Ch. 10- Family

Family Nursing

Assumes that all people, regardless of age are members of some type of family form. Goal: to help a family and its individual members reach and maintain maximum health throughout and beyond the illness experience. Family nursing is the focus across all practice settings and is important in all HC environments. All approaches recognize that patient centered care for one member influences all members and affects family functioning. 3 levels of approaches for family nursing practice: Family as Context Primary focus is on the health and development of an individual family member existing within a specific family environment. Although you focus on an individual member, you Also need to assess how much the family provides the individual's basic needs; needs vary depending on individual's developmental level and situation. Consider the family's ability to help the patient meet physical and psychological needs. Family as Patient Primary focus of care: the family's needs, processes, and relationships (parenting or family caregiving) Your nursing assessment focuses on family patterns vs characteristics of individual members. Concentrate on patterns that are consistent with reaching and maintaining family and individual health. For example, in cases of family caregiving- determine who the family caregivers are, their different roles, and how they interact to meet a patient's needs. Family as System When you care for a family as a system, you are caring for each family member (family as context) and the family unit (family as patient), using all available environmental, social, psychological, and community resources.

Nursing Diagnoses for Families

Examples of Dx: (Can be positive and negative) Conflicting Caregiver Attitude Impaired Family Coping Risk for Caregiver Stress Impaired Family Process Risk for Parent Child Attachment Family able to Participate in Care Planning Family Knowledge of Disease Nursing Dxs that relate to family often focus on a family's ability to cope with current situation. Appropriate use of resources helps families cope with unexpected events that threaten health and stability. Nursing Dxs often focus on changes in family processes and roles. Ex. Man married with 4 children in accident. He's unable to return to work or perform home activities (mowing lawn, etc) Spouse is overwhelmed and plans to meet all needs. Dx: Impaired Family Process related to immobility and temporary changes in family roles.

Factors Influencing Family Forms

Families face many challenges, including changing structures and roles relate to the changing economic status of society. Challenges relating to chronic illness and aging; family caregiving, poverty, homelessness, domestic violence. Factors Influence Family Forms: Family Caregivers The increases in people living with chronic illness/ disability and in older adult population have created a greater need for family caregiving. Caregivers provide most of the physical and emotional care to pts wishing to remain in homes. Most working caregivers rearrange working schedule, decrease hours, or take unpaid leave. Spouses in 60s and 70s are often the major caregivers and have special needs (Box below) Caring for a relative who is frail or chronically ill is an ongoing process in which families must continue to redefine their relationships and roles. Requires more than series of tasks; Encompases cognitive, behavioral, and interpersonal processes. Caregiving activities include: finding resources, providing personal care (baths, feeding, grooming), monitoring for complications or side effects of illness, and providing ADLs (shopping and housekeeping) Provide ongoing emotional support, makes decisions about care options, being a patient advocate, monitoring finances, and painting integrity of family unit. The interpersonal dynamic between family members influences the ultimate quality of caregiving. Can include spouses (age or illness), children caring for parents. Caregivers experience burden and strain; the physical and emotional demands are high. Patient's disease causes changes in family structure and roles. Family caregivers often feel unprepared and suffer with anxiety which can lead to a variety of physical conditions.- depression, cardiac illness, eating disorders. Caregiver will often negate own needs and miss primary care apts, screenings, dental care. Box 10-2- Family Caregiver Concerns for Older Adults Families often need help to determine their caregiving roles for various members (providing financial support, groceries and meds, hands on care) Risk factors related to poor physical health for caregiving dyad include: older age and HS education for lower. Risk Factors assoc with high emotional distress: younger age, female, caring for spouse, living with a patient. A caregiver's mental health is often related to mental health of patient. Many older adults use spirituality to make end of life decisions, cope with life changes, and maintain psychological wellbeing. Social networks and support from close family and friends help to alleviate the stress experienced by caregivers. Individualized caregiver instruction and support are essential. Ex: younger caregivers caring for a spouse need help addressing their own and spouse's psychological distress. While, older caregivers who are less educated need information about healthy behaviors and self-care to help them address their physical health. Poverty Impact of poverty on families is profound Esp vulnerable are female single parent families, families with unrelated individuals, children/children of color. Individuals and families living in poverty are more likely to remain uninsured. Increasing amount of adult "children" living at home and not working is putting strains on families. There is still a challenge for people at or near povery level to access HC. When caring for families in poverty be sensitive to needs for independence and help them obtain appropriate financial and HC resources. (EX.Provide Info about community resource to obtain assistance with food, energy bills, dental and healthcare and school supplies) Homelessness Major public health issue that affects the functioning, health, and well being of the family and its members. chronic homelessness- use shelter for long term housing transitional episodic- need shelter for short period Homeless people tend to be younger, with a catastrophic event requiring shelter. Adults who are homeless face many health risks: More likely to have mental and chronic health probs. Exposure to elements, poor nutritional status, and poor access to healthcare after the homeless Vulnerable to physical and emotional violence, injury, and trauma. Poverty, dom. violen, and reduced govt support for families with children, and lack of affordable housing contribute to homelessness. Children of families who are homeless are often in poor health, higher rates of asthma, stomach probs, mental illness, poor dental health, and poor immunization documentation. Emergency department often becomes only access to HC. Barriers for children: inability to obtain substantial education, lack of supervision and help with school work. As a result: More likely to drop out, risky behaviors, become unemployable. Homelessness increases the risk for developing long term health, psychological and socioeconomic problems, posing a major challenge for society. Domestic Violence DV includes spousal relationships, live-in partners, dating, familial, elder, and child abuse. Emotional, physical, and sexual abuse occurs across all social classes. Factors assoc: stress, poverty, social isolation, psychopathology , learned fam behaviors, alcohol/drug abuse, pregnancy, sexual orientation, and mental illness. Negative long term physical and emotional consequences often linger. One consequence includes moving from one abusive situation to another. Ex. Child abused in home sees marriage as escape, but marries an abuser.

