Week 10 Family- book

Four Views of the Family-table

An illustration of a pair of glasses where the right lens shows four views of the family labeled from top to bottom as: system, component, context, and client.

Communication

Communication patterns are extremely important in healthy families. Healthy communication patterns are characterized by clear and comprehensible messages (e.g., "I would like to go now" or "I don't like it when you interrupt what I'm saying"). Healthy communication within the family encourages members to ask for what they want and need and to share their feelings. Thoughts and feelings can be openly, honestly, and assertively expressed in families where communication is encouraged. Alternatively, those in legitimate positions of power within the family, typically the parents, are able to evaluate the appropriateness of family members' requests. In healthy families, there is a necessary and natural hierarchy for the protection and socialization of younger family members. Parents are the leaders in the family and children are the followers. Despite this arrangement, children can voice their opinions and influence family decisions. In dysfunctional families, this seemingly simple hierarchy becomes unbalanced. When communication among family members is not clear and natural hierarchal roles become confused, communication cannot be used as a means to solve problems or to resolve conflict. The cardinal rule for effective and functional communication in families is "Be clear and direct in stating what you want and need" whether you are in a powerful or a subordinate position. Speak from the "I" position as opposed to deferring to the "you." Clear communication is one of the hardest skills to cultivate in a family system. To be direct, individuals need to first have a sense that they are respected and loved and that it is safe to express personal thoughts and feelings. The consequences of being clear and direct may be unpleasant in a family system that does not tolerate openness.

Family systems theory

Families are social systems, and much can be learned from the systems approach. A system is composed of a set of organized, complex, interacting elements. Nurses use family systems theory to understand how a family is an organized whole as well as a collection of individuals. The purpose of the family system is to maintain stability through adaptation to internal and external stressors that are created by change. Assumptions of family systems theory include the following: • Family systems are greater than and different from the sum of their parts. • There are many hierarchies within family systems and logical relationships between subsystems (e.g., mother-child, family-community). • Boundaries in the family system can be open, closed, or random. • Family systems increase in complexity over time, evolving to allow greater adaptability, tolerance to change, and growth by differentiation. • Family systems change constantly in response to stresses and strains from within and from outside environments. • Change in one part of a family system affects the total system. • Family systems are an organized whole; therefore, individuals within the family are interdependent. • Family systems have homeostatic features to maintain stable patterns that can be adaptive or maladaptive. An excellent way to understand family systems theory is to visualize a mobile that consists of different members of a family suspended from each arm of the mobile; this represents the family as a whole. The parts of the mobile move about in response to changes in the balance. The amount of movement and length of time it takes to achieve a calm, balanced state depends on the severity of the imbalance. The family is a system similar to that of the mobile. When one member is affected by a health event, the whole family and each member of the family is affected differently by this change in balance. Imagine what would happen to the mobile if one of the parts was removed as in the death of a family member, an additional part was added as in the birth or adoption of an infant, an arm of the mobile was extended such as a child moving out of the family home, or one part is yanked really hard and held down for an extended period of time and then suddenly released such as when a family member experiences a life-limiting illness and recovers or proceeds to a chronic illness. The family systems theory encourages nurses to view the individual clients as participating members of a whole family. The goal is for nurses to help families maintain balance and stability in the family system so that the family can maximize their ability to function and adapt. Nurses using this theory determine the effects of illness or injury on the entire family system. Emphasis is on the whole rather than on individuals. Nursing assessment of family systems includes assessment of individual members, subsystems, boundaries, openness, inputs and outputs, family interactions, family processing, and adapting or changing abilities. Examples of assessment questions nurses could ask a family based on a family systems theory would include the following: • Who are the members of your family? • How has one member's illness affected the family? • Who in the family is or will be affected the most? • What has helped your family in the past when you have had a similar experience? • Who outside of your family do you see as being able to help? • How would your family react to having someone from outside the family come to help? • How do you think the children, spouse, or parents are meeting their needs? • What will help the family cope with the changes? Interventions need to build on the strengths of the family to improve or support the functioning of the individual members and the whole family. Some nursing strategies based on a family systems theory include establishing a mechanism for providing families with information about their family members on a regular basis, helping the family maintain routines and rituals, and discussing ways to provide for everyday functioning when a family member becomes ill. The major strength of the systems framework is that it views families from both a subsystem and a suprasystem approach. That is, it views the interactions within and between family subsystems as well as the interaction between families and the larger supersystems, such as the community and the world. The major weakness of the systems framework is that the focus is on the interaction of the family with other systems rather than on the individual, which is sometimes more important.

Family developmental and life cycle theory

Family developmental and life cycle theory provides a framework for understanding normal predicted stresses that families experience as they change and transition over time. In the original theory of family development by Duvall and Miller, they applied the principles of individual development to the family as a unit. The stages of family development are based on the age of the eldest child. Overall family tasks that need to be accomplished for each stage of family development are identified. One developmental concept of this theory is that families as a system move to a different level of functioning, thus implying progress in a single direction. Family disequilibrium and conflicts occur during these expected transition periods from one stage of family development to another. The family begins as a married couple. Then the family becomes more complex with the addition of each new child until it becomes simpler and less complex as the younger generation begins to leave the home. Finally, the family comes full circle to the original husband-wife pair. Recognizing that families of today are different in structure, function, and processes, expanded the work to have the family developmental and life cycle theory include different family structures such as divorced families and blended families. Family developmental and life cycle theory explains and predicts the changes that occur to families and its members over time. Achievement of family developmental tasks helps individual family members to accomplish their tasks. Two of the major assumptions of this theory are as follows: • Families change and develop over time based on the age of the family members and the social norms of the society. Families have predictable stressors and changes based on changes in the family development and family structure. For example, when a family has their first child, there are predictable stresses and goals to accomplish. Also, families who experience a divorce have some predictable stresses based on when in the life cycle of the family the divorce occurs. • Families experience disequilibrium when they transition from one stage to another stage. These transitions are considered "on time" or "off time." For example, a couple in their late 20s having their first child would be considered "on time," whereas a teenager having a child or a 30-year-old wife and mother dying from breast cancer would be considered "off-time" transitions. This theory assists nurses in anticipating stresses families may experience based on the stage of the family life cycle and if the family is experiencing these changes "on time" or "off time." Nurses can also use these predictable stresses to identify family strengths in adaptation to the changes. In conducting an assessment of families. Nursing intervention strategies that derive from the family developmental and life cycle theory help individuals and families understand the growth and development stages and manage the normal transition periods between developmental periods (e.g., tasks of the school-age family member versus tasks of the adolescent family member) with the least amount of stress possible. Family nurses must recognize that in every family there are both individual and family developmental tasks that need to be accomplished for every stage of the individual or family life cycle that are unique to that particular family. The major strength of this approach is that it provides a basis for forecasting normative stresses and issues that families will experience at any stage in the family life cycle. The major weakness of the model is that it was developed at a time when the traditional nuclear family was emphasized and that some theory development has been conducted on how family life cycles or stages are affected in divorced families, stepparent families, and domestic-partner relationships.

