The Child in the Context of Family. Family-Centered Care
Chapter 3 By Nataliya Haliyash, MD,BSN Lecture Objectives Discuss definitions of family
State some nursing theories that provide guidance for understanding families Discuss social science theories that explain family dynamics, processes, and tasks Identify family assessment tools Describe different types of family structures Learn parenting tasks and parenting styles Discuss the role of the nurse in supporting caregivers and their child-rearing practices Describe the elements of family-centered care and provide examples Identify language that reflects family-centered principles Two ways that nurses identify families (by Gilliss (1993))
family as contex: individuals are assessed, the emphasis is on the individual family as a client: family is treated as a set of interacting parts and assessment of the dynamics among these parts is emphasized The legal definition emphasizes relationships through blood ties, adoption, guardianship, or marriage. The biological definition focuses on perpetuating the species. Sociologists define the family as a group of people living together. Psychologists define it as a group with strong emotional ties. Traditional definitions usually include a legally married woman and man with their children. Family is a group of two or more persons related by birth, marriage, or adoption and residing together. the U.S. Bureau of the Census (2000) Definitions of family The family, despite its changing and increasingly diverse nature, remains the basic social unit. The word "family" refers to two or more persons who are related in any waybiologically, legally, or emotionally. Patients and families define their families. In the patient- and family-centered approach, the definition of family, as well as the degree of the family's involvement in health care, is determined by the patient, provided that he or she is developmentally mature and competent to do so. The term "family-centered" is in no way intended to remove control from patients who are competent to make decisions concerning their own health care. In pediatrics, particularly with infants and young children, family members are defined by the patient's parents or guardians. Nursing theories for understanding families
Neuman's System Theory (1983): The family is described as an appropriate target for both assessment and nursing interventions. The way each member expresses self influences the whole and creates the basic structure of the family. The major goal of the nurse is to help keep the structure stable within its environment. Nursing theories for understanding families
Roy's Adaptation Theory (1983): The client is an individual, family, group, or community in constant interaction with a changing environment. The family system is continually changing and attempting to adapt. The goal of nursing is to promote adaptation and minimize ineffective responses. Social Sciences Theories for understanding families
Structural-Functional Theory: The family is viewed as part of the social system, with individuals being parts of the family system. The family, as a social system, performs functions that serve both the individual and society. Individuals act in accordance with a set of internalized norms and values that are learned primarily in the family through socialization. Five functions of the family important to understand:
Affective Socialization and social placement Reproductive Economic Health care The affective function is one of the most vital functions for the formation and continuation of the family unit. This function refers to the family meeting the needs for love and belonging of each member. The family is a home base where the individuals can express their true feelings and thoughts without fear of rejection. Socialization and social placement function refers to teaching children how to function and assume adult social roles. This function involves the acquisition of internal controls needed for self-discipline and values such as what is right and wrong according to society. The health care function includes provision of physical necessities to keep the family healthy, such as food, clothing, and shelter as well as health care (Friedman, 1998). The family keeps its members well by passing on attitudes, values, and behaviors that promote health and by caring for them in times of illness. Social Sciences Theories for understanding families
Duvalls developmental or life-cycle theory (1977): Families experience growth and development in much the same way as individuals. Critical role transitions of individual members, such as birth, retirement, and death of a spouse, are viewed as resulting in a distinct change in the family life patterns. Families develop and change over time in predictable ways. Families and their members perform certain timespecific tasks that are decided upon by themselves, within their cultural and societal context. Family behavior is the sum of the previous experiences of its members as incorporated in the present and in their expectations for the future. 8 Duvall's Developmental Stages
Beginning family Childbearing family Families with preschool children Families with school-aged children Families with teenagers Families launching young adults Middle-aged parents Families in later years FAMILY ASSESSMENT is the process of collecting data about the family structure, and the relationships and interactions among individual members. It is a continuous process. Its aim is to generate Nursing diagnoses with goals and interventions for care created in collaboration with the child and caregivers. Assessment Instruments