Family Forms and Current Trends

Family Forms are patterns of people considered by family members to be included in a family. Remain open about what constitutes a family. Divorce, marring later, early/late childbirth, single parent, adolescent parents, same-sex, older adults, and grandparents raising grandchildren. Current Trends 50% over 15 are married Number of people living alone is increasing Appxtl 40-50% of marriages end in divorce Families increasingly have 2 wage earners 27% of children live with one parent. Birth rate is dropping, but adolescent pregnancy is a concern. Teen pregnancy has long term consequences: Mothers are less likely to finish school Likely to require public assistance live in poverty have children with poorer educational, behavioral, and health outcomes. Teen father stressors- poorer support systems and fewer resources on good parenting. Teen fathers - lower economic status, lower educational attainment, and incarceration. Both adolescent parents often struggle with normal tasks of develpment and are not ready for parenting role- physically, socially, emotionally, financially. Same sex marriage legal and rapidly growing. 65 year and up fasting growing age group and is affecting the "sandwich generation"- children in middle years who must meet their own needs, those of children, and aging parents. Often occurs at expense of own well being and resources. Many grandparents raising grandchildren- rebel of societal factors, such as: military deployment, unemployment, adolescent pregnancy, substance abuse, and divorce.

Family Function

Family function is what a family does, such as how it interacts to socialize younger family members, cooperates to meet economic needs, and relates to larger society. How family functions within itself and society. involves the processes used by the family to achieve goals. Such processes include communication of family members, goal setting, conflict resolution, caregiving, nurturing, and use of internal and external resources. Family needs emotional and psychosocial support throughout the life span/deveopment to be successful.

The Family

Groups of people who share emotional connections and function as a unit. Families face many challenges, including health and illness, childrearing and bearing, and caring for older members. Family characteristics that that help families adapt to challenges: Family durability System of support and structure that extends beyond the walls of the house. Internal strength and durability of a family. Ex: children leaving home as adults Family transcends long periods and inevitable lifestyle changes. Family resiliency Ability to cope with expected and unexpected stressors. Family's ability to Adapt to role and structural changes, family members' developmental milestones, and crises shows resilience. Ex: wager earner loses job and another takes on that role.- family survives and thrives when facing challenges and stressors. Family diversity Uniqueness of how a family is made up. Having children later in life, grandparents in the home. As you care for patients and family, you are responsible for understanding family dynamics- interactions between members that are affected by a family's makeup- or configuration., structure, function, problem solving, and coping capacity. Use this knowledge to build on family's strengths and resources. Living as a family amid an illness is challenging; family functions, communications, and roles are altered. The goal of family centered nursing is to address the comprehensive HC needs of the family as a unit and to advocate, promote, support, and provide for the well-being and health of the patient and individual family members.

