Developing a Family- Focused Nursing Practice Kathryn Hoehn Anderson ● Sharon A. Denham

C H A P T E R 8

C H A P T E R O B J E C T I V E S

1. Describe the nature of the individual-nurse-family relationship and its importance in family nursing practice.

2. Describe the characteristics of a family practice model. 3. Discuss family nursing skills used to provide family nursing care. 4. Demonstrate use of a family nursing model and nursing actions to provide family nursing care. 5. Discuss family nursing approaches/models used in family nursing care practice.

C H A P T E R C O N C E P T S

● Circularity ● Clinical family nursing skills ● Family nursing practice ● Family unit perspective ● Hypothesizing ● Individual-nurse-family

relationship

● Interventive questions ● Neutrality ● Practice model ● Selecting a family nursing

model ● Therapeutic questioning

Introduction

About 35 years ago, the first edition of Family-Focused Care was published, and this thoughtful work crafted some early thinking around nursing actions and family interven- tions (Miller & Janosik, 1980). Since that time, the science around family-focused practice has grown. This chapter considers more current thinking about family practice and explains how this approach can be used in clinical work. By forging an individual-nurse-family rela- tionship with every person receiving care, nurses can build collaborative partnerships with those seeking care. This chapter describes the development and use of an individual-nurse- family relationship, considers the importance of using practice models to guide clinical work with families, and discusses ideas about use of clinical skills in family nursing practice. It explains how to choose and apply a family nursing model when planning care for individual families and addresses the nature and development of the individual-nurse-family relation- ship with family nursing practice. It provides brief explanations of a few select family nursing

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models, describes several family nursing skills important to master, and provides a case example of family nursing care using the Family Health System model (Anderson, 2000). This chapter describes ways to effectively think family not just as a prelude to providing family nursing care, but throughout the caring endeavors.

Family-Focused Nursing Care

In family-focused care, nurses assume a mind-set that continually thinks family as they care for individuals and their families as a unit of care. Family nurses apply all their skills, using technical, mental, and emotional processes. Family theories, as presented in Chapter 7, can be used to guide clinical practice in the ways nurses give care with families, and take action. Nurses who desire to develop a family nursing practice need knowledge about families in- cluding dynamics, history, health patterns, lifestyles, and culture, member, and community connections.

Providing nursing care from a family unit perspective can be challenging and exciting. The family and nurse become true partners in care. Families have information and expertise about their concerns. Stories from their perspective tell of the stresses, difficulties, and worries ex- perienced. They know what is and is not working. Nurses are in positions in which they can help families manage health and illness, developmental concerns, and transitions (Anderson, 2000). Family nursing can enhance awareness, meaning, and potentials of individuals and families (Hartrick, 1997). Family nursing is intentional collaboration and identifies the best ways to help families achieve their health goals. Family nursing looks beyond the individual and the present and includes family and potential future needs (Fig 8.1).

Family Nursing Practice

Nursing is a practice discipline, both an art and a science. The art of nursing is the thera- peutic use of self in delivery of nursing care, and the science is based on research evidence. Nurses need to read and understand research findings and then use that information to help

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FIGURE 8 -1 Family nursing looks beyond the individual and the present.

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individuals and families promote health and manage illness. More still needs to be learned about the implications of intentional family inclusion in nursing actions (Anderson, 2000). Current knowledge is a foundation that clinicians, researchers, and scholars can build upon and use to develop even stronger evidence about what constitutes family nursing practice.

Family nursing practice addresses the needs of individuals and their families who seek health and illness care services. Thinking family includes learning how those seeking care and their family members relate to one another and what these relationships imply for care. Individuals are not just care recipients, but also partners in care with families who are part of the care experience. Nurses need to know how this happens and what it looks like in practice. These things can be demonstrated in clinical experiences, but also through active learning in the classroom.

Individual- N urse- Family R elationsh ip s

When a family care approach is used, care is centered on the family unit and how to satisfy their health or illness needs (Anderson & Valentine, 1998). The concerns addressed are as- sociated with the individual and who that person views as family. What individual and family perspectives need to be heard? People are social animals, often eager to engage others and be noticed. What happens when we get together with others? We often tell stories about what is happening in our life and find out what is happening in theirs. It happens everywhere—at work, with neighbors, with friends, and in families—people tell stories about their lives as they share their life experiences. During times of crisis, at critical life moments, in health or illness, people often want to tell about what happened and their responses.

