronic conditions and provide psychosocial support to facilitate the patient's health. Comparing the desired level of health with the actual state of health enables you to plan effective teaching programs.

* Impact of Illness and Injury

-Any acute or chronic illness influences an entire family economically, emotionally, socially, and functionally and affects a family's decision-making and coping resources. Hospitalization of a family member is stressful for the whole family. Hospital environments are foreign, physicians and nurses are strangers, the medical language is difficult to understand or interpret, and family members are separated from one another. *Acute/Chronic Illness ○During an acute illness such as a trauma, myocardial infarction, or surgery, family members are often left in waiting rooms to receive information about their loved one. Communication among family members may be misdirected from fear and worry. Sometimes previous family conflicts rise to the surface, whereas others are suppressed. When implementing a patient-centered care model, patients' family members and surrogate decision makers must become active partners in decision making and care. Involving family during bedside handover from one care provider to another, for example, provides an opportunity to involve the patient and family in discussing the present and long-term plan of care (Tobiano et al., 2012). When possible, patients and family caregivers want to participate in shared decision making about treatment and ongoing disease/symptom management (Brazil et al., 2012). Incorporating a patient's and family's cultural beliefs, values, and communication patterns is essential to provide individualized patient/family-centered care (Campinha-Bacote, 2011). Chronic illnesses are a global health problem and present continuous challenges for families. Frequently family patterns and interactions, social activities, work and household schedules, economic resources, and other family needs and functions must be reorganized around the chronic illness or disability. Despite the stressors, families want to accept and manage the illness and strive to gain a balance in family life (Arestedt et al., 2013). Astute nursing care involves the patient and family in preventing and/or managing medical crises, controlling symptoms, learning how to provide specific therapies, adjusting to changes over the course of the illness, avoiding isolation, obtaining community resources, and helping the family with conflict resolution (Arestedt et al., 2013; O'Shea et al., 2014). *Trauma ○Trauma is sudden, unplanned, and sometimes life-threatening. Family members often struggle to cope with the challenges of a severe life-threatening event, which can include the stressors associated with a family member hospitalized in an intensive care environment, anxiety, depression, economic burden, and the impact of the trauma on family functioning and decision making (McDaniel and Allen, 2012). The powerlessness that family members experience makes them very vulnerable and less able to make important decisions about the health of the family. In caring for family members, advocate for the patient and family and answer their questions honestly (Grant and Ferrell, 2012). When you do not know the answer, find someone who does. Provide realistic assurance; giving false hope breaks the nurse-patient trust and also affects how the family can adjust to "bad news." When a patient who has experienced trauma is hospitalized, take time to make sure that the family is comfortable. You can bring them something to eat or drink, give them a blanket, or encourage them to get a meal. Sometimes telling a family that you will stay with their loved one while they are gone is all they need to feel comfortable in leaving. *End-of-Life Care ○You will encounter many families with a terminally ill member. Although people equate terminal illness with cancer, many diseases have terminal aspects (e.g., heart failure, pulmonary and renal diseases, and neuromuscular diseases). Although some family members may be prepared for their loved one's death, their need for information, support, assurance, and presence is great (see Chapter 37). Use presence to refine a therapeutic relationship with a patient and family (see Chapter 7). Also use presence and therapeutic communication to enhance family members' relationships with one another and to promote shared decision making (Dobrina et al., 2014). The more you know about your patient's family, how they interact with one another, their strengths, and their weaknesses, the better. Each family approaches and copes with end-of-life decisions differently. Encourage the patient and family to make decisions about care (e.g., pain control or preferred nonpharmacologic comfort measures) and specific therapies. Help the family set up home care if they desire and obtain hospice and other appropriate resources, including grief support (Brazil et al., 2012). Provide information about the dying process and make sure family members know what to do at the time of death. If you are present at the time of death, be sensitive to the family's needs (e.g., provide for privacy and allow sufficient time for saying good-byes).

* Box 2-4 Research for Evidence-Based Practice (EBP): Use of Complementary and Alternative Medicine (CAM) in the United States