Family and Health

Introduction- In the US, there are cultural disparities, and individual family members vary greatly in experiences, beliefs, and values. When a family is victim to low educational preparement, poverty, an decreases social support, these factors compound, mangnifying their effect on health and well being of the family. Economic stability increases a family's access to adequate HC, creates more opty for education, increases good nutrition, and decreases stress. The family is the primary context in which health promotion and disease prevention take place. A family's beliefs, values, and practices strongly influence the family's structure and function; affect family communication patterns, roles, and health promoting practices. Providing culturally appt family centered interventions and teaching can improve family functioning and self care. Some families do not place high value on health; and sometimes harmful practices are accepted. Ex; families using junk food to cope with stress. Family environment is crucial because health behavior reinforced in early life has a strong influence on later health practices. Family environment is also crucial factor in an individuals adjustment to crisis. Although relationships are strained when confronted with illness, research indicates that when family members receive support from HC professionals, they have the potential to adapt to stressors and develop good coping mechanisms. Attributes of Healthy Families Family is exposed to threats, strengths, changes, and challenges; Some families are crisis proof while others are crisis prone: Crisis proof (effective) family -combines need for stability with need for growth and change. This type has a flexible structure that allows different family members to complete tasks and accepts help from outside the family system. Flexible enough to adapt, but not so flexible there's no sense of stability. Controls the environment and influences immediate envt of home, neighborhood, and school. Crisis prone or ineffective family- lacks or believes it lacks control over environment. Hardiness and resiliency moderate a family's stress, thus affecting health of family. Hardiness- internal strengths and durability of the family unit. A sense of control over the outcome of life, a view of change as beneficial and growth producing, and an active rather than passive orientation in adapting to stressful events characterize family hardiness Resiliency- helps to respond in healthy ways when facing stressful events. Family resilience does not develop by evading risks, but through successful application of protective factors such as family cohesion, self-efficacy, and peer acceptance to engage in adverse situations and emerge stronger. Resources (adequate income, education) and techniques (coping resources) that a family uses to maintain a balance or level of health aid in understanding a family's level of resiliency. Genetic factors Genetic factors reflect a family's heredity or genetic susceptibility to diseases that may or may not result in actual development of disease. The scope of genomics in nursing care encompasses risk assessment, risk management, counseling and treatment options, and treatment decisions. When family's know genetic risks, they have opty to make informed decisions about their lifestyle and health behaviors, are more vigilant about recognizing changes in health, and in some cases seek medical intervention earlier. Living with Acute,Chronic Illnesses or Trauma Acute Illness- Any acute or chronic illness influences a family economically, emotionally, socially, and functionally. Will also affect family's decision making and coping resources. During acute illness that requires hospitalization, the entire family is affected. There is often miscommunication due to fear and worry. There are inter professional teams to help meet the needs of families during acute illness. Chronic Illness- present continuous challenges for families. Frequently family patterns and interactions,roles, social activities, work and household schedules, economic resources, and other family needs must be reorganized around the illness or disability. Trauma- sudden, unplanned, and sometimes life threatening . Family members often struggle to cope with the challenges of a sever life threatening event. For ex: they often deal stressors associated with hospitalization in an intensive care environment, anxiety, depression, economic burden, and the impact of trauma on family functioning and decision making. The powerlessness they feel, makes them less able to make important decisions about the health of the family. When Implementing a family-centered care model for patients experiencing acute or chronic illness or trauma, family members and surrogate decision makers became active partners in decisions and care. Involve family during hand-off reporting to involve them in discussing present and long term goals. Consider values, culture, and communication patterns to provide individualized plan. In caring for the family, advocate for the patient and family and answer questions honestly. Ensure the family knows all the members of the team. Provide realistic assurance; do not give false hope which would break the nurse-patient trust. Take time to ensure family is comfortable- making sure they eat, bring blankets, etc. End of Life Care Families with a member who is terminally ill. Even if prepared for family member's death, they will need information, support, assurance, and presence. Use presence to develop a therapeutic relationship with pt and family. Use therapeutic communication to enhance family's relationships with one another and to enhance shared decision making. Encourage patient and family to make decision about care and specific therapies/ hospice care.- And help to set up. Provide information about dying process and what to do at time of death. Be sensitive to their needs- allow for privacy and sufficient time to say goodbye, etc.

