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141 Cards in this Set

  • Front
  • Back
Family Diversity
Family diversity is about recognizing and embracing the uniqueness of each family.
Characteristics that make families diverse:
-culture
-Traditions
-Type/who/#’s in family
-Race ethnicity and religion
-Immigration experiences and the resurgence of ethnic identity and pride
-Generational differences
-Language
-Class and poverty
-Residence and or rgeional differences
-Family forms
Why learn about family diversity ?
-Family affect who we are
-More diverse than ever
-Gloval and national demographic changes reflect diversity
-Diversity of students as learneres and as care givers
I-ncreased commitment to a transcultural multicultural approach
-Need for culturally sensitive relebant nursing care
-Growth in racial and ethnic diversity
-Because diversity is one of the core NEPS curriculum values
Family Diversity Key Points
-The family is society’s transmitter of cultural practices and traditions.

-Culture affects health status and health behavior(s)

-In nursing families, the nurse examines individual diversity and how family diversity influences the individual and vise versa (reciprocity)
What does a family mean to me?
-“a social construct”
-A relationship
-Rooted in our own experience
-A pluralistic, contextual, culturally dependent construct
-Legal
-Census – political
-Changes according to place and time
Legal definition of family:
“…a group of two or more persons residing in the same household who are related by blood, marriage or adoption”
A census family refers to:
…a married couple (with or without children, of either or both spouses), a couple living common-law (with or without children of either or both parents), or a lone parent of any marital status, with at least one child living in the same dwelling. A couple may be of opposite or same sex. This excludes persons living in collective households.
An economic family consists of:
…a group of 2 or more persons who live in the same dwelling and are related to each other by blood, marriage, common law or adoption. The couple may be of opposite or same sex). For 2006, foster children are included.
A family is a group of individuals who are bound by strong emotional ties, a sense of belonging, and a passion for being involved in one another’s lives.

There are 5 critical attributes:
1. The family is a system or unit

2. Its members may or may not be related and may or may not live together

3. The unit may or may not contain children

4. There is commitment and attachment among unit members that include future obligation

5. The unit caregiving functions consist of protection, nourishment, and socialization of its members
Wright and Leahey Definition of Family
The family is who they say they are...
The Vanier Institute of the family (2004) defines families as:
…any combination of two or more persons who are bound together over time by ties of mutual consent, birth and or adoption or placement and who, together, assume responsibility for variant combinations of some of the following:

- physical maintenance and a care of group members
- addition of new members through creation or adoption
- socialization of children
- social control of members
- production, consumption, or distribution of goods and services,
- affective nurturance-love
Why collect data on families?
- Create management plans
- Evaluate and plan policy and programs.
- Describe what is happening in the world.
- A snapshot at a time
- Develop strategies to intervene
- Direction for product and service development
- Interest
Top Ten Trends for Canadian Families
1. Fewer couples are getting legally married.
2. More couples are breaking up.
3. Families are getting smaller.
4. Children experience more transitions as parents change their marital status.
5. Canadians are generally satisfied with life.
6. Family violence is under-reported.
7. Multiple-earner families are now the norm.
8. Women still do most of the juggling involved in balancing work and home
9. Inequality is worsening.
10. The future will have more aging families
family health
- Family health is a dynamic changing state of well-being, which includes the biological, psychological, spiritual, sociological, and culture factors of individual members and the whole family system.


- The term family health refers to the health of both the individual members and the family as a whole

- Family health is a construct that lacks consistency and operationalization.

- Definitions can arise from theoretical perspectives and from discipline orientations.

- Family health often equated with family functioning
The family’s influence on health
- Establish health promoting behaviors
- Define illness
- Confirm the validity of the sick role
- Initiate treatment
- Influence outcomes
Nurse’s role is carried out by
1. Assessing and appraising family meanings of health

2. Determining family strengths and capabilities

3. Educating families about health and healthy living

4. Facilitating family use of health resources

5. Fostering active involvement of families in “Healthy Communities”
RNAO Best Practice Guidelines (2006)
1. Develop an empowering partnership with families

2. Assess families in the context of the event(s) (family perceptions, family structure, environment, family strengths)

3. Identify resources and supports

4.Education

5. Sustain family-centered practice

6. Implement interdisciplinary family-centered practice in the health care setting

7. Advocate for changes in public policy
Family health care nursing is defined as
The process of providing for the health care needs of families that are within the scope of nursing practice. This nursing care can be aimed toward the family as context, the family as a whole, the family as a system or the family as a component of society.
Four approaches to Family Nursing Practice:
1. Family as Context (Individual as client)

2. Family Unit as Client (includes subsystem)

3. Family Systems Nursing

4. Family Groups in Society
Obstacles to Family Nursing Practice
-Family transference/counter-transference
-Environment
-Lack of literature/research
-Lack of comprehensive family assessment models
-Its just “common sense”
-Historical ties with medical model
-Traditional charting systems
-Health care service hours
-Etc.
Family centered care
Key points:

- Principles: mutuality and partnership

- Focus: places family as central to not only the patient but to the patient’s plan of care.