BOX 2-4 RESEARCH FOR EVIDENCE-BASED PRACTICE: Use of Complementary and Alternative Medicine (CAM) in the United States The National Center for Complementary and Alternative Medicine (NCCAM, 2011) defines complementary and alternative medicine (CAM) as a set of varied medical and health care practices, systems, and products that are not usually considered part of conventional medicine. Medicine is practiced by holders of M.D. (medical doctor) or D.O. (Doctor of Osteopathic Medicine) degrees and by their allied health professionals such as physical therapists, psychologists, and registered nurses. Conventional medicine is also called Western or allopathic medicine and is practiced by medical doctors and doctors of osteopathic medicine. Doctors of Osteopathic Medicine (DOs) are fully licensed physicians. They provide a full range of services, from prescribing drugs to performing surgery, and employ a "whole person" approach to health care. DOs focus special attention on the musculoskeletal system, a system of bones and muscles that makes up about two-thirds of the body's mass. They may use osteopathic manipulative treatment, a system of manual therapy, to treat mechanical strains affecting all aspects of the anatomy, relieve pain, and improve physiologic function.and by other related health professionals (such as psychologists, physical therapists, and registered nurses). Acupuncture, biofeedback, relaxation, music therapy, massage, art, music, and dance therapy are some examples of CAM. Western medicine, supported by improved knowledge and advances in technology, has been successful in addressing numerous illnesses. However, there remains a cadre of chronic illnesses and conditions that do not respond well to allopathic treatment. Persons who do not experience relief from chronic conditions often resort to complementary and alternative medicine. However, the boundaries between CAM and conventional medicine are not fixed, and several CAM practices (for example, acupuncture and music therapy) have been becoming more widely accepted. A national survey found that about 38% of Americans use complementary and alternative medicine, a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. Complementary medicine is used together with conventional medicine, and alternative medicine is used in place of conventional medicine (NCCAM, 2011). Another study used a comparative analysis of data from the 2002 and 2007 National Health Interview Survey (NHIS) of the civilian noninstitutionalized U.S. population to investigate recent trends in complementary and alternative medicine (CAM) (Su & Li, 2011). The findings of this study suggest that CAM use has increased significantly in the United States. This increase was more obvious among non-Hispanic Whites than among racial and ethnic minorities. The non-Hispanic White Americans had the highest prevalence rate of using at least one CAM therapy in the period from 2002 to 2007, followed by Asian Americans, African Americans, and Hispanics. This study also revealed that the use of CAM becomes more probable when there is limited access to conventional care. This study also pointed out that the increasing cost of conventional medical care has resulted in increasingly limited access to medical care and is a contributing factor to the rising prevalence of CAM use. The dynamic interplay of many factors that serve as barriers for many ethnic groups to accessing traditional health care and the person's own cultural beliefs warrant a close look at how CAM can greatly augment health care services. This study revealed a growing prevalence of CAM use in the United States; however, the growth in CAM use was not equally distributed across racial and ethnic groups in the United States. The increasing prevalence and the increasing gap in CAM use across racial and ethnic groups highlight the critical need for assessing the health consequences of CAM therapies. There is limited information about efficacy and the possible side effects associated with the use of any specific CAM therapy and its interactive effects with conventional medicine. More studies are needed to provide information about which CAM therapies can be used as an alternative or supplement to conventional medical care.

(Standard 8: Culturally Congruent Practice for Registered Nurses)

Competencies The registered nurse: ▶ Demonstrates respect, equity, and empathy in actions and interactions with all healthcare consumers. ▶ Participates in life-long learning to understand cultural preferences, worldview, choices, and decision-making processes of diverse consumers. ▶ Creates an inventory of one's own values, beliefs, and cultural heritage. ▶ Applies knowledge of variations in health beliefs, practices, and communication patterns in all nursing practice activities. ▶ Identifies the stage of the consumer's acculturation and accompanying patterns of needs and engagement. ▶ Considers the effects and impact of discrimination and oppression on practice within and among vulnerable cultural groups. ▶ Uses skills and tools that are appropriately vetted for the culture, literacy, and language of the population served. ▶ Communicates with appropriate language and behaviors, including the use of medical interpreters and translators in accordance with consumer preferences. ▶ Identifies the cultural-specific meaning of interactions, terms, and content. ▶ Respects consumer decisions based on age, tradition, belief and family influence, and stage of acculturation. ▶ Advocates for policies that promote health and prevent harm among culturally diverse, under-served, or under-represented consumers. ▶ Promotes equal access to services, tests, interventions, health promotion programs, enrollment in research, education, and other opportunities. ▶ Educates nurse colleagues and other professionals about cultural similarities and differences of healthcare consumers, families, groups, communities, and populations. Additional competencies for the graduate-level prepared registered nurse In addition to the competencies of the registered nurse, the graduate-level prepared registered nurse: ▶ Evaluates tools, instruments, and services provided to culturally diverse populations. ▶ Advances organizational policies, programs, services, and practice that reflect respect, equity, and values for diversity and inclusion. ▶ Engages consumers, key stakeholders, and others in designing and establishing internal and external cross-cultural partnerships. ▶ Conducts research to improve health care and healthcare outcomes for culturally diverse consumers. ▶ Develops recruitment and retention strategies to achieve a multicultural workforce. Additional competencies for the advanced practice registered nurse In addition to the competencies of the registered nurse and graduate-level prepared registered nurse, the advanced practice registered nurse: ▶ Promotes shared decision-making solutions in planning, prescribing, and evaluating processes when the healthcare consumer's cultural preferences and norms may create incompatibility with evidence-based practice. ▶ Leads interprofessional teams to identify the cultural and language needs of the consumer.

* Box 2-3: Culturally Competent Care Among Nurses

Culturally Competent Care Among Nurses Cultural competence is becoming an integral part of delivering quality health care services to an increasingly diverse population that includes people from all over the world immigrating to the United States. Both immigrants and individuals belonging to ethnic minority groups are more likely to experience disparities in health care and to have inadequate access to health care services as compared to non-Hispanic Whites. People from different cultural backgrounds have a divergent approach to and understanding of their health and how to utilize health care services. Culturally competent care contributes to mitigating health disparities and increases the likelihood of diagnosing diseases that would most likely affect a given culture. Given the diversity of the U.S. population and the unique impact of culture on health, preparing nurses who are able to provide culturally competent care is indispensable to improve the health status of immigrants and minorities. Many studies have been conducted on various ethnic groups in the United States with the hope of advancing peoples' understanding and competence to provide culturally appropriate health care to all people in this multicultural society. Several studies were also done to assess the status of cultural competence among nurses and to evaluate the effects of cultural training programs. For example, Salman and colleagues (2007) assessed cultural awareness and cultural competence levels among staff nurses who participated in a continuing education program aimed at increasing knowledge of cultural competent care of the geriatric population. Staff nurses who participated in this training program had a higher cultural competence level as compared to nurses who did not join this training program.