Suppose you tempt fate and go out in a snowstorm against your better judgment. Two miles down the road on a steep rural incline you lose control and the car slides off the road and you sit alone in your car. You look around at the lonely desolate place, note the gas tank is half full and the outside temperature is 11 degrees. You put on your hazard lights but know they can’t be seen until someone is dangerously nearby. You grab your cell phone and call someone who cares. Although this person is 30 miles away and not able to help you, the sound of her voice gives comfort and you tell the story of your dilemma. You are in a difficult situation, but here is someone who cares, will listen, and offers comfort. This helps! People usually show up willing to help. Strangers without names suggest tactics that might work, things to try, and ideas to solve the problem. Still fearful and uncertain, you trust their ideas may help get you out of a difficult or troubling situation.

In a way, nurses can be like these strangers, they are present to care in unusual and stressful situations. Individuals and their families enter unfamiliar health care settings filled with fright- ening things, faces, and rules. Often uncertainty about life and what is going on with a health condition is present. A nurse who cares shows up and is prepared to offer help. Though uncertain about the outcome, it is comforting not to be alone. Family nurses reach out to establish a caring connection to individuals and families. It is a relief to meet someone with ideas about things that might help and who is invested in acting in intentional ways to resolve the problem. The history of nursing tells of caring persons available during uncertain times, willing to listen, offer comfort, be present, and provide care.

A narrative or story of personal experience has new meanings, value, and potentials when it is heard and shared with others. Clearly, critical interventions must occur first, but even then care and support are important to care recipients and family units. Family nurses begin relationships by welcoming individuals and families into the relationship, establishing a caring connection leading to an individual-nursing-family relationship, and listening to the health or illness story that communicates individual and family needs and concerns.

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C h aracteristics of th e Individual- N urse- Family R elationsh ip

The individual-nurse-family relationship is a reflective one. This means that what is said or done is thoughtfully appraised from the perspective of others. It allows for acceptance of vul- nerability and examines whether stressors might be physically based, relationship based, or from a prior experience, fears, or external determinants. Nurses establish thoughtful relation- ships with the individual and the family and notices that people often respond out of prior experiences and personal emotional pain. Although the current event might be in sharp con- trast to previous ones, sometimes past events cause lingering impressions that cause present worry, fear, or other emotions. As nurses reflect on the situation at hand, they are careful to put aside biases and assumptions. Assessments help discover the obscure and gain a perspective of patterns and needs. Reflective practice requires checking personal reactions to situations and accepting differences without judgment. It acknowledges various points of view and gives authentic care that is sensitive to other’s needs. The nurse evaluates various needs and whether a partnership to meet family unit goals is being successful. Reflective nurses know that trou- blesome situations are not always due to current circumstances, but may be responses to actions from other circumstances that need addressing from the family perspective.

Stop a minute. Think about what you read in the previous paragraph. How do you define reflective practice? How might reflection cause you to approach a practice situation differently? Do you think about needs and situations before planning care? What are you thinking about after care is given? Do you pause and consider what happened? How did your interaction help the family with healing and easing their suffering (Wright & Bell, 2009)? With helping them with what they are going through? What does the family want to improve in their situ- ation? How might you have done things differently? Take time to reflect before and after care is provided (hypothesizing what is going on). Thus, you consider a variety of options. You might be thinking, “Oh, good, I am already doing just that!” But at other times you might be thinking “I need to learn more about how to think family in action or practice or how to react when others have differing values than mine.” Self-reflection enhances nursing practice.

Actions of th e Individual- N urse- Family R elationsh ip

Nursing actions can support individuals and their family members in many ways. Some nurs- ing actions are aimed at immediate concerns, others are more relevant to the future. Family nurses focus on what the family determines are the priority concerns; the nurse adds expert input for family consideration. For example, a new mother is trying to decide whether to breastfeed her new infant. She may need to learn skills for making the process successful. Her husband and his mother might have an experience in which breastfeeding didn’t work so well and may need information about the long-term health benefits for the child to be able to support the mother’s wishes. When family members are included in the conversation, multiple needs can be addressed. Including family in discussions about breastfeeding could answer questions, explain benefits, and be more useful than just telling the mother that she should breastfeed without considering other family member support. The individual-nurse- family relationship uses a think family perspective including relevant scientific evidence and holistic care for the family unit based on their need priorities. Think about your family and ask yourself, if one of my family members were sick, how would I want to be treated as a family member? How would I want to be included? What would my family prefer? Take a few minutes to review Box 8.1 where you can learn about a family nurse leader from Finland who has been helping students learn about family care for many years.

Initiating th e Individual- N urse- Family R elationsh ip

Individual-nurse-family relationships begin with introductions. Then take time to hear the family health story about their current situation. Communicate the purpose of the

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