- Recognizes: the family as an essential part of care.

- Acknowledges and respects the expertise of the family

- Dates back to the 1950’s – maternity and pediatric care units.
• Four Pillars at the SHR
o Respect and dignity (for knowledge, values, beliefs, culture)
o Information sharing
o Participation
o Collaboration
Current research findings
- Parent-professional interactions greatly influence the quality of health care

- Parents identify establishing rapport and sharing care as key

- Although interactions perceived as positive, not seen as collaborative

- Nurses and doctors evaluated differently
Factors influencing rapport
- Common and relevant goal
- Reciprocal interchange
- Narrowing the knowledge-competence gap
- Clear communication leads to mutual goals and avoids conflict
Strategies To Implement Family Care
- Pre-hospitalization visits
- Pre-surgical education and preparation
- 24-hour visitation guidelines
- Home care services

- Talk with the family about normality of all changes – responses to change and stress

- Regular updates and consultation
- Help families develop advocacy skills
- Education
Children With Special Health Care Needs
- Families are primary caregivers

- Social network evolves to include health professionals

- Family is the principle intermediary between the child and the outside world – advocate

- Family should be the focus in program development
Needs of Families of Critically Ill patients
- Need to be informed**
- Need for assurance (to be respected and to be able to trust)
- Need to comfort
- Need to be comforted
- Need for proximity**
- Need to share what they know
- Need to feel free to ask
- Need to feel they can be unique
- Need to feel valued

? Would our ideas/options/strategies be considered a help or a burden
Family Centered Care: How to do it?
- Treat the patient and the family – they are the center
- Support the family in their needs
- Support them in their family roles
- Listen empathically and actively (values & goals)
-Facilitate decision making (access to information)
- Teach them – and let them teach you – (they are most knowledgeable about their family member and most committed for the lifetime)
- Make appropriate referrals
- Provide anticipatory referrals
- Help ensure that there are support groups (timely)
2 prime molders of family behavior and values
1. Culture
2. Social or economic class
Culture is;
“a blueprint for our way of living, thinking, behaving, and feeling. It circumscribes and guides the ways in which societies and ethnic groups solve their problems and derive meaning from their lives.”
Culture includes:
- Ethnographic variables
Race

- Demographic variables
df

- Status variables
Rich/poor

- Affiliation variables
Who you hang out with
Acculturation:
- the process of assimilating new ideas into an existing cognitive structure

- Occurs on a continuum

- To the dominant culture

- Gradual changes produced in a culture by the influence of another culture leads to increased similarities of the two
Enculturation:
- the adoption of the behavior patterns of the surrounding culture; "the socialization of children to the norms of their culture"

- the process of learning the culture behaviors, knowledge, and values
Assimilation:
the complete and one-way process of one culture being absorbed into the other (or practically extinguished )
Biculturalism:
- participation in two systems
- an important adaptive strategy
Effects of culture on family health status may be explored/understood by looking at such things as:
- Family values
What kind of things are important? Tradition or no?

- Family roles
Who does what in the family?

- Power

- Communication patterns

- Family coping
Definition of Stereotyping
Everyone from a particular culture is viewed as the same and perceived of as fixed in their characteristics.
What are the “isms” and how do they impact on family nursing care?
- “isms”are relatively fixed and stable views of attributes and behaviors

- Racism, sexism, classism, ethnocentrism, ageism, heterosexism
Ethnocentrism:
Lack of cultural relativism
Cultural Imposition:
- A conscious or unconscious process that beliefs and practices are superior or proper

- Forcing values causes cultural conflict
Sociocultural Influences Key Points
- Combined effects of race, ethnicity, gender, and class are critical areas for nurses to address from a family perspective in relation to assessment and intervention.