A genogram is a format for drawing a family tree that records information about family members and their relationships over a period of time, usually three generations. An ecomap is a visual representation of a family in relation to the community. It demonstrates the nature and quality of family relationships and what kinds of resources or energies are going in and out of the family. Genogram Ecomap In-depth Family Assessment
Calgary Family Assessment Model (Wright & Leahey, 1994): Gather information about family structure, development and functioning. Friedman Family Assessment Model (Friedman, 1998): consists of six broad categories of interview questions. FAMILY STRUCTURE The nuclear family is defined as a husband, wife, and their childrenbiological, adopted, or both (Friedman, 1998) The extended family consists of those members of the nuclear family and other blood-related persons such as grandparents, aunts, uncles, and cousins. A blended or stepfamily occurs when a divorced, widowed, or never-married single parent forms a household with a new partner; both partners or only one may have children. FAMILY STRUCTURE Single parent family occurs by means of divorce, separation, death of a spouse, or choice. 90% of them are comprised of single mothers and their children. Gay and lesbian families are increasing in numbers. Because homosexuality is stigmatized in our society, many of these parents are not open about their sexual orientation. Working with Gay and Lesbian Families
When working with families, do not assume that all parents are heterosexual. In obtaining the family history, the following questions may be asked: (1) Who makes up your family? (2) Do you have a partner? (3) Do you share parenting responsibilities with anyone else? (4) Who else is responsible for the child's care if you are not available? Culturally Sensitive Care
Is care provided with awareness of child's and familys own values and beliefs and recognize how they influence their attitudes and actions. Cultural sensitivity means having an awareness and appreciation of cultural influences in health care and being respectful of differences in cultural belief systems and values. A multicultural perspective means using appropriate aspects of the family's cultural orientation to develop health care interventions. PARENTING Parenting is a dynamic process that evolves over time as parents acquire experience and mature as individuals. The social goal of parenting is to guide and nurture children so that they become productive members of society. The personal goal is a desire to raise a child, see aspects of oneself continue to exist such as perpetuating the family line. Parenting by Developmental Stage Parenting by Developmental Stage Parenting by Developmental Stage Parenting Styles (1) authoritarian or autocratic,
(2) authoritative or democratic, (3) indulgent or permissive, (4) indifferent or uninvolved. Socialization Socialization is a process of learning the rules and expected behaviors of a society. One goal of parenting is to socialize children, which includes teaching which behaviors are expected and appropriate, and fostering the development of self-control. This is also the goal of discipline, which comes from the root word disciplinare to teach or instruct. Effective discipline should include three components:
(1) a positive, supportive, nurturing caregiverchild relationship, (2) positive reinforcement techniques to increase desirable behaviors, (3) removal of reinforcement or use of punishment to reduce or eliminate undesirable behaviors. SPECIAL PARENTING SITUATIONS
adolescent parents, adoption, grandparents as parents, foster parents. IMPLICATIONS FOR NURSING
Nurses can play a vital role in supporting parenting as they work with families. This work must be done in collaboration with parents if positive results are to be achieved. Assessment of parenting
The parent's views on parenting Clarifying cultural and social expectations for parenting Identifying issues or children's behaviors that are of concern to parents Evaluating the interactions between children and their parents during health care encounters The identified problems should:
Be confirmed or clarified with parents Be mutually agreed upon as the priority issues parents wish to address Collaboration with parents
Identifying: Resources for implementing the plan Strategies that are congruent with parental beliefs Outcomes for determining effectiveness of the plan Family-centered Care Family-centered care is an approach to the planning, delivery, and evaluation of health care that is governed by mutually beneficial partnerships between health care providers, patients, and families. Family-centered vs. Patient-centered pediatric vs. adult care
Family-centered vs. Family-focused collaborative vs. expert and unit of intervention In family-focused care, professionals provide care from the position of the expertthey tell families what to do.They consider the family the unit of intervention. Family-centered care is characterized by a collaborative approach to caregiving and decision-making.Each party respects the knowledge, skills, and experience the other brings to the health care encounter. Clarification The definition of family (and degree of family involvement in health care) is controlled by the patient, provided he/she is developmentally mature and competent to do so.In pediatrics, families define for themselves who their family members are. Family-centered vs. family-focused: Both approaches acknowledge involvement with the family.In family-focused care, professionals provide care from the position of the expertthey tell families what to do.They consider the family the unit of intervention.Family-centered care is characterized by a collaborative approach to caregiving and decision-making.Each party respects the knowledge, skills, and experience the other brings to the health care encounter. Languagehow are your words interpreted?