Box 10.1 Family Forms

Nuclear Family- consists of 2 adults and 1 or more children. Extended Family- includes relatives, aunts, grandparents, etc. in addition to nuclear family Single parent Family- formed when one parent leaves nuclear family (death, divorce, desertion) or when single person decides to have or adopt a child. Blended Family- formed when parents bring children from previous marriages or other parenting relationships into a new joint living situations. Alternative family- Multi-adult households, grand families (grandparents caring for children), communal groups of children, "non families" (adults living alone), cohabitating partners.

Family-Centered Care and Nursing Process

Nurses interact with families in a variety of community-based and clinical settings. Apply the nursing process and use critical thinking to develop and implement family-centered nursing. The approach to the nursing process is the same, whether your focus is family as context, patient, or system. When caring for families, use the same process as individuals, but also incorporate needs of the family. For care of families, use these approaches to organize a family approach to the nursing process: 1.Assess all individuals within family context. 2.Assess the family as patient 3.Asses family as system. .

Planning Family-Centered Care

Once you identify nursing diagnoses, work together with your patients and their families to develop plans of care that al members clearly understand and mutually agree to follow. The goals and outcomes need to be concrete and realistic, compatible with family's developmental stages, and acceptable to family's lifestyle. Offering alternatives for care activities and asking family for their own ideas/ suggestions helps to include them in the decision making and better meet needs of patient. Collaborate with other disciplines increases likelihood of a comprehensive approach to family's health needs and ensures better continuity of care.

Family Structure

Structure is based on the ongoing membership of the family and the pattern of the relationships, which are often numerous and complex. Each family has a unique structure and way of functioning. (ex: family members have relationships with spouse, children, employers, work colleagues.) The multiple relationships on each family member are often sources for personal and family stress. Can either enhance or detract from family's ability to respond to stressors of daily life. Structures that are too rigid or too flexible can threaten family function. Rigid structures- each member has specified tasks to complete. (Ex: mother is ONLY person who can provide emotional support and/or perform household duties) A change in health status in a member can burden a family because no other person is available/ considered acceptable to do task. Flexible- extremely flexible can cause absence of stability which prevents other family members from taking action during crisis or rapid change.

Definition of a Family

The definition of a family is significant and affects who is included on health ins policies, access to school records, files joint tax returns, and who is eligible for sick leave benefits or public assistance programs The family is what the individual believes the family to be. You must care for both the family and the patient. Effective nursing administrators have a clear vision that caring for families is crucial to the mission of their HC agency and health of nation.

Concept of Family

The specific relationships among patients, families, and HC providers are at the center of patient and family care. As a nurse, assess for and understand how your patients define their families and how they perceive the general state of member relationships. Think of a family as a set of relationships that a patient identifies as a family, or as a network of individuals who influence one another's lives, biological or not.

Evaluating the Outcomes of Family Care

Though the Family's and Patients Eyes Obtain family's perspective of care provided and if it met the family's needs. If not met, determine what they think is missing modify interventions or make referrals. Evaluation is continuous. Patient and Family Outcomes Evaluation is patient and family centered. When you care for family as context, focus on whether individual patient and family member needs were met (how did each member deal with the disease). When you care for family as patient, your measure of family health is more than an evaluation of the health of all family members. You evaluate the change in FUNCTIONING and its satisfaction of new level of functioning. When you care for family as a system, include extended family members (support system), outside and inside interventions -how these affected the family.(outcomes)