- Attention to our own personal views is important in order to demonstrate respect for the diversity of cultures.
Cultural Competence
- Although individuals may belong to the same cultural group, the assumption that they are the same is an ecologic fallacy (drawing conclusions, generalizations)

- Cultural competence is really nursing competence

- Acknowledging ethnocentrism of contemporary Western health care

- Acknowledging differences in patients and families in their response to illness

- Members of a cultural group may accept or reject or modify traditional norms

- Cultural knowledge important in programs, content, community care

- Need to account for change, fluidity, hybridity of families within a community (where people live)

- Caring, respect, compassion, sincerity

- Flexibility, explanations,

- Family-centered care

- Openness to complementary, alternative therapies
3 principles of culture-sensitive care
1. Knowledge about a client’s cultural perspective

2. Mutual respect between client and nurse

3. Negotiation around important cultural factors
Family Cultural Sensitivity
1. Attitude we exhibit through our skills, knowledge and personality

2. Recognize cultural differences and similarities within and among families

3. Respect the strengths and legitimacy of different practices
-Embrace diversity
-Keen observations NOT assumptions
-Process approach NOT “cookbook approach”
Culture affects family beliefs and practices
-How services are accessed and utilized

-Our health and illness beliefs and attitudes

-Choices we make

Eg:
Jehovah’s witness
Some women won’t expose selves to men
Who is the decision maker in families
Circumcision
Multiculturalism
- Canada’s colonial past (English, French ground white Eurocentric ideology, silence other voices)

- Racism affects health, access to services

- Language barriers, especially older adults

- Post-colonialism as a guide for nursing cultural research
Cultural safety
- Need to question everyday practice

- Imposing own cultural and biomedical framework, culturally unsafe nursing practices

- Actions to recognize, respect, and nurture the unique cultural identity and safely meet their needs

- Critical assessment of the effects of power, race, gender, and social class on health
Theoretical Perspectives
- Relationship between family theory, research, and nursing practice

- CFAM’s theoretical perspectives

- Family systems theory

- Developmental and family life cycle theory
Theory Based Practice
- Theories guide nursing practice by giving us a perspective on family life.

- Theories help us have a basis for family assessment and interventions.

- Theories help us characterize, explain, and predict – provides a common language
Goals of theory utilization:
Describe
Explain
Predict

Theories increase our knowledge
Theories enhance our understanding
Theories improve our nursing care
Theoretical pluralism:
: involves the selection and use of multiple theories for practice in accordance with the demands of the situation
CFAM - Theoretical Foundations

6 theoretical foundations for the CFAM:
1. Postmodernism
2. Systems Theory
3. Cybernetics
4. Communication Theory
5. Change Theory
6. Biology of Cognition
Postmodernism
- Values pluralism – acknowledges that many world views and explanations exist

- Debate about knowledge – where does it come from, postmodernists question taken for granted ideas/assumptions

- How do we see this in CFAM?
Value all versions of the story and everyone’s experience of illness/suffering
Systems Theory
- A system is a complex of elements in mutual interaction

How do we see this in CFAM?
- Individuals and the whole
- Family as a whole is greater than the sum of its parts
- A change in 1 family member affects all members
- Families create balance between change and stability
Cybernetics
- Science of communication and control theory

- Shifts the focus from substance to from (not what is being said, but how it is being said)
Communication Theory
- All non verbal communication is meaningful

How does is communication theory apparent in CFAM?
- Attention to channels of communication (digital/analog)
- All communication has two levels – content and relationship
Change Theory
There are two levels of change….
1. First-order change
Adjustment to a situation

2. Second-order change
Having to adapt the whole system

========================
9 concepts of Change Theory
1. Change is dependent on the perception of the problem
2. Change is determined by structure
3. Change is dependent on the context
4. Change is dependent on co-evolving goals for treatment
5. Understanding alone does not equal change
6. Change does not always occur equally in all family members
7. Facilitating change is the nurse’s responsibility
8. Change occurs by fitting interventions offered by the nurse with the biopsychosocial-spirtitual structures of the family
9. Change can have multiple causes
Biology of Cognition
- There are two avenues that we can use to explain our world
1. Objectivity – one domain of reference explains the world – we exist independently of observers
2. Objectivity in parentheses – truths are created and brought forth by observer ---- nothing is certain, everyone’s view is version of a presumably correct interpretation


“We bring forth our realities through interacting with the world, ourselves, and others through language”

What does this mean????
- Reality isn’t waiting to be discovered, we bring it life through our interactions with ourselves/others, we construct our realities and understandings
Assumptions of Systems Theory
- The family is viewed as a social system comprising a small group of people who share common goals and functions, and who interact and interrelate with each other and their environment….An individual is both a part and a whole in a family

- Family systems features are designed to maintain stability (adaptive or maladaptive)

- Families are dynamic and respond to stresses from the internal and external environment

- Nurses see clients as participating members of a larger family system. Emphasis is on the whole family.