*Family Theories and Framework - Family Systems Theory - Living Systems Theory - Bowen's Family Systems Theory

Family theory stems from a variety of interrelated disciplines (Ward & Hisley, 2009). Family systems theory explains patterns of living among the individuals who comprise family systems. In systems theory, behaviors and family members' responses influence patterns. Meanings and values provide the vital elements of motivation and energy for family systems. Every family has its unique culture, value structure, and history. Values provide a means for interpreting events and information, passing from one generation to the next. Values usually change slowly over time. Families process information and energy exchange with the environment through values. For example, holiday food traditions may be changed slightly by a daughter-in-law whose own daughter may then adjust the traditional recipe within her own nuclear family. System boundaries separate family systems from their environment and control information flow. This characteristic forms a family internal manager that influences and defines interactions and relationships with one another and with those outside the family system. Family forms a unified whole rather than the sum of its parts—an integrated system of interdependent functions, structures, and relationships. For example, one drug-dependent individual's health behavior influences the entire family unit. Living systems are open systems. As living systems, families experience constant exchanges of energy and information with the environment. Change in one part or member of the family results in changes in the family as a whole. For example, loss of a family member through death changes roles and relationships among all family members. Change requires adaptation of every family member as roles and functions assume new meanings. Changes families make are incorporated into the system. When the system is the family, issues can be clarified using family processes, communication interaction among family members, and family group values. In Bowen's Family Systems Theory, birth order is considered an important determinant of behavior (Ward & Hisley, 2009). In addition, family patterns of behavior differentiate one family from another (Ward & Hisley, 2009). When an individual family member expresses behaviors that differ from the learned family pattern, differentiation of self occurs. Interaction among family members and the transmission of these interaction patterns from one generation to the next provide the framework for the family systems approach (Ward & Hisley, 2009). The framework for health promotion introduced by Pender and colleagues (2011) recognizes the family as the unit of assessment and intervention, because families develop self-care and dependent-care competencies; foster resilience among family members; provide resources; and promote healthy individuation within cohesive family structures. Furthermore, because family often provides the structure for implementing health promotion, family assessment becomes an integral tool to foster health and healthy behaviors (Pender et al., 2011).

Healthy People 2020 and Leading Healthy Indicators 2020: 12 Topics with Leading Health

Healthy People 2020 is looking for real stories from organizations implementing innovative programs to target specific Leading Health Indicators. Share your story! The Leading Health Indicators (LHIs) are composed of 26 indicators organized under 12 topics. The Healthy People 2020 LHIs are: Access to Health Services * Persons with medical insurance (AHS-1.1) * Persons with a usual primary care provider (AHS-3) Clinical Preventive Services * Adults who receive a colorectal cancer screening based on the most recent guidelines (C- 16) * Adults with hypertension whose blood pressure is under control (HDS-12) * Persons with diagnosed diabetes whose A1c value is >9 percent (D-5.1) * Children aged 19 to 35 months who receive the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella, and PCV vaccines (IID-8) Environmental Quality * Air Quality Index (AQI) exceeding 100 (EH-1) * Children exposed to secondhand smoke (TU-11.1) Injury and Violence * Fatal injuries (IVP-1.1) * Homicides (IVP-29) Maternal, Infant, and Child Health * All Infant deaths (MICH-1.3) * Total preterm live births (MICH-9.1) Mental Health * Suicides (MHMD-1) * Adolescents who experience major depressive episodes (MDE) (MHMD-4.1) Nutrition, Physical Activity, and Obesity * Adults who meet current Federal physical activity guidelines for aerobic physical activity and muscle-strengthening activity (PA-2.4) * Adults who are obese (NWS-9) * Obesity among children and adolescents (NWS-10.4) * Total vegetable intake for persons aged 2 years and older (NWS-15.1) Oral Health * Children, adolescents, and adults who visited the dentist in the past year (OH-7) Reproductive and Sexual Health *Sexually active females aged 15 to 44 years who received reproductive health services in the past 12 months (FP-7.1) * Knowledge of serostatus among HIV-positive persons (HIV-13) Social Determinants * Students who graduate with a regular diploma 4 years after starting 9th grade (AH-5.1) Substance Abuse * Adolescents using alcohol or any illicit drugs during the past 30 days (SA-13.1) * Adults engaging in binge drinking during the past 30 days (SA-14.3) Tobacco * Adults who are current cigarette smokers (TU-1.1) * Adolescents who smoked cigarettes in the past 30 days (TU-2.2)

*Teaching and Learning

It is impossible to separate teaching from learning. Teaching is the concept of imparting knowledge through a series of directed activities. It consists of a conscious, deliberate set of actions that help individuals gain new knowledge, change attitudes, adopt new behaviors, or perform new skills (Billings and Halstead, 2012). An educator needs to be knowledgeable about the subject matter and patient teaching principles in order to provide individuals with guidance, appropriately set the learning pace, and creatively introduce concepts to successfully achieve the desired learning objectives. Learning is the purposeful acquisition of new knowledge, attitudes, behaviors, and skills through an experience or external stimulus (Bastable, 2014). It is a process of both understanding and applying newly acquired concepts. A new mother exhibits learning when she demonstrates how to bathe her newborn. The mother shows transfer of learning when she uses the principles she learned about bathing a newborn when she bathes her older child. Teaching and learning generally begin when a person identifies a need for knowing or acquiring an ability to do something. Teaching is most effective when it responds to the learner's needs. An educator assesses these needs by asking questions and determining a learner's interests. Interpersonal communication is essential for successful teaching to occur (see Chapter 24).