Social and family policy challenges

National, state, and local social and family policies provide challenges to nurses' practice. As professionals, public health nurses are accountable for participating in the three core public health functions: assessment, policy development, and assurance. National family policy refers to government actions that have a direct or indirect effect on families. The range of social policy decisions that affect families is vast, such as health care access and coverage, low-income housing, Social Security, welfare, food stamps, pension plans, affirmative action, and education. Although all government polices affect families in both negative and positive ways, the United States has little overall explicit family policy. Most government policy indirectly affects families. The Family Medical Leave legislation passed in 1993 by the US Congress is an example of a type of family policy that has been positive for families. A family member may take a defined amount of leave for family events (e.g., births, deaths) without fear of losing his or her job. Despite its controversial introduction, many programs exist for families, such as Social Security, Head Start, and the Healthy Marriage Initiative. Another beneficial program is Temporary Assistance to Needy Families. Not all programs are available to all families. State assistance for families varies by state. Also, learn how the Affordable Care Act affects families. The challenges of social policy for families are numerous. Given the ongoing debate as to what constitutes a family, social policies may specify a definition that is not consistent with the family's own definition. Examples include same-sex partnerships and marriage, legal definition of parents, reproductive and fertility issues (e.g., a surrogate mother decides she wants to keep the baby), or issues involving care of older adults (e.g., a niece wants to institutionalize an older aunt with dementia because her children are not available). Besides how families define themselves, governments define health care services that affect families. Teen pregnancy prevention is a monitored health status throughout the United States and a good example of the challenges of family health policy. In some states, any child who is sexually active may have access to reproductive health services. This is a family policy to which some families object, yet the sexually active teenager is protected by laws, both state and federal. The teenager who requests confidential services is protected by Title X and the Health Insurance Portability and Accountability Act (HIPAA) federal regulations, given the state law allowing access to services. Providers can encourage teens to talk with their parents, but ultimately it is the teen's decision. Nurses need to know about these policies because they participate in carrying out family policy and have a responsibility to inform state policy regarding the services they provide. Nurses participate in enforcing laws and regulations that affect the family, such as state immunization laws. Most states have some school immunization laws that exclude from school children who are not vaccinated. If the child does not have that particular set of immunizations and the parents do not want the child vaccinated, two sets of laws are in conflict—the immunization laws and the school attendance laws. The state could provide a mechanism for a waiver or the child could be excluded from school, thus making home schooling the only option. Health care insurance is a social and family policy issue. Medicare and Medicaid, enacted in 1965, provide some health care for the elderly and low-income families. Today Medicare covers nearly 44 million beneficiaries with enrollments expected to rise to 79 million by 2030. Both living wills and durable powers of attorney for health care, legal contracts that designate a person to make health care decisions when the individual is incapacitated, are more commonplace today than in the past. However, without these legal instruments, families are faced with making end-of-life decisions for their loved ones. Although Medicare and Medicaid provide health care to many, a significant population is still uninsured. Emergency departments continue to be the only access to health care for the uninsured and a convenient and accessible source of health care for many without access to a health care provider. The H1N1 pandemic was an excellent example of mobilizing community partnerships to solve health problems. In one county health department, space for storing vaccines was insufficient in the county health clinics, so arrangements were made with the law enforcement departments to store vaccines in their secure evidence refrigerators. Other examples of partnering included collaboration with Health and Human Services departments and homeless programs to get at-risk populations and the homeless vaccinated. County health departments and pediatricians worked together to vaccinate members of families who had infants under six months of age, since these infants were too young to receive the H1N1 vaccine. Similarly, during the COVID-19 pandemic, many for-profit companies partnered with state or national governments to provide testing for the virus. For example, CVS, the drug store chain, partnered early in the pandemic to provide highly organized drive-through testing centers. Also, many hospitals partnered with local health departments to give the vaccines. Often firefighters and members of the military worked beside nurses to provide injections. These are only a few examples of social and family policy in which nurses are involved. Population-focused nurses need to be involved at the state, local, and national level in making policy that affects families. Using the core public health functions as a framework allows the population-focused nurse to view the broad spectrum of activities that improve the lives of communities, families, and the individuals within those families.

EVIDENCE-BASED PRACTICE-table

Reducing obesity in the United States is a Healthy People 2030 objective. Data collected by the Centers for Disease Control and Prevention found that the prevalence of obesity among adults in the United States in 2017-18 was 42.4%. Obesity is more prevalent in some groups. Specifically, non-Hispanic blacks (49.6%) had the highest age-adjusted prevalence of obesity, followed by Hispanics (44.7%), non-Hispanic whites (42.2%), and non-Hispanic Asians (17.4%). The study also found that men and women with college degrees had lower obesity prevalence compared to a similar age and gender group with less education. It is not surprising that among youth, the prevalence of childhood obesity decreased with increasing level of education of the head of the household. The study did not find a correlation in youth obesity and income.

Characteristics of Healthy Families-table

1. The family tends to communicate well and listen to all members. 2. The family affirms and supports all of its members. 3. The family values teaching respect for others. 4. The family members have a sense of trust. 5. The family plays together, and humor is present. 6. All members interact with each other, and a balance in the interactions is noted among the members. 7. The family shares leisure time together. 8. The family has a shared sense of responsibility. 9. The family has traditions and rituals. 10. The family shares a religious core. 11. The family honors the privacy of members. 12. The family opens its boundaries to admit and seek help with problems.

Theory-based Family Nursing-table

A Venn diagram of three overlapping ovals shows three components of the emerging family nursing theories labeled clockwise as: nursing models or theories, family social science theories, and family therapy theories.

Bioecological Family Systems Model: Level of Systems-table

A circular figure of five concentric circle shows levels of systems labeled from inside to outside as: • Microsystem. • Mesosystem. • Exosystem. • Macrosystem. • Chronosystem.

Family Functions

A healthy family provides its members with tools to guide effective interactions within the family. The family also extends its influence when an individual functions in other intimate relationships, the workplace, culture, and society in general. The tools acquired through activities associated with family life include management activities, boundary delineation, communication patterns, emotional support, and socialization.

Mapping out a pedigree

A pedigree is a drawing of a family tree used by health care professionals and genetic counselors to assess families and try to spot patterns or indications that may be helpful in diagnosing or managing an individual's health. The pedigree symbols are used globally. A useful example of how to develop a pedigree can be found at the Iowa Institute of Human Genetics. This site gives step-by-step instructions for drawing a pedigree. Steps to take when helping a family or member of a family draw a pedigree are: • Talk to the client and/or family, and ask questions and collect all information, including biological parents, brothers and sisters, including half-siblings, children, grandparents, aunts and uncles, cousins, nieces and nephews, and include the family member giving the history. • Draw a basic outline of the family tree using pedigree symbols. • Next to each family member's name, write down everything you know about his or her health and medical history. You can also ask family members if you are uncertain. If a family member is adopted, you can possibly collect information on either or both the adopted and birth families. • Include the following information: (1) age or date of birth, (2) age or date of death and cause of death for family members who have passed away, (3) medical conditions and how old the person was when diagnosed with the condition, and (4) where each side of the family comes from originally and pertinent cultural heritage (e.g., England, Iceland, Mexico, Ashkenazi or Eastern European Jewish).

Assessment

A variety of assessment tools are available to help the nurse and nurse therapist assess how the family functions as a unit. These tools can also help to identify individual members' perceptions of how the family communicates and how they deal with emotional issues such as anger, conflict, and affection. You can even use some tools to show the family how they work together as a unit to plan and solve problems and to demonstrate how they make important decisions for the family. General assessment tools can show how a family functions.

Making an appointment with the family

After the decision is made regarding where to meet the family, the nurse contacts the family. It is important to remember that the family gathers information about the nurse from this initial phone call to arrange a meeting, so the nurse should be confident and organized. After the introduction, the nurse concisely states the reason for requesting the family visit and encourages all family members to attend the meeting. The How To Make an Appointment With the Family box reviews steps for making an appointment with the family. Determine if you need an interpreter with you or if you need to arrange to have one available by phone during the visit. Several possible times for the appointment can be offered, including late afternoon or evening, which allows the family to select the most convenient time for all members to be present. It is important to remember that families ultimately retain control of the situation and they do not have to let the nurse enter their home.

Emotional Support

All families, regardless of how healthy they are, encounter conflicts. In the most functionally healthy families, feelings of affection generally are paramount, and family members realize that bursts of anger and conflict reflect a short-term response. Anger and conflict do not dominate the family's pattern of interaction. Healthy families are concerned with one another's needs, and family members' emotional and physical needs are met most of the time. When members' emotional needs are met, they feel support from those around them and are free to grow and explore new roles and facets of their personalities. A family dominated by conflict and anger alienates its members, leaving them isolated, fearful, and impaired emotionally.

Self-Assessment

Although nurse generalists do not provide family therapy, they do interact with patients and families. Most nurses come from families, and because no family is perfect, nurses may identify with certain family dynamics, which can trigger uncomfortable feelings. Nurses should be aware that their personal backgrounds, family of origin issues, and styles of interacting might affect their responses to patients and families. As a nurse, you can even become triangulated into a patient's family system. You may notice that the patient is not speaking directly to his spouse but is speaking through you. A family member may attempt to bring you into a triangle by sharing negative information about the patient, particularly poor treatment by the patient toward this family member. Triangulation makes effective therapeutic intervention difficult. Having an anxiety level greater than the situation warrants is one indication that you are involved in triangulation. Direct communication on your part and encouraging the same in the patient and family members will help keep you out of unhelpful triangles.