Family Assessment

Using family-centered approach to assessment allows you to establish a working relationship with a patient and family. A complete assessment provides a full picture of patient needs as a member of the family and of family needs as well. If assessment is complete, this ensures patient and family needs are identified and goals and interventions for health care can be established. Often you will participate in conflict resolution between family members, to help them resolve problems in a healthy way. Ask assessment questions to identify external and internal resources as necessary. Ex: "Who can run errands? Any church/ others who can provide respite care? Your goal is to help family reach optimal function, given the resources, capacities, and desire to be healthier. Nurse plays an essential role in helping families adjust to acute, chronic, and terminal illness. But first, it is essential to understand the family unit and what the illness means to members of the family and how it affects the family function and structure, and any support needed. The measure of family health is more than a summary of the health of the members. The form, structure, function, and health of the family are areas UNIQUE to the family assessment. There are several culurally sensitive tools and models that assess family dynamics. One ex is Calgary Family Assessment Model (below) Box 10.3- Family Assessment Questions based on Calgary Assessment Model: Assess Family Structure: Determine members, relationships, and the context of the family. Who are the members? How are they related to you? Who lives with you? Anyone recently moved out? Anyone who doesn't live with you whom you consider to be family? Developmental Assessment Determine how the family adapts to change and difficult times. What transitions or changes has your family experienced most recently? (death, divorce, birth) Are any members having problems currently affecting family? (school probs, acute/chronic illness) What aspects of your fam do you enjoy the most? What plans have you or your family made to care for family members in poor health? Family Functioning Addresses how individuals behave in relation to one another. Includes instrumental aspects which are routine activities (meals, laundry) and expressive aspects (communication, problem solving/ coping skills, roles, beliefs, influence and power). Describe a recent problem and how your family resolved it? Who is the caregiver for children or older adults? What coping strategies does your family use? (exercise, overeating, arguing) What are your family's beliefs about health/illness? End of life care? Advance Directives? What does your family mean to you? How does your family celebrate birthdays? holidays? weddings? How do members manage their health? or manage care of sick member? When someone is ill, who is caregiver? Is it always the same? While completing the assessment, consider knowledge of patient's illness and its effect on the family and how significant a role the family will play in recovery. Begin the assessment by determining patient's definition and attitude toward the family. If you determine the family is important to the patient, next determine family form and membership by asking who the patient considers family. To assess family structure, ask questions to determine the power structure and patterning of roles. "Who decides where to vacation? Who usually prepares the meals?" Assess family functions such as the ability to provide emotional support for members, the ability to cope with current health problems or situations, and the appropriateness of its goal settings. Also determine if family has sufficient economic resources and extensiveness of social network to provide support. Cultural Aspects in Family Assessment Culture is an important variable when assessing a family because race, ethnicity, language, and norms affect structure, function, health beliefs, values, and way a family perceives events. Knowing a family's culture and the meaning of that culture to a family's structure and functioning, health practices, and family celebrations helps to design family-centered care. To determine the influence on culture in a family ask about cultural background with questions such as: Foods? Health practices from culture (meditation)? who cares for family members? Role of grandparents? A comprehensive, culturally sensitive family assessment is critical to understand family life, current changes within it, and a family's overall goals and expectations. Discharge Planning Begins at the initiation of care; includes the family; Nurse is responsible to assess who will provide caregiving at home and what will be needed in the home at the time of discharge. Consider how pt's physical and/or cognitive limitations will affect daily living activities and impact on the family. Ex. If older adult discharged and cannot perform dressing changes, you need to find out if a family member or neighbor is willing and able. If not, arrange for home care.