- Any change in one family member affect all members

- Nurse’s goals are to help maintain or restore the stability of the family, to help them achieve highest level of functioning.
Concepts to Systems Theory
1. All parts of the system are interconnected

2. The whole is more than the sum of its parts

3. All systems have some form of boundaries or borders between the system and its environment

4. Systems can be further organized into subsystems

================================
- Family as client perspective

- Nurses assist to maintain and regain family stability

- Assessment questions focused on family as a whole

- Interventions must address individuals, subsystems within the family, and the whole family all at once

Goal: Help family reach stability by building on strengths as a family, using knowledge of the family as a social system, and understanding how family is an interconnected whole that is adapting to a health event of a family member.
Concept 1: All parts of the system are interconnected
What influences one part of the system affects all parts of the system

All members affected because they are connected

Effect on members varies in intensity and quality
Concept 2: The whole is more than the sum of its parts
- Family is considered more than the individual lives of family members.

- All relationships are viewed together

- The family as a whole are affected by an unexpected life event.

- Ex. In order to think about how the family as a whole, think about how each family member acts during a ritual or routine.

- Individuals are best understood within their larger context
-by studying the whole
Concept 3: All systems have some form of boundaries or borders between the system and its environment
- Families control the information and people coming into its family system to protect individual family members or family as a whole.

- Boundaries - continuum from closed to open

Boundaries are physical or imaginary lines that are used as barriers to entry in the family system
- Closed: More isolation and limits passage of energy, ideas, people and information
- Open: Greater interchange of information, energy, and people
- Flexible: Control and selectively open or close to gain balance or adapt to the situation.
Concept 4: Systems can be further organized into subsystems
- Consider subsystems of the family

- These subsystems take into account: structure, function, processes

- By understanding structure, function, and processes, interventions can achieve specific family outcomes
Developmental and Family Life Cycle Theory
- Looks to explain changes in the family system over time

- Each family will experience each stage of development uniquely, but are stressed and go through common and predictable stages of change and transition

- Often to do with coming and going of family members (birth, launching children, retirement)

- Generally predictable, despite cultural and ethnic variations
Assumptions
- Family behaviour is influenced by the past experiences of the family and its members, incorporated into the present and into future expectations

- Families develop and change over time in similar ways and patterns

- Families and family members seek to perform certain developmentally specific tasks at certain family stages, set by both themselves and by societal, cultural contexts
Stages:
An interval of time where the relationships between the structure, interactions and roles within the family are both qualitatively and quantitatively distinct from other periods (ex. Families with preschool children)
Transitions:
Separate each developmental stage from the next. Transitions are normal, though the function of different roles and the expectations of different family members may differ
Tasks:
Generated when the family as a unit strives to meet the demands and needs of family members, who are each striving to meet their own individual developmental tasks. Successful achievement contributes to satisfaction and success with tasks at later developmental stages
Example: Eight Stage Family Life Cycle
1. Married Couple
2. Childbearing Families with Infants
3. Families with Preschool Children
4. Families with School-Age Children
5. Families with Adolescents
6. Families with Young Adults – Launching
7. Middle-Aged Parents
8. Aging Families
Concept 1: Families Develop and Change over Time
- Family interactions among members change over time in relation to their structure, function, and processes.

- Examine the predictable stresses and changes as they relate to the age of the family members and the social norms individuals experience.

- Certain family tasks need to be accomplished at each stage of family development.
Concept 2: Families experience transitions from one stage to another
- Disequilibrium occurs in the family during the transitional periods from one stage of development to the next stage.

- Family stress greatest at the transition points as families adapt to achieve stability, redefine their concept of family, and realign relationships.

- Developmental tasks are general goals, rather than specific jobs that must be accomplished.

- Families may arrive at similar developmental levels using difference processes
Nursing Interventions for Family Development
- Begin by determining the family structure and where this family lies on the continuum of family life cycle stages.

- Using the developmental tasks outlines for the stage, the nurse can anticipate stressors or assess developmental tasks not being accomplished.

- Interventions may include helping the family to understand individual and family developmental tasks. Could include helping family understand the normalcy of disequilibrium during transitions.

- Each family must accomplish every individual and family developmental task for the stage. Nurse there to support both.

- Nurse to help family adjust and adapt to transitions.