Domains of Learning: Cognitive, Affective and Psychomotor * Box 25-2: Appropriate Teaching Methods Based on Domains of Learning

Learning occurs in three domains: cognitive (understanding), affective (attitudes), and psychomotor (motor skills) (Bastable, 2014). Health topics involve one or all domains or any combination of the three. You often work with patients who need to learn in each domain. For example, patients diagnosed with diabetes need to learn how diabetes affects the body and how to control blood glucose levels for healthier lifestyles (cognitive domain). In addition, patients begin to accept the chronic nature of diabetes by learning positive coping mechanisms (affective domain). Finally many patients living with diabetes learn to test their blood glucose levels at home. This requires learning how to use a glucose meter (psychomotor domain). The characteristics of learning within each domain influence your teaching and evaluation methods. Understanding each learning domain prepares you to select proper teaching techniques and apply the basic principles of learning. Box 25-2 Appropriate Teaching Methods Based on Domains of Learning *Cognitive • Discussion (one-on-one or group) • Involves nurse and one patient or a nurse with several patients • Promotes active participation and focuses on topics of interest to patient • Allows peer support • Enhances application and analysis of new information • Lecture • Is more formal method of instruction because it is educator controlled • Helps learner acquire new knowledge and gain comprehension • Question-and-answer session • Addresses patient's specific concerns • Helps patient apply knowledge • Role play, discovery • Allows patient to actively apply knowledge in controlled situation • Promotes synthesis of information and problem solving • Independent project (computer-assisted instruction), field experience • Allows patient to assume responsibility for completing learning activities at own pace • Promotes analysis, synthesis, and evaluation of new information and skills *Affective • Role play • Allows expression of values, feelings, and attitudes • Discussion (group) • Allows patient to receive support from others in group • Helps patient learn from others' experiences • Promotes responding, valuing, and organization • Discussion (one-on-one) • Allows discussion of personal, sensitive topics of interest or concern *Psychomotor • Demonstration • Provides presentation of procedures or skills by nurse • Permits patient to incorporate modeling of nurse's behavior • Allows nurse to control questioning during demonstration • Practice • Gives patient opportunity to perform skills using equipment in a controlled setting • Provides repetition • Return demonstration • Permits patient to perform skill as nurse observes • Provides excellent source of feedback and reinforcement • Assists in determining patient's ability to correctly perform a skill or technique • Independent projects, games • Requires teaching method that promotes adaptation and origination of psychomotor learning • Permits learner to use new skills

*Basic Learning Principles: Motivation to Learn - Attentional Set, Motivation and Use of Theory to Enhance Motivation and Learning, Psychosocial Adaptation to Illness, and Active Participation