Family unavailable for interview Compliance is poor Presented the Chinese food summary, but dad claims the suggestions dont apply One of my cases is a 5-year old Downs kid Another thing to think about is family-centered language.These are examples of professionals statements that are not very family-centered.Think about how they might be interpreted by the family or by other professionals: This was in a hospital chart 4 days in a row, at 1 pm. What the professional did not know was that the family spent most days (and nights) in the room, but left between 12:30 pm and 2 pm for lunch at the individuals request. The family was trying, blood glucose levels were improving, butnot ideal. This was a posting on a listserve; it turned out that the family was from Japan. Think about how you would react if this statement was made about your child. Family-centered Language
When we recognize that people with disabilities are people first, we can begin to see how people with disabilities are more like people without disabilities than they are different. Kathie Snow, 1998 Kathie Snow has written about using People-First Language.Some of her writing is in your handout material. Does anybody have any thoughts about this statement?What do you think it means? Some people view it as, I am defined by who I am, not by what my disability is. Kathy Snow says: My son Benjamin, is 11 years old.He loves the Lone Ranger, ice cream, and playing on the computer.He has blonde hair, blue eyes, and cerebral palsy.His disability is only one small piece of his life. Family-centered Language: People-first language
Focus on the individual, not the disability; do not refer to the disability unless its relevant Avoid labeling people: a Downs kid vs. a child who has Down syndrome Emphasize abilities not limitations: confined to a wheelchair vs. uses a wheelchair Avoid negative or sensational descriptions (achieved a near-normal life despite suffering from) Avoid using normal to describe people without disabilities 1. When I introduce myself to people, I dont tell them Ill never be a prima ballerina.I focus on my strengths, not on what I cant do. 2. Labeling is demeaning and doesnt reflect a persons individuality or equalityand does not convey respect. Other examples from Kathie Snow: A parent of a child who wears glasses doesnt say, My child is myopic.A person with a medical diagnosis of cancer doesnt say I am cancerous. 3. I dont say, My son cant write with a pencil, I say, My son uses a computer to write. 4. Keep the disability in perspective.Avoid making somebody a victim (e.g., avoid she suffers from Down syndrome or he is a tragic victim of blindness.)Avoid making people superheros. 5. Instead of normal use typical or without disability or without diabetes etc. Arguments against person-first language (& some rebuttal) [these discussion points may or may not come up; use them as time allows and depending on the audience] But we use non-person first language for things that arent related to disabilityyou wouldnt say the person who provides nutrition services or the person who grandmothers. It is appropriate for society to categorize people without person-first language in some cases, but not when referring to disabilities.Disabilities are not defining characteristics in which a profession (e.g., the nutritionist v. the person who provides nutrition services) or a role in society (the grandmother v. the person who grandmothers). We call people patients all the timebut thats what they are when they are in the hospital, right? This is often a judgment call.If you are working in a hospital, the people who are receiving the medical care are indeed patients.For some people, this okays the use of the term patient.Other people prefer to use a different term (the clients name?) when referring to an individual, reserving the use of patient to refer to a general group of people. But this is how weve always said it; nobody else uses that kind of language. stereotypes die slowly People-first Language
Change the following from language to avoid to people-first language the handicapped normal kid he is autistic hes one of my cases a quadriplegic she is learning disabled a victim of epilepsy Ask participants to fix the terms on this slide.Suggested responses: People with disabilities Child who is developing typically He has autism I see him in clinic Person with quadriplegia Person with a learning disability Person with epilepsy HIPPA and the Privacy Rule
Patients must have access to their medical information A written consent must be completed before medical information is released More information: Can you think of how this might have an impact on your practice? Sharing information with other health care providers Sharing information with school staff, other people involved in a childs life Q&A?