- Assist families and individuals move towards completion of developmental tasks

- Help families find a balance between individual and family needs

- Provide anticipatory guidance and teaching in order to fulfill a family’s health goals or to work with families experiencing challenges in their development

- Consider the effects of ethnicity, religion, socioeconomic status, race, environment, etc. on how and when a family makes transitions
Part 3: CFAM - Theoretical Foundations
A note about frameworks (i.e. CFAM/CFIM)

- Conceptual and theoretical frameworks provide a rationale and guide for decision-making in a range of practice situations

- Selection of a model must correspond with a nurse’s philosophy of practice

- Underlying theoretical assumptions of models are the foundation of how those models are operationalized
What are some features of a good assessment tool?
-Thoroughness
-Relatedable/relevance
-Ease of use
Genograms reveal:
Interactional patterns, potential sources of support
Ecomaps reveal:
Systems outside of the family (support/stressors)
Family Assessment and Intervention Model
- Developed by Berkey-Mischke and Hanson

- Families are dynamic, open systems that are in interaction
with their environment

- Focuses on the cause of family stress and family reactions to stress

- Interventions should be strength based, and utilize the families problem solving strategies
Family Systems Stressor-Strength Inventory (FS3I):
- an assessment/intervention/measurement tool to complement the model

- Designed to assist nurses work with families that are undergoing a stressful health event

- Family systems stressor – general
- Family stressors – specific
- Family system strengths
Friedman Family Assessment Model
- The family is a subsystem of the wider society

- The family is a small group, and posses generic features that are common to all small groups

- As a social system the family functions to serve both the individual and society

- Individuals act in accordance with norms/values learned through socialization
Categories of the Friedman Model
1. Identification data
2. Developmental data
3. Environmental data
4. Family structure
5. Family functions
6. Family stress and coping
CFAM and CFIM
- Developed by Wright & Leahey

- First published in 1984

- Integrated, multidimensional framework

- Within CFAM, there are three major assessment categories – to obtain a macroview of the family nurses can assess all three areas (and subcategories) OR can use a specific portion of the model (microview)
What are the three categories/components of CFAM
1. Structural Assessment
2. Developmental Assessment
3. Functional Assessment
CFAM - Structural Assessment
(Internal, External, Context)

Subcategories of internal structure
- family composition, gender, sexual orientation, rank order, subsystems, boundaries
- Anyone with an alliance or different level of conflict/understanding

What questions could you ask a family to assess their external structure?
- Who else is involved?

Context
- Ethnicity, race, social class, spirituality/religion, environment
CFAM - Developmental Assessment
- This aspect of CFAM involves exploring the developmental life cycle, a cycle that is unique to each family

What is family development?
- The unique path constructed by a family
- The interaction between the development of the individual and the phase of the family developmental life cycle

What is a family life cycle?
- The typical path that most families go through

**Review page 285 of the Wright & Leahey chapter in Potter and Perry – it outlines the stages, emotional processes, and changes for developmental tasks
Page 107 W and L text (2009) Stages of Divorce Family Life Cycle
LGBQITT Family Life Cycle (page 114 W and L)
CFAM - Functional Assessment
(Instrumental, Expressive)

There are two basic aspects of family functioning, according to Wright & Leahey (2009)
1. Instrumental
2. Expressive

What are instrumental aspects of family functioning, and why do we care about this?
- Activities of daily living

Example: Incontinence as the result of an illness will affect an individual/family ADLs (may need assistance with toileting)
======================
Expressive functioning has nine categories :
1. Emotional communication
2. Verbal communication
3. Nonverbal communication
4. Circular communication
5. Problem solving
6. Roles
7. Influence and power
8. Beliefs
9. Alliances and coalitions
Limitations of Circular Pattern Diagrams
- Can tempt us to look within families for collaborative causation of the problem

- May encourage nurses to believe they are outside the family system – cannot decontextualize the family from their social/historical surroundings

- CPDs ignore power differentials between the parties

- May not provide transparency about other issues affecting communication (r/t power – i.e. abuse/violence/intimidation)
Using and Assessing CFAM (or any model/tool)
- Using assessment tools and models requires that we also use our critical thinking skills

- Application, synthesis, evaluation, reflection of tools and models will guide our beliefs and actions/use of the tool/model
What types of questions can we ask ourselves that utilize critical thinking?
- How did things turn out?
- What worked in the situation?
- What didn’t work in the interview?
- What will you do differently next time?
- Self Evaluation!!!!
Family Nursing Process
Assessment of the family story
Analysis of the family story
Design a family plan of care
Family intervention
Family evaluation
Nurse reflection
Considerations when Interviewing Families
- Maximize your time-effectiveness

- Strengths and problems focused

- Multiple realities, openness to differences, diversity

- Skills and competencies need time to be developed (labs, clinical setting, writing)
Stages of the Family Nursing Interview
1. Engagement
2. Assessment
3. Intervention
4. Termination

May be a process that continues past one interview…
Phase 1: Engagement – Purpose
- To promote a positive nurse-family relationship

- To recognize the unique strengths and resources that each family member brings to this relationship

- To prevent future practitioner-family misunderstandings
Phase 1: Engagement – Skills & Ideas
Invite all family members who are concerned, present, or involved to attend the interview

Explain the purpose, length, and structure of the interview (i.e. the presenting problem)

Start with introductions and a structural assessment – address individual family members for information

What other ways can we engage families, and continue to engage families?