Overview of Family Therapy

As a treatment approach, family therapy began to emerge in the 1920s as social psychologists recognized that behaviors among family members mutually influence the behaviors of individual members. The two major aims of family therapy are to: 1. Improve the skills of the individual members 2. Strengthen the functioning of the family as a whole Family therapists are trained and practice at the advanced level. While you will not be conducting family therapy without an advanced degree, registered nurses often lead family groups for the purpose of education or support. Knowledge of basic family therapy skills will help you with group work. It will also provide you with information you can use for community referrals. Family therapists use various strategies to assess a family's level of functioning. However, the following areas are almost always explored: • Cohesiveness—how much time do members spend together as a family unit? • Communication—do the members respectfully listen to one another's concerns and ideas and allow for open discussion when a disagreement arises? • Appreciation—do the individual members contribute in meaningful ways to the functioning of the family and offer gratitude to one another that supports self-esteem? • Commitment—do the individual members consider the impact of their actions on the family as a whole and in a manner that promotes unity? • Coping—do the family members demonstrate the ability to support one another during times of crisis? • Beliefs and values—does the family identify with or practice within a collective moral, ethical, or spiritual set of standards? Specific approaches to therapy vary according to the philosophical viewpoint, education, and training of individual therapists. Family therapy's effectiveness is not tied to any particular theoretical approach. Multiple-family group therapy is a useful therapeutic modality for families who are facing similar difficulties. By hearing other families discuss their problems, family members identify and gain insight into their own problems. New skills can be modeled and learned in the context of the group. In the case of multiple-family therapy, several families meet in one group with one or more therapists, usually once a week. A review of the literature showed multiple-family therapy as a best practice in schizophrenia and has shown promise in other psychiatric disorders, such as mood disorders, eating disorders, and substance use and addiction.

Determining where to meet the family

Before contacting the family to arrange for the initial appointment, the nurse decides the best place to meet with the family, which might be in the home, clinic, or office. The following list identifies questions nurses need to consider before meeting the family. The type of agency in which the nurse works may determine where the family meeting is held (e.g., home health is conducted in the home, and mental health agencies meet the family in the clinic). Assessment of families requires an organized plan before you see the family. This plan is developed through the following questions: 1. Why are you seeing the family? 2. Are there any specific family concerns that have been identified by other sources? 3. Is there a need for an interpreter? 4. Who will be present during the interview? 5. Where will you see the family and how will the space be arranged? 6. What are you going to be assessing? 7. How are you going to collect the data? 8. What services do you anticipate the family will need? 9. What are the insurance sources for the family? 10. What cultural factors need to be considered in working with this family? One major advantage to meeting in the family home is seeing the everyday family environment. Family members are likely to feel more relaxed in their home, thereby demonstrating typical family interactions. Meeting with a family in their home emphasizes that the whole family and not one family member is the client. This approach allows the whole family to participate in the identification and resolution of the health problem. Conducting the interview in the home may increase the probability of having more family members present. There are two important disadvantages of meeting in the family home: (1) the family home may be the only sanctuary or safe place for the family or its members to be away from the scrutiny of others, and (2) meeting with a family on their ground requires the nurse to be highly skilled in communication by setting limits and guiding the interaction. Conducting the family appointment in the office or clinic allows easier access to other health care providers for consultation. An advantage of using the clinic may be that the family situation is so intense that a more formal, less personal setting may be necessary for the family to begin discussion of emotionally charged issues. A disadvantage of not seeing the everyday family environment is that it may reinforce a possible culture gap between the family and the nurse.

Boundaries

Boundaries maintain distinctions between and among individuals in the family. They also distinguish between the family and individuals external to it. The establishment and maintenance of flexible and appropriate boundaries are essential to healthy family functioning. Minuchin identified three types of boundaries within families: clear, diffuse, and rigid.

Family Dynamics Terms-table

Boundaries: Clear boundaries are those that maintain distinctions between individuals within the family and between the family and the outside world. Clear boundaries allow for a balanced flow of energy between members. The roles of children and parent(s) are clearly defined. Diffuse or enmeshed boundaries are those in which there is a blending together of the roles, thoughts, and feelings of the individuals so that clear distinctions among family members fail to emerge. Rigid or disengaged boundaries are those in which the rules and roles are adhered to no matter what. Differentiation: The ability to develop a strong identity and sense of self while at the same time maintaining an emotional connectedness with one's family of origin. Double bind: Double binds occur between two or more people as a repeated experience. They involve two or more conflicting messages, a situation in which a positive command (often verbal) is followed by a negative command (often nonverbal). Double binds leave recipients confused, trapped, and immobilized because there is no appropriate way to act. A classic example is the command to "be spontaneous." Family life cycle: The family's developmental process over time, which occurs in stages. Traditional stages include single young adult, newly married couple, a family with young children, a family with adolescents, launching children, and a family in later life. Needless to say, there are many different types of family life cycles, including single-parent families or families without children. Hierarchy: The function of power and its structures in families, differentiating parental and sibling roles and generational boundaries. Multigenerational issues (or intergenerational issues): Emotional patterns of interaction between family members that are passed down from previous generations. Examples of these patterns include the reenactment of fairly predictable and almost ritual-like patterns, repetition of themes or toxic issues, and repetition of reciprocal dyads, such as one person being the overfunctioner and another the underfunctioner. Scapegoating: A form of displacement in which a family member, usually the least powerful or most different) is blamed for another family member's distress. The purpose is to keep the focus off the painful issues and the problems of the blamers. In a family, the blamers are often the parents and the scapegoat is a child. This child may continue to be scapegoated into adulthood. Sociocultural context: The framework for viewing the family in terms of the influence of gender, race, ethnicity, religion, economic class, and sexual orientation. Triangulation: Triangulation is used to balance anxiety, distance, and conflict in a two-person relationship by inserting a third person into the relationship.

Genograms

Bowen provided much of the conceptual framework for the analysis of family relational patterns using genograms. He proposed that the family is organized according to generation, age, sex, roles, functions, and interests. Bowen suggested that where each individual fits into the family structure influences the family functioning, relational patterns, and type of family formed in the next generation. He further contended that sex and birth order shape sibling relationships and characteristics, just as some patterns passed from one generation to the next result in persistent, interactive, emotional patterns, and triangulation. The genogram is an efficient clinical summary and format for providing information and defining relationships across at least three generations. By creating a genogram, nurses and therapists are able to map the family structure and record family information that reflects both history and current functioning. The information included on a genogram should include demographic data such as geographic location of family members, their respective occupations, and educational levels. You should also record functional information regarding medical, emotional, and behavioral status. Finally, note any critical events, such as important transitions, moves, job changes, separations, illnesses, and deaths. Females are represented in circles and males are represented in squares.

Four approaches to family nursing

Central to the practice of family nursing is conceptualizing and approaching the family from four perspectives. Each approach has an implication for nursing assessment and intervention. Which approach nurses use is determined by many factors, including the health care setting, family circumstances, and resources available to the nurse: • Family as a context or structure. The family has a traditional focus that places the individual first and the family second. The family as context serves as either a resource or a stressor to individual health and illness issues. A nurse using this focus might ask an individual client, "How has your diagnosis of type 1 diabetes affected your family?" or, "Can your son help you get up and down the stairs?" • Family as client. The family is the primary focus, and individual members are second. The family is seen as the sum of individual family members. The focus is concentrated on each individual as he or she affects the family as a whole. From this perspective, a nurse might say to a family member who has just become ill, "Tell me about what has been going on with your own health and how you perceive each family member responding to your diagnosis of liver cancer." Or, "How has your diagnosis of diabetes affected your family?" • Family as a system. The focus is on the family as a client, and the family is viewed as an interacting system in which the whole is more than the sum of its parts. This approach simultaneously focuses on individual members and the family as a whole at the same time. The interactions among family members become the target for nursing interventions (e.g., the direct interactions between the parents, or the indirect interaction between the parents and the child). The systems approach to family always implies that when something happens to one family member, the other members of the family system are affected. Questions nurses ask when approaching a family as system are, "What has changed between you and your spouse since your child's head injury?" or, "How do you feel about the fact that your son's long-term rehabilitation will affect the ways in which the members of your family are functioning and getting along with one another?" • Family as a component of society. The family is seen as one of many institutions in society, along with health, education, religious, or financial institutions. The family is a basic or primary unit of society, as are all the other units, and they are all a part of the larger system of society. The family as a whole interacts with other institutions to receive, exchange, or give services and to communicate. Nurses have drawn many of their tenets from this perspective as they focus on the interface between families and community agencies. Using this framework, the nurse might use these questions: "How do you protect your family from the COVID-19 virus when your husband has to go to work for the transit authority?" This is the approach that a public health nurse would use to implement population-centered strategies to improve the health of the community.

An Individual's Family Life Structure Over Time-table

Childhood: The factors includes the details for 'lives in'. Adulthood: The factors include the details for partner, spouse or parent, custodial parent, partner or parent, partner or parent, spouse biological or stepparent, married or aging family (married), and widow or widower (single). The linear flowchart at the bottom leads to one another as follows: Family of origin (lives in), single parent family (lives in), stepfamily (lives in), cohabitation (partner), commuter marriage (spouse or parent), single parent family (custodial parent), cohabitation (partner or parent), and stepfamily (spouse biological or stepparent).