Motivation to Learn *Attentional Set. An attentional set is the mental state that allows the learner to focus on and comprehend a learning activity. Before learning anything, patients must give attention to, or concentrate on, the information to be learned. Physical discomfort, anxiety, and environmental distractions influence the ability to focus. Therefore determine a patient's level of comfort before beginning a teaching plan and ensure that the patient is able to focus on the information. As anxiety increases, a patient's ability to pay attention often decreases. Anxiety is uneasiness or worry resulting from anticipating a threat or danger. When faced with change or the need to act differently, a person often feels anxious. A mild level of anxiety motivates learning. However, a high level of anxiety prevents learning from occurring. It incapacitates a person, creating an inability to focus on anything other than relieving the anxiety. Assess for and moderate the patient's anxiety (see Chapter 38) before educating to improve his or her comprehension and understanding of the information given (Bastable, 2014). Motivation. *Motivation Motivation is a force that acts on or within a person (e.g., an idea, emotion, or a physical need) to cause the person to behave in a particular way (Miller and Stoeckel, 2015). If a person does not want to learn, it is unlikely that learning will occur. You assess a patient's motivation to learn and what the patient needs to know to promote adherence to his or her prescribed therapy. Unfortunately not all people are interested in maintaining health. Many do not adopt new health behaviors or change unhealthy behaviors unless they perceive a disease as a threat, overcome barriers to changing health practices, and see the benefits of adopting a healthy behavior. For example, some patients with lung disease continue to smoke. No therapy has an effect unless a person believes that health is important and that the therapy will improve health. *Use of Theory to Enhance Motivation and Learning. Health education often involves changing attitudes and values that are not easy to change simply through transfer of information. Therefore it is important for you to use various theory-based interventions when developing patient education plans. Learning theories focus on how individuals learn and can facilitate the teaching-learning process by creating the desired climate and guiding the selection of instructional strategies. Because of the complexity of patient education, different theories and models are available to guide patient education. Using a theory that matches a patient's needs and personal learning preferences allows the patient to become an active participant, leading to effective instruction. Social learning theory provides one of the most useful approaches to patient education because it considers the personal characteristics of the learner, behavior patterns, and the environment and guides the educator in developing effective teaching interventions that result in improved motivation and enhanced learning (Bastable, 2014; Sanderson et al., 2012). According to social learning theory, a person's state of mind and intrinsic motivational factors (i.e., sense of accomplishment, pride, or confidence) reinforce behaviors and influence learning (Burkhart et al., 2012). This type of internal reward system allows a person to attain desired outcomes and avoid undesired outcomes, resulting in improved motivation. Self-efficacy, a concept included in social learning theory, refers to a person's perceived ability to successfully complete a task. When people believe that they are able to execute a particular behavior, they are more likely to perform the behavior consistently and correctly. Self-efficacy beliefs come from four sources: enactive mastery experiences, vicarious experiences, verbal persuasion, and physiological and affective states (Bandura, 1997). Understanding the four sources of self-efficacy allows you to develop interventions to help patients adopt healthy behaviors. For example, a nurse who is wishing to teach a child recently diagnosed with asthma how to correctly use an inhaler expresses personal belief in the child's ability to use the inhaler (verbal persuasion). Then the nurse demonstrates how to use the inhaler (vicarious experience). Once the demonstration is complete, the child uses the inhaler (enactive mastery experience). As the child's wheezing and anxiety decrease after the correct use of the inhaler, he or she experiences positive feedback, further enhancing his or her confidence to use it (physiological and affective states). Interventions such as these enhance perceived self-efficacy, which in turn improves the achievement of desired outcomes. Self-efficacy is a concept included in many health promotion theories because it often is a strong predictor of healthy behaviors and because many interventions improve self-efficacy, resulting in improved lifestyle choices (Bandura, 1997). Because of its use in theories and research studies, many evidence-based teaching interventions include a focus on self-efficacy. When nurses implement interventions to enhance self-efficacy, their patients frequently experience positive outcomes. For example, researchers associated interventions that included self-efficacy with effective management of diabetes and glycemic control (Tan et al., 2011), self-management of asthma in school-age children (Burkhart et al., 2012), and improved functioning along with a reduction in symptoms related to anxiety and depression (Brown et al., 2014). *Psychosocial Adaptation to Illness. A temporary or permanent loss of health is often difficult for patients to accept. They need to grieve, and the process of grieving gives them time to adapt psychologically to the emotional and physical implications of their illnesses. The stages of grieving (see Chapter 37) include a series of responses that patients experience during a loss such as illness. They experience these stages at different rates and sequences, depending on their self-concept before illness, the severity of the illness, and the changes in lifestyle that the illness creates. Effective, supportive care guides the patient through the grieving process. Readiness to learn is related to the stage of grieving (Table 25-1). Patients cannot learn when they are unwilling or unable to accept the reality of illness. However, properly timed teaching facilitates adjustment to illness or disability. Identify a patient's stage of grieving on the basis of his or her behaviors. When a patient enters the stage of acceptance, the stage compatible with learning, introduce a teaching plan. Continuous assessment of a patient's behaviors determines the stages of grieving. Teaching continues as long as the patient remains in a stage conducive to learning. *Active Participation. Learning occurs when a patient is actively involved in an educational session (Edelman et al., 2014). A patient's 341involvement in learning implies an eagerness to acquire knowledge or skills. It also improves the opportunity for the patient to make decisions during teaching sessions. For example, when teaching car-seat safety during a parenting class, hold a teaching session in the parking lot where the participants park their cars. Encourage active participation by providing the learners with several different car seats for them to place in their cars. At the completion of this session, the parents are able to determine which type of car seat fits best in their cars and which is the easiest to use. This provides participants with the information needed to purchase the appropriate car seat.

* Definitions: Ethnicity, Ethnic Group, Minority Group, Race, Culture, Value and Value Orientation

Race and ethnicity categories in the United States are defined by the Office of Management and Budget (OMB), with the latest set based on a 1997 revision of a 1977 standard (Humes et al., 2011). The minimal race categories for collecting data on race and ethnicity are Black/African American, American Indian/Alaska Native, Asian, Native Hawaiian and other Pacific Islander, and White; and the minimal ethnicity categories are Hispanic/Latino and Not Hispanic/Latino origin (Humes et al., 2011). Race and ethnicity are different but somewhat alike. Race is associated with power and indexes the history or ongoing imposition of one group's authority above another. Ethnicity focuses on differences in meanings, values, and ways of living (practices) (Markus, 2008). Race has been defined as "a dynamic set of historically derived and institutionalized ideas and practices that: sorts people into ethnic groups according to perceived physical and behavioral human characteristics; associates differential value, power, and privilege with these characteristics and establishes a social status ranking among the different groups; and emerges (a) when groups are perceived to pose a threat (political, economic, or cultural) to each other's world view or way of life; and/or (b) to justify the denigration and exploitation (past, current, or future) of, and prejudice toward, other groups" (Markus, 2008, p. 654). A definition provided for ethnicity is that "ethnicity is a dynamic set of historically derived and institutionalized ideas and practices that allows people to identify or to be identified with groupings of people on the basis of presumed (and usually claimed) commonalities including language, history, nation or region of origin, customs, ways of being, religion, names, physical appearance, and/or genealogy or ancestry; can be a source of meaning, action, and identity; and confers a sense of belonging, pride, and motivation" (Markus, 2008, p. 654). A minority group consists of people who are living within a society in which they are usually disadvantaged in relation to power, control of their own lives, and wealth (Hammond & Cheney, 2009). In the 2010 U.S. Census, just one third of the U.S. population reported their race and ethnicity as something other than non-Hispanic White alone, and this group was referred to as the "minority" population for the report (Humes et al., 2011). The minority population in the United States increased from 86.9 million to 111.9 million between 2000 and 2010, and this represented a growth of 29% during the decade (Humes et al., 2011). *Culture, Values, and Value Orientation ○Ethnicity is evidenced in customs that reflect the socialization and cultural patterns of the group. Culture, as an element of ethnicity, refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups (The Office of Minority Health, 2005). It is "shaped by values, beliefs, norms, and practices that are shared by members of the same cultural group" (Giger & Davidhizar, 2008, p. 2). ○Values are beliefs about the worth of something and serve as standards that influence behavior and thinking. Cultural values "are unique, individual expressions of a particular culture that have been accepted as appropriate over time. They guide actions and decision-making that facilitate self-worth and self-esteem" (Giger & Davidhizar, 2008, p. 2). Relative to health, cultural values "shape human behaviors and determine what individuals will do to maintain their health status, how they will care for themselves, and others who become ill, and where and from whom they will seek health care" (Boyle, 2008, p. 266). ○ Value orientations, learned and shared through the socialization process, reflect the personality type of a particular society. The dominant value orientations are shared by the majority of the group. Kluckhohn's model (1953) of value orientations incorporates themes regarding basic human nature, the relationship of human beings to nature, human beings' time orientation, valued personality type, and relationships between human beings. Website Resource 2A shows various solutions to the questions proposed by Kluckhohn.