ALWAYS --- Recognize when to refer
Phase 2: Assessment – Purpose
Problem identification
- Explore presenting concerns/issue/suffering

Relationship between family interactions and the issue
- Nurse explores how the health issue is affecting family life and relationships

Attempted solutions
- Exploration of solutions that have been attempted, and their effects on the issue

Goal Exploration
- Examination of family specified goals/outcomes that the family is seeking
Phase 2: Assessment – Skills & Ideas
Explore assessment components of the CFAM
- Structural, developmental, functional
- Tools: ecomaps, genograms
- Use the information you obtain to help form ideas about strengths and potential identified problems

Ask each family member to share information

Obtain verification of your understanding of strengths/problems, seek opinions about the most important issues

Use Calgary Family Assessment Model as a framework to help plan your interview and analyze the information

Know your limits
Phase 2: Assessment - Structural Assessment
Internal structure
- Who is in the family, how are they connected?

External structure
- How is the family connected to outside members?

Context
- Relevant background information

Tools: Genogram & Ecomaps
Phase 2: Assessment – Developmental Assessment
Stages of development (phases)
- (leaving home, marriage, young children, adolescents, launching children, later life)

Tasks associated with the developmental phase
- (i.e. refocus on midlife marital/career issues)

Attachments between family members
- (i.e. parents maintain marital bond, and continue personal/adult conversations +child-centred)
Phase 2: Assessment–Functional Assessment
Instrumental functioning
- Routine activities

Expressive Functioning
- Communication (emotional, verbal, nonverbal, circular), problem solving, roles, influence/power, beliefs, alliances/coalitions
Phase 3: Intervention– Purpose
- Validate emotional responses

Offer commendations
- About things they are doing well… but don’t kiss ass

Plan interventions to address the 3 domains of family functioning
1. Cognitive domain
2. Affective domain
3. Behavioral domain
Phase 3: Intervention– Skills & Ideas
- Encourage family members to explore possible solutions to problems

- Plan interventions in the three domains

- Provide information to enhance knowledge and facilitate problem solving skills

- If appropriate, assign tasks aimed at improving family function
Phase 4: Termination – Purpose, Skills & Ideas
- Refer when/if required (know your limits)

- Provide information

- Obtain feedback about the status of concerns/progress

- Identify additional supports

- Summarize positive efforts

- End the interview
Genograms & Ecomaps
What are they?
Genogram: A diagram of the family constellation

Ecomap: a diagram of connections to the outside world
Genograms & Ecomaps
Why do them?
- A genogram, placed on a chart, is a reminder to “think family”

- Engages families

- Tools for family assessment, planning and intervention
Data Collection for Genograms
Who is in the immediate family?
Who is the ‘index person’ (person with the health concern)
How is everyone related?

Important information to gather:
- Age, sex, names, health concerns, occupation, dates and nature of relationships

Seek information consistently (i.e. Across generations)

Additonal/relevant information (i.e. Geographic location, interactional patterns etc.)
Why use a 15-minute interview
Simply put…. “Time is of the essence”
- Changes in health care delivery
- Budget constraints
- Increased acuity
- Staff cutbacks

Need to capitalize on moments to interact with families
- Family nursing knowledge easily and effectively applied in very brief family meetings can be beneficial
- Purposeful, informative, and healing
- Even if short, SOME involvement is better than NO involvement
Key Ingredients to the 15 minute interview
- Therapeutic conversation
- Manners
- Genograms & Ecomaps
- Therapeutic questions
- Commending family strengths
Ingredient #1 - Therapeutic Conversation
- Purposeful, time-limited (what might the purpose be?)