Clear Boundaries

Clear boundaries are adaptive and healthy. All members of the family understand these boundaries and they give family members a sense of self. They are firm, yet flexible, and provide a structure that responds and adapts to change. Clear boundaries allow family members to take on appropriate roles and to function without unnecessary or inappropriate interference from other members. They reflect structure while simultaneously supporting healthy family functioning and encouraging individual growth.

HOW TO MAKE AN APPOINTMENT WITH THE FAMILY-table

Data collection starts immediately upon referral to the nurse. The following are suggestions that will make the process of arranging a meeting with the family easier: 1. Remember that the assessment is reciprocal and the family will be making judgments about you when you call to make the appointment. 2. Introduce yourself and state the purpose for the contact. 3. Do not apologize for contacting the family. Be clear, direct, and specific about the need for an appointment. 4. Arrange a time that is convenient for the greatest possible number of family members. 5. If appropriate, ask if an interpreter will be needed during the meeting. 6. Confirm the place, time, date, and directions.

Family health

Despite the focus on family health in nursing, the meaning of family health lacks consensus and is not precise. The term family health is often used interchangeably with the concepts of family functioning, healthy families, or familial health. Hanson defines family health as "a dynamic changing relative state of well-being, which includes the biological, psychological, spiritual, sociological, and cultural factors of individual members and the whole family system." This holistic approach refers to individual members as well as the family unit as a whole. An individual's health affects the entire family's functioning, and in turn the family's functioning affects the health of individuals. Thus assessment of family health involves simultaneous assessment of individual family members and the family system as a whole, and the community in which the family is embedded. Health professionals have tended to classify clients and their families into two groups: healthy families and nonhealthy families, or those in need of psychosocial evaluation and intervention. A popular term for nonhealthy families is dysfunctional families, also called noncompliant, resistant, or unmotivated—terms that label families who are not functioning well with each other or in their communities. Families are neither all good nor all bad; rather, all families have both strengths and difficulties. Families with strengths, functional families, or balanced families are often referred to as healthy families. All families have seeds of resilience. Families with strengths, functional families, and resilient families are terms often used to refer to healthy families. Research has been conducted about healthy families, but it is clear that the issues examined all concern relational needs. These families tend to be affectionate in their relationships with one another. This means that in healthy families, the basic survival needs are met. Balanced families also are able to adapt to situations; they are flexible in terms of leadership, relationships, rules, control, discipline, negotiation, and role sharing.

Diffuse Boundaries

Diffuse boundaries result in unclear boundaries and a lack of independence. Individuals in families with diffuse boundaries may have problems defining who they are. When boundaries are diffuse, individuals tend to become overly involved with one another. This overinvolvement is referred to as enmeshment. When boundaries are diffuse, everyone, and thus no one, is in charge. It is not clear who is responsible for decisions and who has permission to act. Diffuse boundaries are particularly problematic when parent/child role enactment becomes blurry—for example, when a parent may be unemployed and one of the children takes responsibility for earning money to meet the family's basic needs. In families with diffuse boundaries, individual members are discouraged from expressing their own views. Differentiation, or the ability to possess a strong identity and sense of self while maintaining an emotional connection with the family, is also discouraged. To an outsider, it may appear that family members are extremely close, and family members may believe that they are of one mind. They may take comfort that everyone thinks the same way. "No one in our family likes seafood." That sense is typically false, and deeper analysis often results in the discovery of suppressed frustrations, anger, and passive-aggressive behaviors. Expression of separateness or independence is viewed as disloyalty to the family. Members are prone to psychological or psychosomatic symptoms, probably as a function of the individuals' inability to actually say or even to recognize how they feel. During times of change or crisis, whether the crisis is one of normal development (such as when a baby is born or an elderly grandparent dies) or one that is unanticipated (such as the loss of a pregnancy or serious debilitating injury to a family member), adaptation of both individuals and of the family as a whole is extremely difficult.

Triangulation

Dyads, consisting of two people, are often emotionally unstable. When tension in a dyad builds and communication fails, triangulation may be used to balance the relationship. Triangulation occurs when one family member does not communicate directly with another family member but will communicate with a third family member. This forces the third family member to be part of the triangle, and communication is then routed through the third person or even a pet. For example, Charlotte is the youngest child of Amanda and Andrew. Charlotte has sensed increasing tension in her parents' marriage since her older siblings left home. When things get especially conflicted between Amanda and Andrew, Amanda vents her frustrations to Charlotte and even confided that Andrew had an affair. Charlotte is afraid that her parents will get a divorce when she goes away to college and is considering attending a local community college rather than her dream university. In this and many other cases, the family triangle serves to stabilize interpersonal relationships in the short term. Triangulation can also be a form of splitting within the family system. One person may play a third family member against the one with whom he or she is upset. This splitting is accomplished through exaggeration, telling half-truths, or other manipulation of facts to present an untrue picture of the targeted person. Although triangles within families tend to be structurally stable, the intensity of the triangulation process varies over time. During stressful times, triangulation may increase. Family triangles are destructive and may create emotional instability over the long-term family life-cycle. Triangulating behavior occurs everywhere, not only in families but also in social situations among friends and in the workplace. You can monitor your own indirect communication and make an effort to communicate directly. Obviously, splitting behaviors are almost always emotionally unhealthy and should definitely be avoided.

Management

Every day in every family, decisions are made regarding issues of power, resource allocation (i.e., who gets what), rule-making, and the provision of financial support. These decisions contribute to adaptive family functioning. In healthy families, it is usually the adults who mutually agree on how to perform these management functions. In families with a single parent, these management functions may often become overwhelming. In chaotic families, an inappropriate member, such as a teenager, may be the one who makes management decisions. Although children learn decision-making skills as they mature and increasingly make decisions and choices about their own lives, they should not be expected or forced to take on this responsibility for the family. A 12-year-old child, for example, should not be the one to decide whether to pay the gas bill or buy groceries.

Rigid Boundaries

Families with rigid boundaries demand adherence to rules and roles—some apparent and some less so—regardless of circumstances or outcomes. Boundaries can be so firmly closed that family members are disengaged and avoid one another, resulting in little sense of family loyalty. In families in which rigid boundaries predominate, communication is minimal, and members rarely share thoughts and feelings. Isolation may be a marked feature in such family systems. Disengaged family members lead highly separate and distinct lives. Because they do not learn intimacy in the family setting, individuals from disengaged families do not tend to develop insights into their own feelings and emotions. As a result, they may have a hard time bonding with others and participating in new family structures when they leave their families of origin and begin their lives as adults.

Working with families for healthy outcomes

Family nurses should transcend the traditional nursing approach as a service model and change their practice to a capacity-building model. In a capacity-building model, nurses assume the family has the most knowledge about how their health issues affect the family, supports family decision making, empowers the family to act, and facilitates actions for and with the family. The goal of family nursing is to focus care, interventions, and services to optimize the self-care capabilities of families and to achieve the best possible outcomes. Nurses work with all types of family structures in a variety of settings. Each family is unique in how it responds to the stresses that evolve when a family member experiences a health event. Public health nurses are in a unique position to help families by providing direct care, removing barriers to needed services, and improving the capacity of the family to take care of its members.

Family functions and structures

Knowledge of family functions and structures is essential for understanding how families influence health, illness, and well-being. Family functions are the ways in which families meet the needs of (1) each family member, (2) the family as a whole, and (3) their relationship to society. Historically families have performed these functions: 1. Economic function: Family income is a substantial part of family economics, but it is also related to family consumerism, money management, housing decisions, insurance choices, retirement, and savings. Family economics affect and reflect the nation's economy. 2. Reproductive function: The survival of a society is linked to patterns and rates of reproduction. The family has been the traditional structure in which reproduction was organized. Today, the reproductive function of family has become more separated from traditional family structure as more children are born outside of marriage and into nontraditional family structures. 3. Socialization function: A major expectation of families is that they are responsible for raising their children to fit into society and take their place in the adult world. In addition, families disseminate their culture, including religious faith and spirituality. However, some families choose to teach their children to try to change or rebel against society, which typically causes community problems. 4. Affective function: Families establish boundaries and structure that provide a sense of belonging and identity of who the family members are individually and to their family. The purpose of the affective function is to learn about intimate reciprocal caring relationships, to learn about dependency and how to nurture future generations. 5. Health care function: Families teach members the concepts of health, health promotion, health maintenance, disease prevention, and illness management. Family members provide informal caregiving to ill family members and are primary sources of support. Family structure refers to the characteristics and demographics (e.g., sex, age, number) of individual members who make up family units. More specifically, the structure of a family defines the roles and the positions of family members. Family structures have changed over time to meet the needs of the family and society. The great speed at which changes in family structure, values, and relationships are occurring makes working with families in the twenty-first century exciting and challenging. According to Kaakinen, the following aspects need to be addressed when determining the family structure: 1. The individuals that compose the family 2. The relationships between them 3. The interactions between the family members 4. The interactions with other social systems The family structure changes and modifies over time. An individual may participate in a number of family life experiences over a lifetime. For example, a child may spend the early, formative years in the family of origin (mother, father, siblings); experience some years in a single-parent family because of divorce or death; and participate in a stepfamily relationship when the single parent who has custody remarries. This same child as an adult may experience several additional family types: cohabitation while completing a desired education, and then a commuter marriage while developing a career. As an adult, the individual may divorce and become a custodial parent. The custodial parent may live with another partner and later marry a partner who also has children. As couples age, they have to address issues of the aging family, and subsequently the woman may become an older single widow. Thus nurses work with families representing different structures and living arrangements. Prospects for families in the 21st century are numerous. New family structures that are currently experimental will emerge as everyday "natural" families (e.g., families in which the members are not related by blood or marriage, but who provide the services, caring, love, intimacy, and interaction needed by all persons to experience a quality life). Also, some individuals choose not to have children. At times it is helpful to understand families through a narrow framework of family function and structure. However, a family is a system within itself as well as the basic unit of a society. Some would argue that the traditional concept of family is disintegrating based on how the structure and functions of the family have changed over time. On the other side of that debate, families change in response to the societal changes and are ever evolving and thriving as they seek different ways of interconnectedness. Families depend on a variety of agencies to provide safety, such as law enforcement, and other agencies, such as churches, synagogues, and other religious organizations, are involved in the passing on of religious faith. Education (socialization function) is relegated to the schools. Family names are no longer needed to confer status as in the past, when names were important in a community.