* Role of the Nurses in Teaching and Learning: SPEAK-UP

Role of the Nurse in Teaching and Learning Nurses have an ethical responsibility to teach their patients (Heiskell, 2010). In The Patient Care Partnership, the American Hospital Association (2003) indicates that patients have the right to make informed decisions about their care. The information required to make informed decisions must be accurate, complete, and relevant to patients' needs, language, and literacy. The Joint Commission's Speak Up Initiatives helps patients understand their rights when receiving medical care (TJC, 2015b). The assumption is that patients who ask questions and are aware of their rights have a greater chance of getting the care they need when they need it. The program offers the following Speak Up tips to help patients become more involved in their treatment: • Speak up if you have questions or concerns. If you still do not understand, ask again. It is your body, and you have a right to know. • Pay attention to the care you get. Always make sure that you are getting the right treatments and medicines by the right health care professionals. Do not assume anything. • Educate yourself about your illness. Learn about the medical tests that are prescribed and your treatment plan. • Ask a trusted family member or friend to be your advocate (advisor or supporter). • Know which medicines you take and why you take them. Medication errors are the most common health care mistakes. • Use a hospital, clinic, surgery center, or other type of health care organization that has been checked out carefully. For example, TJC visits hospitals to see if they are meeting TJC quality standards. • Participate in all decisions about your treatment. You are the center of the health care team. In addition, patients are advised that they have a right to be informed about the care they will receive, obtain information about care in their 338preferred language, know the names of their caregivers, receive treatment for pain, receive an up-to-date list of current medications, and expect that they will be heard and treated with respect. Teach information that patients and their families need. You frequently clarify information provided by health care providers and are the primary source of information that patients need to adjust to health problems (Bastable, 2014). However, it is also important to understand patients' preferences for what they wish to learn. For example, a patient requests information about a new medication, or family members question the reason for their mother's pain. Identifying the need for teaching is easy when patients request information. However, a patient's need for teaching is often less obvious. To be an effective educator, the nurse has to do more than just pass on facts. Carefully determine what patients need to know and find the time to educate them when they are ready to learn. When you value and provide education, patients are better prepared to assume health care responsibilities. Nursing research about patient education supports the positive impact of patient education on patient outcomes

* 25-1: Relationship Between Psychosocial Adaptation to Illness, Grief and Learning: DABRA

STAGE: *Denial or disbelief Patient avoids discussion of illness ("I'm fine; there's nothing wrong with me"), withdraws from others, and disregards physical restrictions. Patient suppresses and distorts information that has not been presented clearly. LEARNING IMPLICATIONS FOR NURSE & FAMILY CAREGIVER: -Provide support, empathy, and careful explanations of all procedures while they are being done. -Let patient know that you are available for discussion. -Explain situation to family or significant other if appropriate. -Teach in present tense (e.g., explain current therapy). RATIONALE: -Patient is not prepared to deal with problem. -Any attempt to convince or tell patient about illness results in further anger or withdrawal. -Provide only information patient pursues or absolutely requires. STAGE: *Anger Patient blames and complains and often directs anger toward nurse or others. LEARNING IMPLICATIONS FOR NURSE & FAMILY CAREGIVER: -Do not argue with patient but listen to concerns. -Teach in present tense. -Reassure family and significant others that patient's anger is normal. RATIONALE: Patient needs opportunity to express feelings and anger; he or she is still not prepared to face future. STAGE: *Bargaining -Patient offers to live better life in exchange for promise of better health. ("If God lets me live, I promise to quit smoking.") LEARNING IMPLICATIONS FOR NURSE & FAMILY CAREGIVER: -Continue to introduce only reality. -Teach only in present tense. RATIONALE: -Patient is still unwilling to accept limitations. STAGE: *Resolution -Patient begins to express emotions openly, realizes that illness has created changes, and begins to ask questions. LEARNING IMPLICATIONS FOR NURSE & FAMILY CAREGIVER: -Encourage expression of feelings. -Begin to share information needed for future and set aside formal times for discussion. RATIONALE: -Patient begins to perceive need for assistance and is ready to accept responsibility for learning. STAGE: *Acceptance Patient recognizes reality of condition, actively pursues information, and strives for independence. LEARNING IMPLICATIONS FOR NURSE & FAMILY CAREGIVER: -Focus teaching on future skills and knowledge required. -Continue to teach about present occurrences. -Involve family/significant other in teaching information for discharge. RATIONALE: Patient is more easily motivated to learn. Acceptance of illness reflects willingness to deal with its implications.