Implementing Family-Centered Care

You will provide family-centered care in a variety of HC settings. - acute care, restorative, continuing, etc. It is imp to develop individualized nursing implementations to meed needs of patients and families: 1.Health Promotion: When implementing family nursing, health promotion interventions are designed to improve or maintain the physical, social, emotional, and spirtitual well-being of the family. Health promotion behaviors should be tied to the developmental stages of the members (adequate prenatal care for childbearing family or adherence to immunizations for childrearing family) The interventions you implement should enable both members and family to reach optimal levels of wellness. Whether you provide care for family as context, patient, or system EB nursing interventions increase their ability to provide care, remove barriers to HC, and perform tasks the family is not currently able to do. Assist family in problem solving and express sense of accceptance and caring by listening carefully to members concerns and suggestions. 2.Educator One fo the roles you need to adopt is that of educator. Health education is a process by which a patient and nurse share information. Sometimes use direct questioning, but the methods are generally subtle- using observations to gauge needs for education (dad not washing umbilical cord; help using walker) Use respectful communication- don't come off authoritative, communicate your observations and offer help. Try to avoid patient embarrassment. "I notice you are trying not to touch the cord, I see that a lot. Do you mind if I show you?" You will also recognize patient and family learning needs based on a pt's health condition and physical and mental limitations. Your focus may be on the caregiver to prepare to mange skills and processes needed to mange pt needs at home. 3. Using family strengths Help families use their strengths to meet their goals and focus on strengths and not weaknesses. Refer families to health promotion programs aimed at enhancing strengths as needed. Box 10.5- EBP Caregiving for Family Caregiver Caregiver Burden and Well being: When a family member has an acute or chronic illness or trauma that changes physical or cognitive function, it is often a life changing event that affects all family members. Family faces many changes in family dynamics, social interactions, financial commitments, and emotional support systems. AS a result, family members report stress and burnout related to the continual demands of caregiving role. Lower levels of caregiver burden are associated with better mental health in caregivers. Caregiver coping (esp during hospitalization) is influenced by their communicaiton with providers, access to patient , and presence of staff helping explain pt's problems and treatment plan. Provide interventions tailored to the needs of the caregiver will reduce caregiver burden and improve caregiver coping and quality of life. Teach caregivers to focus on the present moment using mindfulness interventions (meditation, breathing exercise) to reduce burden and improve mental health. Carefully assess mental health of caregiver. Encourage to discuss feelings about responsibilities and help shape perceptions in a way to improve mental health. Encourage to remain engaged in pt care during hospitalizations. Teach those living with dementia patients different coping techniques and redirect behavioral disturbances to help improve caregiver's sleep and reduce burden, distress, and risk of developing depression. Be aware of cultural implications of mental illnesses that affect caregiver (social stigma). Refer to support groups. Help families communicate to avoid conflict. ASses the effect (physical, mental, financial) of pt's disability on a family. Provide support and pt education. Use telephone or internet assisted technologies to provide support and pat education when it is difficult for caregiver to receive effective support due to geographical constrains (rural area). Acute Care (Implementation) Family needs to be a central focus in acute care setting. Need to anticipate types of interventions needed to support family and patient's needs up to and including discharge. The Synergy Model recognizes the importance of relationship between Nurse and patient and family to create a healing environment. When there is synergy between these, optimal patient outcomes result. Include caregivers in patient's care during admission to prepare for role and reduce stress following discharge. Acute care often includes providing information about end of life care. Discharge Planning (Implementation) Includes coordination of resources in the community and patient's home. Be sure caregiver is prepared and knows where to obtain necessary supplies. Communication Good communication is necessary due to multiple providers of the patient. Use communication techniques that are supportive, clear to understand, and consistent and advocate for family's expectations. Clear/ plain language communication (interpreters if necessary) enables family to understand issues, types of decisions, and potential outcomes. Help family identify methods to maintain open communication with HC team and a plan to communicate patient's status with others (using a blog, etc.) Restorative and continuing Care(Implementaion) Home care nurses help patients remain in homes following acute injuries or illness, surgery, or exacerbation of chronic illness. Maintaining patient's functional abilities within context of the family. Make sure home environment will accommodate a pt's strengths and limitations. It also requires finding ways to better the lives of individuals who are chronically ill or disabled and families. Family Caregiving Show caregivers how to perform specific aspects of physical care (dressing changes), help find homecare equipment (oxygen therapy), and identify other community resources. (respite care). Stressful for family members as caregivers due to relationship changes. Nurse has role in helping caregiving and patient develop communication and problem solving skills. Decline of health and dysfunctional relationships can develop if caregiver not adequately prepared. Be sure to educate caregiver about caregiver stress and signs and symptoms; use principles of teach back to ensure understating. Establish caregiving schedule for all family members can participate. Recognize caregiver has their own physical and emotional needs. Teach them to meet those needs and set up respite as needed. Connect with community resources Box10.6- Caregiver Strain Symptoms: Teaching strategies: Explain to caregivers signs and symptoms of role strain: Change in appetite/weight, sleeping disturbance, or leisure activities. Social withdrawal, irrititbilty, anger, or changes in health. Loss of interest in appearance. Discuss situations which role may intensify (ex. pt's health status changes or needs hospitalization) Describe importance of family members setting up schedules to give rest. Provide info about community resources for transportation, respite care, and support groups. Offer opty to ask questions and proved phone number for questions Provide family members with the contact info of pts' HC provider and instruct them to call if caregiver has health probs, caregiver seems overly exhausted, or observe changes in caregivers interactions and attention to normal activities. Evaluation: Use teach back strategies to evaluate learning. "I want to be sure I explained. Describe 2 or 3 effects caregiving can have on you"