Foundations for Population Health in Community/Public Health Nursing pg 341- 357 Family development and family nursing assessment and genomics

Family nursing is practiced in all settings. The trend in the delivery of health care has been to move health care to community settings; thus, family nursing is pertinent to nurses in community health. Public health nurses need skills that enable them to move between working with individual families, bridge relationships between family and the community, advocate for family and community legislation, and influence policies that promote and protect the health of populations. Family nursing is a specialty area that has a strong theory base and blends both public health and family-based nursing. Family nursing consists of nurses and families working collaboratively and with other members of health, educational, and social service teams to ensure the success of the family and its members in adapting to responses to health and illness. The purpose of this chapter is to present a current overview of families and family nursing, theoretical frameworks, and strategies for assessing and intervening with families in the community. Nurses practicing in the community use the core competencies for public health professionals, and the core public health functions of assessment, assurance, and policy development to promote the interconnectedness of individual health with the health of families and communities.

Theories for working with families in the community

Family nursing theory is an evolving synthesis of the scholarship from three different traditions: family social science, family therapy, and nursing. Of the three categories of theory, the family social science theories are the most well developed and informative with respect to how families function, the environment-family interchange, interactions within the family, how the family changes over time, and the family's reaction to health and illness. Therefore, in this chapter, three family social science theories that blend well with public health nursing are reviewed. These social science theories are the family systems theory, family developmental and life cycle theory, and the bioecological systems theory.

Varcarolis' Foundations of Psychiatric-Mental Health Nursing pg. 619 - 624 (through genogram) Family Interventions

In Western culture, the uniqueness of the individual and the search for autonomy are celebrated. Yet we are also defined and sustained by interwoven systems of human relationships, including the relationships developed with our family members. Families are the foundation and structure of most societies. Families are defined by reciprocal relationships in which persons are committed to one another. Healthy family relationships support the well-being of individual family members. When children do not have family support—for instance, in cases of loss due to the ravages of war—they tend to respond with a range of adjustment difficulties and guilt reactions. These reactions can influence their health and well-being for years, if not a lifetime. In other cases, the family remains physically intact, yet family members do not support one another. Emotional stress or trauma experienced by one family member, as well as complex life challenges faced by the family as a whole, can threaten interactions. For those families and for the members within them, family support and/or therapy are needed. The family is the primary social system to which a person belongs and, in most cases, it is the most powerful system of which a person will ever be a member. The dynamics of the family subtly and significantly influence the beliefs and actions of individual members across the lifespan. Healthy families tend to deal better with developmental changes than less healthy families. However, even "normal" changes such as the birth of a child can test the strength of relationships even in the most resilient family.

Examples of Dysfunctional Communication-table

Manipulating Instead of asking directly for what is wanted, family members manipulate others to get what they want. For example, a child starts a fight with a sibling to get attention. Another example is when a request is granted with "strings attached" so that the other person has a difficult time refusing the request: "If you clean my room for me, I won't tell Daddy you are getting bad grades in school." Distracting To avoid functional problem solving and resolving conflicts within the family, family members introduce irrelevant details into problematic issues. Generalizing Members use global statements such as "always" and "never" instead of dealing with specific problems and areas of conflict. Family members may state, "Harry is always angry," instead of exploring why Harry is upset. Blaming Family members blame others for failures, errors, or negative consequences of an action to deflect the focus from them. Placating Family members pretend to be well-meaning to keep peace in the family. "Don't yell at the children, dear. I put the shoes on the stairs."

Evaluation of the plan

In evaluating the outcome, nurses use critical thinking to determine whether the plan is working. When the plan is not working, the nurse and the family work together to determine the barriers interfering with the plan or determine if something changed in the family story. Family apathy and indecision are known to be barriers in family nursing. Friedman and colleagues also identified the following nurse-related barriers that can affect achievement of the outcome: 1. Nurse-imposed ideas 2. Negative labeling 3. Overlooking family strengths 4. Neglecting cultural or gender implications Family apathy may occur when there are value differences between the nurse and family; the family is overcome with a sense of hopelessness; the family views the problems as too overwhelming; or family members fear failure. Additional factors must be considered because family members may be indecisive for the following reasons: • They cannot determine which course of action is better. • They have an unexpressed fear or concern. • They have a pattern of making decisions only when faced with a crisis. An important part of the judgment step in working with families is the decision to terminate the relationship between the nurse and family. Termination is phasing out the nurse from family involvement. When termination is built into the interventions, the family benefits from a smooth transition process. The family is given credit for the outcomes of the interventions that they helped design. Strategies often used in the termination component are as follows: (1) decreasing contact with the nurse; (2) extending invitations to the family for follow-up; and (3) making referrals when appropriate. The termination should include a summative evaluation meeting in which the nurse and family put a formal closure to their relationship. When termination with a family occurs suddenly, the nurse needs to determine the forces bringing about the closure. The family may be initiating the termination prematurely, which requires a renegotiating process. The insurance or agency requirements may be placing a financial constraint on the amount of time the nurse can work with a family. Regardless of how termination comes about, it is important to recognize the transition from depending on the nurse on some level to having no dependence. Strategies that help with the termination are as follows: (1) increase the time between the nurse's visits; (2) develop a transition plan; (3) assess the family support systems; (4) make referrals to other resource; and (5) provide a written summary to the family.

Planning for personal safety

It is critical to plan for your own safety when you make a home visit. Learn about the neighborhood you will be visiting, anticipate the needs you may have, and determine whether it is safe for you to make the home visit alone or if you need to arrange to have a security person with you during the visit. Always have your cell phone fully charged and readily available. The following strategies will help to ensure your safety when you visit families in their homes: 1. Leave a schedule at your office and stay in touch with the office. 2. Plan the visit during safe times of the day and know exactly where you are going. 3. Dress appropriately; wear little or no jewelry and take little money. 4. Put any valuables in your trunk before you leave for an appointment. 5. Avoid secluded places if you are alone; keep a buffer zone of a car length between you and the car in front of you so you can maneuver if you are in danger. 6. Obtain an escort, a coworker or volunteer if you think there is a need to do so. If you feel unsafe, do not visit. 7. Sit between the client and the exit. 8. Check in with your office at the end of the day. 9. Establish parameters; that is, make it clear that you have a schedule to keep in case you have to leave for any reason. 10. Be aware of who else is in the apartment or house for both confidentiality and safety. 11. Ask about pets if you have allergies; find out if they are friendly or not. 12. Guard your own privacy and pay attention to what you put on social media.