Health Teaching and Health Promotion (For Registered Nurses)

Standard 5B. Health Teaching and Health Promotion The registered nurse employs strategies to promote health and a safe environment. Competencies The registered nurse: ▶ Provides opportunities for the healthcare consumer to identify needed healthcare promotion, disease prevention, and self-management topics. ▶ Uses health promotion and health teaching methods in collaboration with the healthcare consumer's values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic status. ▶ Uses feedback and evaluations from the healthcare consumer to determine the effectiveness of the employed strategies. ▶ Uses technologies to communicate health promotion and disease prevention information to the healthcare consumer. ▶ Provides healthcare consumers with information about intended effects and potential adverse effects of the plan of care. ▶ Engages consumer alliance and advocacy groups in health teaching and health promotion activities for healthcare consumers. ▶ Provides anticipatory guidance to healthcare consumers to promote health and prevent or reduce the risk of negative health outcomes. Additional competencies for the graduate-level prepared registered nurse, including the APRN In addition to the competencies of the registered nurse, the graduate-level prepared registered nurse or advanced practice registered nurse: ▶ Synthesizes empirical evidence on risk behaviors, gender roles, learning theories, behavioral change theories, motivational theories, translational theories for evidence-based practice, epidemiology, and other related theories and frameworks when designing health education information and programs. ▶ Evaluates health information resources for applicability, accuracy, readability, and comprehensibility to help healthcare consumers access quality health information.

Chapter 10: Caring for Families (Potter et al., 2017, 117-122)

The Family: What is Family? Defining family initially appears to be a simple undertaking. However, different definitions result in heated debates among social scientists and legislators. The definition of family is significant and affects who is included on health insurance policies, who has access to children's school records, who files joint tax returns, and who is eligible for sick-leave benefits or public assistance programs. The family is defined biologically, legally, or as a social network with personally constructed ties and ideologies. For some patients, family includes only people related by marriage, birth, or adoption. To others, aunts, uncles, close friends, cohabitating people, and even pets are family. Understand that families take many forms and have diverse cultural and ethnic orientations. No two families are alike; each has its own strengths, weaknesses, resources, and challenges. You must care for both the family and the patient. Effective nursing administrators have a clear vision that caring for families is crucial to the mission of the health care facility and the health of the nation. *Family Forms and Current Trends ○Nuclear Family The nuclear family consists of husband and wife (and perhaps one or more children). ○Extended Family The extended family includes relatives (aunts, uncles, grandparents, and cousins) in addition to the nuclear family. ○Single-Parent Family The single-parent family is formed when one parent leaves the nuclear family because of death, divorce, or desertion or when a single person decides to have or adopt a child. ○Blended Family The blended family is formed when parents bring unrelated children from prior adoptive or foster parenting relationships into a new, joint living situation. ○Alternative Family Relationships include multi-adult households, "skip-generation" families (grandparents caring for grandchildren), communal groups with children, "non-families" (adults living alone), cohabitating partners, and homosexual couples. * Focus on Older Adult ○Family Caregiver Concerns • Assess a family for the existence of caregivers who provide daily or respite care for older-adult family members. For example, determine the caregiving roles for members of the family (e.g., providing additional financial support, designating someone to obtain groceries and medications, providing hands-on physical care). • Assess for caregiver burden such as tension in relationships between family caregivers and care recipients, changes in level of health of caregivers, changes in mood, and anxiety and depression (Tamayo et al., 2010). • Assess caregivers' spiritual well-being. Many older adults use spirituality and religion to cope with life changes and maintain psychological well-being (Kim et al., 2011). • Later-life families have a different social network than younger families because friends and same-generation family members often have died or been ill themselves. Look for social support within the community and through church affiliation (Tamayo et al., 2010). • Take time to provide and reinforce individualized caregiver instruction. Teach caregivers the importance of presence, hope, and sharing with loved one and other family caregivers (Dobrina et al., 2014).

American Nurses Association (ANA) (2015) Nursing Scope and Standards of Practice (3rd ed.)