- Art of listening

- Potential for healing as they bring family together

- Every minute is a potential opportunity for patient and family members to be acknowledged and affirmed

- Critical distinction between time effective 15 min interview vs. social interactions
Ingredient #2 - Manners
- Simple acts of courtesy (politeness, respect, kindness)

Introductions
- Explaining role, procedure, use names, speaking directly to patients/families (not around them), eye contact, encourage participation

Why do we care?
- Contributes to the growth of a trusting relationship
- Not attending to these things can damage the relationship with a patient/family

Do what you say you are going to do when you say you’ll do it
Ingredient #3 – Genograms and Ecomaps
Genograms are very important if you are caring for patients for more than one day (brief-about 2 minutes)

Good starting point
- engages the family, gives you (the nurse) a starting point, groundwork, and familiarity

Essential information:
- Identify individuals, ages
- Occupations/school grade
- Religion, Ethnic background
- Current health status of all members /concerns
Ingredient #4 – Therapeutic Questions – examples in text
Utilize linear, circular and interventive questions (this is an asepct of the CFIM – to be discussed later)

Think of at least 3 key questions you will routinely ask, to involve family members

Basic themes to address:
- Sharing of information
- Expectations of hospitalization
- Clinic or home care visits
- Challenges, sufferings
- Most pressing concerns or problems
Examples of key questions:
- How can we be most helpful to you and your family during your hospitalization?

- What has been the most and least helpful to you in past hospitalizations?

- What is the greatest challenge facing your family right now?

- What do you need to best prepare you for going home?
Key Ingredient #5 – Commendations
- Positive statements about family strengths, resources, or competencies

What is the difference between a commendation and a compliment?
- Commendation: Observation of behavior across time/patterns of behavior
- Compliment: observation of a one-time occurrence

WHY?
- Internalized by the family – may affect a families engagement, uptake, utilization of resources, also helps the family to view themselves differently

- Be a family “strengths” detective
- Ensure that there is enough evidence for the commendation
- Offer a commendation (if possible) within the first 10 minutes of your interaction, and at the end of your interaction, before offering opinions – may increase the receptivity of the family
Overview of the 15 minute interview
- Begin a therapeutic conversation with a purpose

- Use manners to engage/reengage – introduce purpose of your 15 minutes

- Assess key areas of internal/external structure and function

- Ask 3 questions of family members

- Commend the family on 1-2 strengths

- Evaluate usefulness and conclude
What is the CFIM?
An organizational framework used to conceptualize the intersection between a particular domain of family functioning and the specific interventions offered by the nurse (Wright & Leahey, 2009)

- Strengths based, resiliency oriented

- Within CFIM a nurse can only offer interventions, not insist or demand a particular change or way of functioning

- Assists in determining the domain of family functioning that predominantly needs changing
What would affect a family’s openness to interventions presented by the nurse?
- History of family interactions among and between individual members and health care professionals

- Relationship of the family with the nurse

- The nurses’ ability to help the family reflect on the health problem/issue

- Health status

- Genetic makeup of the family
How do we determine the “fit” of an intervention?
- “Fit” is determined through therapeutic conversation and collaboration with the family

- “Fit” involves recognizing the reciprocity between our opinions and ideas (as the nurse) and the experiences of the family (as it relates to the illness/problem)
There are three domains of family functioning – (think CAB)
1. Cognitive Domain
a. What is the goal of an intervention within the cognitive domain?
- To change the perceptions and beliefs of family members
- Change the way a family perceives a health problem so that family members can discover new solutions to problems

2. Affective Domain
a. What is the goal of an intervention in the affective domain?
- Reduce or increase intense emotions that may be impeding efforts around problem solving (to facilitate problem solving)
b. What type of emotions may impede problem solving efforts?
- Being overwhelmed, concerned, sad, angry etc.

3. Behavioural Domain
a. What is be the goal of an intervention in the behavioural domain?
- To help the family to interact with and behave differently in relation to each other (increase support etc.)
b. How can nurses help to accomplish this goal?
- Invite family members to engage in a specific behavioural task
- Interventions may be aimed at helping family members to behave and interact in ways that are different from their “normal” pattern
Interventions with CFIM
The intervention process provides a context in which the family can make necessary changes that enhance the possibility of healing

Interventions are:
- Purposeful
- Conscious
- Observable behavior by the nurse

Interventions create a context for change
Key points about Interventions
Interventions should be targeted:

The most profound and sustaining changes are those that occur within the:

One intervention can simultaneously affect all three domain of family functioning

Assessment and intervention can occur simultaneously
- As you help the family gain an understanding of their health experience, the family may be able to make informed choices
Types of interventions we can use with families:
- Interventive questions
- Offer information
- Commend individual and family strengths
- Validate or normalize emotional response
- Encourage the telling of illness narratives
- Draw forth family support
- Encourage family members to be caregivers and offering caregiver support
- Encourage respite
- Devise rituals
Interventive Questions
- Simplest but most powerful intervention
- Intended to effect change in any/all of the three domains of family functioning