Interviewing the family: Defining the problem

It is important to build a trusting family-nurse relationship. Working with families requires nurses to use therapeutic communication efficiently and skillfully by moving between informal conversation and skilled interviewing strategies. Prepare your family questions before your interview based on the best family theory given what is known about the family situation. Remember that it is important to introduce yourself to the family and initiate conversation with each member present. Spending some initial time on informal conversation helps put the family at ease, allows them time to assess the person or nurse, and disperses some of the tension surrounding the visit. Involving each family member in the conversation, including children, the elderly, or a disabled family member, demonstrates respect and caring and sends the message that the purpose of the visit is to help the whole family and not just the individual family member. Shifting the conversation into a more formal interview can be accomplished by asking the family to share their story about the current situation. If the nurse focuses only on the medical aspect or illness story, much valuable information and the priority issue confronting the family may be missed in the data collection. The purpose of the interview is to gather information and help the family focus on their problem and determine solutions. The specific therapeutic questions listed below have been found to provide important family information: 1. What is the greatest challenge facing your family right now? 2. Who in the family do you think the illness has the most impact on? 3. Who is suffering the most? 4. What has been the most and least helpful to you in similar situations? 5. If there is one question you could have answered, what would it be? 6. How can we best help you and your family? 7. What are your needs/wishes for assistance now? Encourage several members of the family to provide input into the discussion. One strategy is to ask the same question of several different family members. It is critical for the nurse to not take sides in the family discussion and to focus on guiding them in their decision making. In addition to the family story, the nurse will likely need to ask specific assessment questions about the family member who is in need of services.

Socialization

It is within families that individuals first learn social skills, such as how to interact in nonfamily venues, how to negotiate for personal needs, and how to plan. Children learn through parents' role modeling. Children learn through behavioral reinforcement about how to function effectively within the family and, when the system is successful, how to apply those skills in society. Each developmental phase for family members and for the family as a whole brings new demands and requires new approaches to deal with changes. Parents are socialized into their family roles as they address the growth and developmental needs of each child. Parents' roles change when the children mature and leave home. This may necessitate partners' renegotiation of the patterning of their lives together. As time goes on, the parents may need their adult children's help if they become less able to care for their own needs. It is not surprising that families have difficulty negotiating role change. Periods of change increase the overall stress within families. If the family is socialized to manage stress through open, direct communication, this period may be short-lived. However, if the family is not socialized to emotionally support its members or communicate effectively, the stress may linger, deteriorating the family's ability to function. In response to the demands of change, healthy families demonstrate flexibility in adapting to new roles. Through well-organized management activities, firm but flexible boundary delineation, strong and appropriate communication patterns, ongoing provision of emotional support, and adept socialization, healthy families provide tools to their members to facilitate functioning for the present and into the future.

Challenges for nurses working with families in the community

Many challenges exist that influence the practice of family nursing in the community. The definition of what constitutes a family has changed over time; there are single-parent families, same-gender families, two parents of different gender families, multigenerational families living together, grandparents raising grandchildren. To make this more complex, there is no single agreed-upon definition of family. Many policies related to families assume legal marriage and that children will be raised by married-couple families. For example, Social Security benefits are based on earnings of a spouse to determine retirement security for the living survivor. According to the US Census Bureau, 4 million out of about 12 million single-parent families have children under the age of 18, and more than 80 percent are headed by single mothers. In the current health care system, families are significant members of health care teams because they are the consistent person or people involved in the care. Nurses are responsible for the following: • Helping families promote their health • Meeting family health needs • Coping with health problems within the context of the existing family structure and community resources • Collaborating with families to develop useful interventions Nurses must be knowledgeable about family structures, functions, processes, and roles. In addition, nurses must be aware of and understand their own values and attitudes pertaining to their own families, as well as being open to different family structures and cultures. Nurses are often the link between the family and the services that a member or members need. Nurses need excellent communication and negotiation skills because they often must advocate for the family as well as explain to the family what another agency representative is telling them.

Family and Household Structures-table

Married family • Traditional nuclear family • Dual-career family • Spouses reside in the same household • Commuter marriage • Husband or father is away from the family • Stepfamily • Stepmother family • Stepfather family • Adoptive family • Foster family • Voluntary childlessness Single-parent family • Never married • Voluntary singlehood (with children, biological or adopted) • Involuntary singlehood (with children) • Formerly married • Widowed (with children) • Divorced (with children) • Custodial parent • Joint custody of children • Binuclear family Multiadult household (with or without children) • Cohabitating couple • Commune • Affiliated family • Extended family • New extended family • Home-sharing individuals • Same-sex partners

Preencounter data collection

Nurses need to use excellent communication skills to help families prioritize the issues they are confronting, identify their needs, and develop a plan of action. Family members are experts in their own health. They know the family health history, their health status, and their health-related concerns. Nurses gather information about the family from many sources as well as directly from the family. Data collection begins when an actual or potential problem is identified by a source, which may be the family, the health care provider, a school nurse, or a caseworker. The assessment process and data collection begin as soon as the referral occurs or the appointment is made. Sources of pre-encounter data the nurse gathers include the following: • Referral source. This would be information that led to the identification of a family problem and could include demographic information and subjective and objective information. • Family. A family may identify a health care concern and seek help. During the initial intake or screening procedure, valuable information can be collected from the family. Information is collected during phone interaction with the family member, even when calling to set up the initial appointment. This information might include family members' views of the problem, surprise that the referral was made, reluctance to set up the meeting, avoidance in setting up the interview, or recognition that a referral was made or that a probable health care concern exists. • Previous records. Previous records may be available for review before the first meeting between the nurse and the family. Often, a record release for information is necessary to obtain family or individual records. However, one challenge may be that many of the electronic health records are premade templates that ignore family information.

Application of the Nursing Process

Nurses prepared at the basic level meet the needs of patients and families in inpatient and outpatient settings. Their work as part of the healthcare team can contribute significantly to the quality of intervention and patient outcomes. Psychiatric-mental health advanced practice registered nurses who have graduate or postgraduate training in family therapy may practice as nurse family therapists.

Designing family interventions

Nurses will be challenged to help families identify the primary problem confronting them and to step aside and accept the family priority as they work in partnership with the family to keep their interventions simple, specific, timely, and realistic. It is essential that the family participate in determining the primary need and in designing interventions. As the nurse designs interventions for the family, it is important to consider the health literacy of the client. It is important to view the family with an open approach because the central issue identified by the referral source may not be the actual problem the family is experiencing. Of all of these problems, the nurse worked with the family to help them identify that their major concern centered on nutritional management, which ultimately affects the administration of medication. The major difference between the two scenarios presented here was the way in which the nurse framed questions while listening to the family story. In the first scenario, the nurse asked questions that allowed for consideration of only one aspect of family health. This type of step-by-step, nurse-led, linear problem-solving process is tedious and time consuming, and will likely cause errors in the identification of the most pressing family concern. In the second scenario, the nurse asked questions that allowed for critical thinking about the family view of their challenges. The nurse gathered information from the referral source, conducted an assessment of the impact of the new diagnosis on the whole family, and collaboratively the nurse and family identified the critical family issue that had a more far-reaching effect on the health of the whole family.

HEALTHY PEOPLE 2030-table

Objectives Specific to Families and Family Nursing • AH-03: Increase the proportion of adolescents who have an adult they can talk to about serious problems. • MICG-17: Increase the proportion of children who receive a developmental screening. • FP-09: Increase the proportion of women who get needed publicly funded birth control services and support.

LEVELS OF PREVENTION-table

Primary prevention • Educate parents about healthy nutritional choices for young children and the risks associated with obesity. • Provide counseling and weight management for overweight children and teens. • Help mothers who qualify for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) complete the extensive paperwork. Secondary prevention • Screen teens for obesity with body mass index (BMI) greater than or equal to 30 for obesity. • Analyze children's height and weight growth as part of annual health assessments. Tertiary prevention • Work with schools to improve the quality of food offered in school lunches. • Help communities establish local farm-to-school networks, create school gardens, and ensure that more local foods are used in the school setting.