The Scope of Nursing Practice describes the "who," "what," "where," "when," "why," and "how" of nursing practice. Each of these questions must be answered to provide a complete picture of the dynamic and complex practice of nursing and its evolving boundaries and membership. The definition of nursing provides a succinct characterization of the "what" of nursing. Registered nurses and advanced practice registered nurses comprise the "who" constituency and have been educated, titled, and maintain active licensure to practice nursing. Nursing occurs "when" ever there is a need for nursing knowledge, wisdom, caring, leadership, practice, or education, anytime, anywhere. Nursing occurs in any environment "where" there is a healthcare consumer in need of care, information, or advocacy. The "how" of nursing practice is defined as the ways, means, methods, and manners that nurses use to practice professionally. The "why" is characterized as nursing's response to the changing needs of society to achieve positive healthcare consumer outcomes in keeping with nursing's social contract with an obligation to society. The depth and breadth in which individual registered nurses and advanced practice registered nurses engage in the total scope of nursing practice is dependent on their education, experience, role, and the population served. These definitions are provided to promote clarity and understanding for all readers: Healthcare consumers are the patients, persons, clients, families, groups, communities, or populations who are the focus of attention and to whom the registered nurse is providing services as sanctioned by the state regulatory bodies. This more global term is intended to reflect a proactive focus on health and wellness care, rather than a reactive perspective to disease and illness. Registered nurses (RNs) are individuals who are educationally prepared and licensed by a state, commonwealth, territory, government, or regulatory body to practice as a registered nurse. "Nurse" and "professional nurse" are synonyms for a registered nurse in this document.

* Attributes of Families: Structure and Function

The family is a dynamic unit; it is exposed to threats, strengths, changes, and challenges. Some families are crisis proof, whereas others are crisis prone. The crisis-proof, or effective, family is able to combine the need for stability with the need for growth and change. This type of family has a flexible structure that allows adaptable performance of tasks and acceptance of help from outside the family system. The structure is flexible enough to allow adaptability but not so flexible that the family lacks cohesiveness and a sense of stability. The effective family has control over the environment and influences the immediate environment of home, neighborhood, and school. The ineffective, or crisis-prone family lacks or believes it lacks control over its environments. Hardiness and resiliency are factors that moderate a family's stress. Family hardiness is the internal strengths and durability of the family unit. A sense of control over the outcome of life, a view of change as beneficial and growth producing, and an active rather than passive orientation in adapting to stressful events characterize family hardiness (McCubbin et al., 1996). Resiliency helps to evaluate healthy responses when individuals and families experience stressful events. Resources and techniques that a family or individuals within the family use to maintain a balance or level of health aid in understanding a family's level of resiliency. *Genetic Factors. ○Genetic factors reflect a family's heredity or genetic susceptibility to diseases that may or may not result in actual development of a disease. The scope of genomics in nursing care is broad and encompasses risk assessment, risk management, counseling and treatment options, and treatment decisions (Calzone et al., 2012). Clinical applications of genetic and genomic knowledge for nurses have implications for care of people, families, communities, and populations across the life span (Calzone et al., 2013). In certain families identification of genetic factors and genetic counseling help family members decide whether or not to test for the presence of a disease and/or to have children (Calzone et al., 2013; Kirk, 2013). Some families choose not to have children, whereas others choose not to know genetic risks and have children; other families choose to know the risk and then determine whether or not to have children. Some of these diseases (e.g., heart or kidney disease) are manageable. With genetic risks for certain cancers such as certain breast cancers, a woman may choose prophylactic bilateral mastectomies to reduce the risk for developing the disease. Families with genetic neurological diseases such as Huntington's disease may choose not to have children. When families know of these risks, they have the opportunity to make informed decisions about their lifestyle and health behaviors, are more vigilant about recognizing changes in their health, and in some cases seek medical intervention earlier (Kirk, 2013).

* Box 2-1 Healthy People 2020: Selected National Health Promotion and Disease Prevention Objectives for Emerging Populations

• Increase the number of persons with health insurance to 100%. (Baseline: 83.2% [lower in ethnic minorities] of persons under 65 years covered by health insurance in 2008) • Increase the proportion of persons who have a specific source of ongoing care to 89.4%. (Baseline: 81.3% in 2008) • Reduce the overall cancer death rate. Target: 160.6 deaths per 100,000 of the population. (Baseline: 178.4 deaths per 100,000 of the population in 2007) • Prevent diabetes. Target: 7.2 new cases per 1000 per year, ages 18-84. (Baseline: 8 new cases in past 12 months, 2006-2008) • Increase the proportion of persons with diabetes who receive formal diabetes education. Target: 62.5%. (Baseline: 56.8% of persons with diabetes received formal education in 2008) • Reduce coronary heart disease deaths. Target: 100.8 deaths per 100,000. (Baseline: 126 coronary artery disease deaths per 100,000 in 2007) • Reduce AIDS among adolescents and adults. Target: 13 new cases per 100,000. (Baseline: 14.4 cases of AIDS, aged 13 and older in 2007) From U.S. Department of Health and Human Services. (2012). Healthy People 2020 (Vol. 1). Washington, DC: U.S. Government Printing Office. Also see developing data and goals for the Healthy People 2020 at www.healthypeople.gov.

Box 7-2 Characteristics and Indicators of Healthy Families

• Maintains trust traditions and shares quality time. • Evolves during crises and respects each member of the group. • Communications are open and members listen to each other. • Family table time and conversation occur regularly. • Establishes patterns to promote mental health: interacting, communicating, and expressing affection, aggression, sexuality, and similar interactions. • Maintains routines that promote health patterns of nutrition, hygiene, rest, physical activity, and sexuality. • Maintains routines to promote safety and injury prevention; health protection; disease prevention; smoking, alcohol, or substance abuse; and/or violence. • Maintains morale and motivation, rewarding achievement, meeting personal and family crises, setting attainable goals, and developing family traditions, loyalties, and values. • Promotes strategies to make decisions about health and illness. • Members act as interactive caregivers across the life span to socialize children and adolescents, to participate in the community, and to support members as they age.