There are TWO types of interventive questions
1. Circular
2. Linear
Circular Questions
Intent:
- To effect change, to facilitate behavioural change
- Reveal a family’s understanding of a problem
Linear Questions
Intent:
- Investigative
- Explore the description/perception of a problem
- Often used to being gathering information
The primary difference between circular and linear questions
Circular questions always seek relationships/connections between ideas, individuals, beliefs etc. (in a context of compassion and curiosity)

Linear questions always focus on cause and effect
Four types of circular questions
1. Difference Questions
Explore differences between people, relationships, ideas, time, beliefs

2. Behavioral effect Questions
Explore the effect of one family member’s behaviors on another

3. Hypothetical/future-oriented Questions
Explore family options and alternative actions or meanings in the future

4. Triadic –
question posed to a third person about the relationship between 2 other people
DIFFERENCE QUESTIONS & DOMAINS
Cognitive

Affective

Behavioral

HINTS for identifying difference questions
- Look for words such as best, most
- The question my be about a behaviour (i.e. worried), but if you are asking who is “MOST” worried – it is a difference question
BEHAVIORAL EFFECT QUESTIONS & DOMAIN
Cognitive

Affective

Behavioral

HINTS for identifying Behavioral questions
- behaviours, look for words such as “you do” “feel” “make sense of” etc.
Hypothetical/Future Oriented Questions & Domain
Cognitive

Affective

Behavioral

HINTS for identifying difference questions
- Look for words such as if “what if” “would you do”
- May involve speculating on another’s behaviours etc.
Triadic Questions and Domain
Cognitive

Affective

Behavioral

HINTS for identifying triadic questions
- A question exploring relationships between 2 other people
What is a commendation
An observation of a pattern of behaviour that occurs across time
How do we know if a commendation is effective?
Immediate and long term positive reactions
Interventions with CFIM Inventions to change the Affective Domain
Validating/Normalizing Emotional Responses
- “It’s normal to feel that way”
- Normalizing /reassuring changes in relationships due to illness

Encouraging the Sharing of Illness Narratives
- Not just the story of the illness, typically elicited (symptoms, treatments, history of illness etc.)
- Expression of the impact of illness on various family members

Drawing Forth Support
- Encouraging family members to listen to each other
- Through providing opportunities for family members to express their feelings – nurse can enable the identification of family strengths/resources
Interventions with CFI M Inventions to change the Behavioural Domain
Encouraging family members to be caregivers and offering caregiver support
- Family members may be intimated by the thought of providing care, a nurse could support them

Encouraging respite
- Family caregivers typically do not give themselves respite
- Feelings of guilt associated with “taking a break”

Devising Rituals
- What types of rituals does your family engage in daily/yearly/culturally?
- Chronic illness/hospitalization may interrupt rituals
The 3 most common errors:
1. Failing to create a context for change

2. Taking sides

3. Giving too much advice prematurely
Error Number 1: Failing to create a context for change
- In creating this context for change, both the nurse and family undergo change

- A context for change is the central foundation of the therapeutic process

- All obstacles to change must be removed
How to avoid failing to create a context for change
1. Show interest, concern and respect for each family member

2. Obtain a clear understanding of the most pressing concern or greatest suffering

3. Validate each member’s experience

4. Acknowledge suffering and the sufferer
Error # 2: Taking sides
- Most common error

- Most often done unintentionally

- Results in some family members feeling disrespected, disempowered, non-influential
How to avoid taking sides
1. Maintain curiosity

2. Remember that the glass can be half full AND half empty at the same time

3. Ask questions that invite an exploration of both sides of a circular interactional process

4. Remember that all family members experience some suffering when there is a family problem

5. Give equal time and interest to each family member

6. Remember that information is “news of a difference”

7. Avoid allowing family members to “tell” on others (avoid side conversations)
Error # 3: Giving too much advice prematurely: Why is this a common problem?
- Nurses are in a socially sanctioned position that involves offering advice, information, opinions

- Families are often keen and receptive to nurse’s knowledge

- Timing and judgment are critical in deciding when, how, and what type of advice is offered
Avoid giving premature advice by:
1. Offering advice, opinions or recommendations only after a thorough assessment has been done and a full understanding of the family’s health concern or problem has been gained

2. Offering advice without believing that the suggestions are the “best” ideas or opinions

3. Asking more questions than offering advice during initial conversations

4. Obtaining the family’s response and reaction to the advice