Traditional Family Life Cycle Stages and Family Developmental Tasks-table

Stages of Family Life Cycle: Married couple Childbearing families with infants Families with preschool children Families with school-age children Families with adolescents Families launching young adults Middle-aged parents Aging parents Family Developmental Tasks: Establish relationship as a family unit, role development Determine family routines and rituals Adjust to pregnancy and then birth of infant Learn new roles as mother and father Maintain couple time, intimacy, and relationship as a unit Understand growth and development, including discipline Cope with energy depletion Arrange for individual time, family time, and couple time Learn to open family boundaries as child increases amount of time spent with others outside of the family Manage time demands in supporting child's interests and needs outside of the home Establish rules, new disciplinary actions Maintain couple time Adapt to changes in family communication, power structure, and decision making as teen increases autonomy Help teen develop as individual and family member As young adult moves in and out of the home, allocate space, power, communication, roles Maintain couple time, intimacy, and relationship Refocus on couple time, intimacy, and relationship Maintain kinship ties Focus on retirement and the future Adjust to retirement, death of spouse, and living alone Adjust to new roles (i.e., widow, single, grandparent) Adjust to new living situations, changes in health

Bioecological systems theory

The bioecological systems theory was developed by Urie Bronfenbrenner to describe how environments and systems outside of the family influence the development of a child over time. Even though this theory was designed around how both nature and nurture shape the development of a child, the same underlying principles can be applied when the client is the family. This theory is useful for public health nurses since it helps identify the stresses and potential resources that can affect family adaptation. The family as the client is at the center of the concentric circles. Each of the levels contains roles, norms, and rules that influence the current situation of the family. Microsystems are composed of the systems and individuals that the family directly interacts with on a daily basis. These systems vary for each family, but could include their home, neighborhood, workplace, schools, extended family, health care system, community/public health system, or close friends. Mesosystems are the systems that the family interacts with frequently but not on a daily basis. These systems vary based on the situation in which the public health nurse is working with a family. Some ideas for systems at this level could be a home health aide who comes to the home twice a week, a hospice nurse who comes to the home once a week, a social worker, church members who come to deliver food to the family, the transportation system, the school system, specialty physicians, pharmacy, or extended family. Exosystems are external environments that have an indirect influence on the family. Examples of these systems could be the economic system, local and state political systems, religious system, the school board, community/health and welfare services, the Social Security office, or protective services. Macrosystems are broad overarching social ideological and cultural values, attitudes, and beliefs that indirectly influence the family. Examples include a Jewish religious ethic, a cultural value of autonomy in decision-making, or ethnicity. Chronosystems refer to time-related contexts in which changes that have occurred over time may influence any or all of the other levels/systems. Examples include the death of a young parent, a divorce and remarriage, war, natural disasters, or a pandemic. One assumption of this model is that what happens outside of the family is equally as important as what happens inside the family. The interaction between the family and the systems in which it interacts is bidirectional in that the family is affected by the outside systems and the family affects these systems. The strength of this model is that it provides a holistic view of interactions between the family and society. In working with the family, a critical intervention strategy is drawing a family ecomap that shows the systems with which the family interacts, including the flow of energy from that system into the family or out of the family. The family ecomap is a visual diagram of the family unit in relation to other units or subsystems in the community. It can serve to organize and present factual information and show the nature of relationships among family members, and between family members, and the community. The weakness of this model is that it does not address how families cope or adapt to the interaction with these systems. In addition to these three types of theories that describe ways to work with families, the Friedman Family Assessment Model draws on the structure-function framework and on developmental and systems theory. The model with its broad approach to family assessment views families as a subsystem of society. The family is viewed as an open social system. The family's structure (organization) and functions (activities and purposes) and the family's relationship to other social systems are the focus of this approach. This assessment approach is important for family nurses because it enables them to assess the family system as a whole, as part of the whole of society, and as an interaction system. The general assumptions for this model are (1) the family is a social system with functional requirements; (2) the family is a small group possessing certain generic features common to all small groups; (3) the family as a social system accomplishes functions that serve the individual and society; and (4) individuals act in accordance with a set of internalized norms and values that are learned primarily in the family through socializations. The guidelines for the Friedman Family Assessment Model consist of the following six broad categories of interview questions: 1. Identifying data 2. Developmental family stage and history 3. Environmental data 4. Family structure, including communication, power structures, role structures, and family values 5. Family functions, including affective, socialization, and health care 6. Family coping Each category has several subcategories. There are both long and short forms of this assessment tool. In summary, this approach was developed to provide guidelines for family nurses who are interviewing a family to gain an overall view of what is going on in the family. The questions are extensive, and it may not be possible to collect all the data at one visit. All the categories may not be pertinent for every family.

Genomics and family health

The mapping of the human genome created a major shift in how professionals provide care and approach public health. April 2020 marked the 17th anniversary of the completion of the Human Genome Project (HGP). The terms genetics and genomics are often used interchangeably. However, they are different. Genetics refers to the study of the function and effect of single genes that are inherited by children from their parents. Genomics is the study of all of a person's genes, including their interaction with one another as well as the interaction of a person's genes with the environment (National Human Genome Research Institute). The stated goals of the HGP were determining the sequences of the 3 billion chemical base pairs that make up human DNA; storing this information in databases; improving tools for data analysis; transferring related technologies to the private sector; and addressing the ethical, legal, and social issues that may arise. Many genetic tests have implications for families, and it is important for nurses to help individuals, families, and communities understand the purpose, limitations, potential benefits, and potential risks of a test before submitting samples for analysis. Over the years a variety of home tests have been developed, and they are controversial. At the core of the issues related to genetics and genomics is DNA. DNA is the chemical inside the nucleus of a cell that has the genetic instructions for making living organisms. DNA can be compared to long-term storage or a blueprint or code to construct other components of cells such as proteins and ribonucleic acid (RNA) molecules. The DNA segments that carry the genetic information are called genes. Within cells, DNA is organized into long structures called chromosomes. These chromosomes are duplicated before cells divide, in a process called DNA replication. DNA is composed of four bases: adenine (A), guanine (G), cytosine (C), and thymine (T). Genes are composed of specific sequences of these bases. Alterations in the usual sequence of bases that form a gene or changes in DNA or chromosomal structures are called mutations. A large number of agents are known to cause mutations. These mutations, which are attributed to known environmental causes, can be contrasted with spontaneous mutations, which arise naturally during the process of DNA replication. Approximately 3 billion DNA base pairs must be replicated in each cell division, and considering the large number of mutagens to which we are exposed, DNA replication is fascinatingly accurate. A key reason for this accuracy is a mechanism called DNA repair, which occurs in all normal cells of higher organisms. It is estimated that repair mechanisms correct at least 99.9% of initial errors. Chemicals produced in industry are now known to be mutagenic in laboratory animals. A mutagen is a chemical or physical phenomenon that promotes errors in DNA replication. Among these are nitrogen mustard, vinyl chloride, alkylating agents, formaldehyde, sodium nitrite, and saccharin. In addition, ionizing radiation, such as those produced by x-rays and from nuclear fallout, can promote chemical reactions that change DNA bases or break the bonds of double-stranded DNA. How does an understanding of DNA and the science of genetics relate to public health nursing and family nursing? The field of genetics shows that human disease comes from the collision between genetic variations and environmental factors. While we cannot change the genes of our fellow human beings, nurses in public health are uniquely poised to advocate for environmental changes (for example, advocating for colorectal cancer screening for those with a family history of colorectal cancer) that can impact the wider health of humankind. As knowledge has evolved with the mapping of the human genome, our understanding of this interaction continues to advance. For example, more than 50 hereditary cancer syndromes have been described. If a person is concerned that he or she may have an inherited cancer susceptibility syndrome in the family, it is generally recommended that when possible, a family member with cancer have genetic counseling and testing first, to identify with more certainty if the cancer in the family is due to an inherited genetic variant. The features of a person's personal or family medical history that particularly in combination may suggest a hereditary cancer syndrome include: • Cancer was diagnosed at an unusually young age • Several different types of cancer occurred in the same person • Cancer in both organs in a set of paired organs, such as both kidneys or both breasts • Several first-degree relatives (the parents, siblings, or children of an individual) have the same type of cancer (for example, a mother, daughter, and sisters with breast cancer); family members with breast or ovarian cancer; family members with colon cancer and endometrial cancer • Unusual cases of a specific cancer type (for example, breast cancer in a man) • The presence of birth defects that are known to be associated with inherited cancer syndromes, such as certain noncancerous (benign) skin growths and skeletal abnormalities associated with neurofibromatosis type 1 • Being a member of a racial or ethnic group that is known to have an increased risk of having a certain inherited cancer susceptibility syndrome and having one or more of the above features as well • Several family members with cancer Nurses can play a key role both by assisting patients with obtaining their personal family history and also helping patients and families navigate through the disclosure process and uncovering their personal and family health history and understanding specific genetic tests and the costs of these tests. In addition, if patients are willing to make lifestyle changes or health decisions, the appropriate psychosocial support and education can be provided to clients and their families. Nurses can answer questions and assist in challenges these clients and families face with making decisions when there is any suspicion of increased risk for genetically based diseases. In order to provide appropriate nursing care that includes gathering genetic information in the family health history, it is essential that nurses be knowledgeable. The Centers for Disease Control and Prevention (CDC) recommends that all public health workers need to be aware of the advances in the field of genomics. While various health care professional groups have developed competency lists for their members, the guidelines by the American Nurses Association are useful for nurses who work with families in the community. These competencies have four major sections. Each section has a set of skills the nurse should have. The overall domains are: • Professional practice: nursing assessment: applying/integrating genetic and genomic knowledge • Identification • Referral • Provision of education, care and support Help families complete a health history by using these steps: 1. Inform the family that a family health history is a written or graphic record of diseases or health conditions present in their biological family. 2. Encourage the family to develop a three-generation history of biological relatives, their age of diagnosis of a chronic disease, and the age and cause of death of any deceased family members. 3. Explain to the family that this type of history is a useful tool to help them know about their health risks and to prevent disease in themselves and their close relatives. 4. Tell the family that the health history is not a one-time document, but rather one that should be updated periodically. 5. Suggest that the family consider using the CDC online tool "My Family Health Portrait" to collect and organize their family health history.

Models of Contemporary Family Therapy-table

Therapy: Contextual Family of origin Experiential-existential Structural Strategic Cognitive-behavioral Theorists: Ivan Boszormenyi-Nagy (1987) Murray Bowen (1978) Michael Kerr (1988) Carl Whitaker (1978) Virginia Satir (1967) Salvador Minuchin (1974) Jay Haley (1967) Aaron Beck (2003) Assumptions: Values and ethics transcend generations and drive behaviors and relationships Past issues influence present relationships Anxiety inhibits change Symptoms are indicators of stress and lower differentiation Multigenerational transmission process Battle for structure, initiative, and self-worth Growth occurs through shared experience Inflexible structure leads to dysfunction Restructuring leads to improved functioning Family members perpetuate problems through their actions People resist change Family relationships, cognitions, emotions, and behaviors mutually influence one another Cognitive inferences evoke emotion and behavior Concepts: Family problems arise from conflicts relating to loyalty, entitlement, legacy, and accounting Family viewed as a system of emotional relationships Triangulation and cutoff Differentiation of self Multigenerational transmission process Sibling position matters Symptoms express family pain Use of nurturing to identify dysfunctional communication patterns Identify patterns of enmeshment and disengagement Clarify boundaries Symptoms are messages which serve functions in maintaining family homeostasis Family rules are unspoken Incongruous hierarchies Focuses on negative cognitions Uses learning theory to alter patterns leading to destructive behaviors Use of "homework" assignments Goals: Gain insight into problematic relationships originating in the past to promote a "balanced ledger" Foster differentiation and decrease emotional reactivity Guide the family to identify and develop their own solutions to dysfunctional behavior patterns Improve family relationships through restructuring the family hierarchy and boundaries Realign family hierarchy through the use of rituals that change repetitive and maladaptive patterns of interaction Improve patterns of negative behaviors through changing thought patterns, which alleviates symptoms

Family Structure

When Duvall described family functioning, she was referring to the nuclear family—mother, father, and children. Today, family structures are more complex. The following types of families that exist in the US include: • Nuclear family: Children living with two parents who are married to each other and are each the biological or adoptive parents to all the children in the family. • Single-parent family: Children living with a single adult of either gender. • Unmarried biological or adoptive family: Children living with two unmarried parents who are the biological/adoptive parents to all the family's children. • Blended family/stepfamily: Children living with one biological/adoptive parent and that parent's spouse. • Cohabitating family: Children living with one biological/adoptive parent and that parent's unmarried cohabitating partner. • Extended family: Children living with at least one biological/adoptive parent and at least one related nonparent adult (age 18 or older), such as a grandparent or adult sibling. • Grandparent family: Children living with one or more grandparents. • Childless family: Consists of partners living together and working together. They may have extensive involvement with pets and children of siblings and friends. • "Other" family: Children living with related or unrelated adults who are not biological or adoptive parents. This includes children living with grandparents and foster families. As the notion of family has broadened to incorporate nontraditional family structures, it has been a challenge for family therapists to recognize and incorporate similarly broad definitions of family in their work.

Concepts Central to Family Therapy The Identified Patient

When a family seeks treatment, the first task of the therapist is to address the presenting problem. That problem often belongs to the identified patient. The identified patient is an individual in the family typically regarded by family members as "the problem," the family member whose beliefs, perceptions, actions, and responses demand an immediate fix. Sometimes known as the family symptom-bearer, this person is generally the focus of most of the family system's concern. From a therapeutic point of view, the identified patient may indeed be a problem. Yet this person may also serve to divert attention from other hidden problems of the family. The symptoms of the identified patient may actually serve as a stabilizing mechanism to bring about relatively cohesive behavior in a distressed family, at least in the short term. Identified patients may be aware, even on a remote level, of the role they serve in stabilizing the family. For example, adult children may sacrifice their autonomy by staying in the home to hold their parents together. This behavior demonstrates a violation of role boundaries. The patient may or may not be the one who initially seeks help from inpatient or outpatient services. Some families will enter therapy on the recommendation of a clinician, as noted in the previous vignette with Diego's family. In other cases where criminal behavior is involved, a court may mandate family therapy. A family member other than the identified patient may initiate a request for therapy as well.

Remember this!

• Families are the context within which health care decisions are made. Nurses are responsible for assisting families in meeting health care needs. • Family nursing is practiced in all settings. • Family nursing is a specialty area that has a strong theoretical base. • Family demographics is the study of structures of families and households, as well as events that alter the family, such as marriage, divorce, births, cohabitation, and dual careers. • Demographic trends affecting the family include the age of individuals when they marry, an increase in interracial marriages with subsequent children, an increase in the number of divorced individuals remarrying, an increase in dual-career marriages, an increase in the number of children from families in which marriage is disrupted, a large increase in the divorce rate, a dramatic increase in cohabitation, an increase in the number of children who spend time in a single-parent family, a delay of childbirth, an increase in the number of children born to women who are single or who have never married, and an increase in the number of children who live with grandparents. • Traditionally, families have been defined as a nuclear family: mother, father, and children. A variety of family definitions exist, such as a group of two or more, a unique social group, and two or more individuals joined together by emotional bonds. • The six historical functions performed by families are economic survival, reproduction, protection, cultural heritage, socialization of young, and conferring status. Contemporary functions involve relationships and health. • Family structure refers to the characteristics, gender, age, and number of the individual members who make up the family unit. • Family health is difficult to define, but it includes the biological, psychological, sociological, cultural, and spiritual factors of the family system. • The four approaches to viewing families are family as context, family as a client, family as a system, and family as a component of society. • Nurses should ask clients whom they consider to be family and then include those members in the health care plan. • The purpose of the initial family interview is based on the identified issue. • It is important for the nurse to recognize that the family has the right to make its own health care decisions. • Nurses who work with families must evaluate the family outcomes and response to the plan, not the success of the interventions. • The future of the family, health care, and nursing is not an exact science. However, all areas are changing and many challenges are to be understood and overcome in this new century.

Approaches to Family Nursing-table

• Family as context: Individual as foreground; and family as background. • Family as client: Family as foreground; and individual as background. • Family as component of society: The components include legal, education, health, social, financial, religion, and family. It also includes church, medical center, school, family home, and bank. • Family as system: Interactional family.

Examples of Assessment Questions Nurses Can Ask Based on the Family Developmental and Life Cycle Theory-table

• How has time that the family spends together been affected? • How has communication among and between the family members been altered? • Has physical space in the home been changed to meet the needs of the evolving family? • In what ways have the informal roles of the family been changed? • What changes are being experienced in family meals, recreation, spirituality, or sleep habits? • How are the family finances affected as the family members age? • Who should be included in the family decision making?

Family-Related Nursing Diagnoses-table

• Risk for caregiver stress • Caregiver stress • Risk for impaired parenting • Impaired parenting • Readiness for effective parenting • Risk for impaired caregiver child attachment • Impaired caregiver child attachment • Impaired family processes • Readiness for positive family processes • Sexual dysfunction • Lack of resilience • Risk for disturbed personal identity • Disturbed personal identity • Relationship problem • Risk for chronic low self-esteem • Chronic low self-esteem • Impaired social interaction • Risk for impaired family coping • Impaired family coping

Family Interview Questions-table

• What do you believe is the most important or pressing issue right now? • What have you done to improve the situation? • Share with me your primary goal in the immediate situation. • What are the main problems you are having related to ____? • What is causing you the most stress? • How has this stress affected you and the members of your family? • How are the everyday needs of the family getting done (e.g., cooking, shopping, cleaning, laundry, transportation, sleeping)? • How well is your family managing this stress? • What results or outcomes do you hope for? • What do you feel you need to help solve this situation? • What can your family do for you? • Who do we need to involve in this situation? • What information do you need to know? • Walk me through a typical 24-h day in your home. • During times of need, where can you go for support and resources? • What do you think would help me better understand what you are experiencing? • How does your family anticipate caring for ___? • How does this situation affect you financially? • Where, how, and from whom do you receive your support, inspiration, and energy to maintain the responsibilities required of you? • What has been the biggest surprise to you about all of this? • How do you think your family roles and routines are going to change in this situation? • How have you and your family prepared to provide care for ____? • What are your family plans for when you have to return to work? • What does your family do to feel relief or take a break? • What are some specific changes that you and your family members have had to make? • What do you fear the most about ____?