Unit 4 Assessment. Intervention. and relational nursing PDF

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Module 5: Family Nursing Assessment and Intervention & Relational Nursing Bell, J.M. (2011). Relationships: the heart of the matter in family nursing. Journal of Family Nursing, 17(1), 310. doi: 10.1177/1074840711398464External tool Painful article…don’t read it if you took 102/201  By orienting our assessment and intervention to focus on relationships, family nursing practice, family nursing education, and family nursing research might be expanded in several ways.  Named the clinical interventions necessary for building and maintaining a therapeutic relationship “creating a context for change.” These interventions include: o creating a collaborative relationship, focusing the therapeutic conversation on the family’s most pressing concerns, and removing obstacles in the relationship.  Malcolm Gladwell (2005), in his book Blink, underscores the importance of the first few seconds of any encounter and uses research about rapid cognition to show that the human brain has an amazing ability to “thin-slice” (p. 23) and form impressions of others in a glance. Important for nurses to: o Greet the family by introducing self, offering a handshake, using eye contact and facial expressions to convey interest, explaining the setting and nature of the work, offering an agenda or plan for the therapeutic conversation, offering parameters about the duration and scope of the therapeutic relationship such as the frequency of meetings. 

Immersion in practice with families offers opportunities for clinical scholars to examine the practice, describe the practice, and continuously learn from families which results in the discovery, organization, analysis, synthesis, and transmission of knowledge. o One hypothesis about why clinical scholarship and intervention research focused on the process of intervention has not been extensively used is that perhaps few nurses and other health care professionals actually offer a full scope of practice to families.  In other words, perhaps expert practice with families is not yet frequently occurring or is not sufficiently visible to be easily examined, named, and synthesized to be replicated by others

Black, K. & Lobo, M. (2008). A conceptual review of family resilience factors. Journal of Family Nursing, 14(1), 33-55. doi: 10.1177/1074840707312237External tool  The concept of resilience was originally developed by studying the positive adaptation of children under adverse circumstances and has since been applied to the study of family systems.  Family health: a dynamic changing relative state of well-being which includes the biological, psychological, spiritual, sociological, and culture factors of the family systems  Family resilience: as characteristics, dimensions, and properties of families which help families to be resilient to disruption in the face of change and adaptive in the face of crisis situations Hx of the Concept of Resilience  Evidence shows that since the 1970s, many children raised in high-risk environments did not mirror their deprived environments, but rather thrived and grew up to become productive and loving individuals  Although many deprived or traumatized children became blocked from growth or trapped in a victim position, about half of children exposed to high-risk circumstances overcame them, were able to lead loving and productive lives, and went on to raise their own children well

Family Resilience

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With the evolving concept of family resilience, the focus is shifting away from identifying individual personality factors toward the crucial influence of positive relationships with family, kin, and mentors. o the dynamic process of resilience is best understood through the context of a broader, interrelational framework. A family Black, Lobo / Conceptual Review of Family Resilience 35 resilience perspective recognizes parental strengths, family dynamics, interrelationships, and the social milieu o This strength-based approach considers family stresses and challenges not as damaging but rather as opportunities for fostering healing and growth - The phenomenon of resilience requires attention to a range of possible psychological outcomes and not just a focus on an unusually positive one or on super-normal functioning - There are times when family demands exceed the family’s capabilities. o When these imbalances exist, some capabilities may supersede others toward regaining equilibrium. o Some family processes fail to adapt with poor immediate and long-term outcomes Prominent Family Resilience Factors - There is no universal list of key, effective protective and recovery factors, but there are recurrent and prominent attributes among resilient, healthy families: o a positive outlook: Confidence and optimism; repertoire of approaches; sense of humor o spirituality: Shared interval value system that gives meaning to stressors o family member accord: Cohesion; nurturance; authoritative discipline; avoidance of hostile parental conflict o Flexibility: Cohesion; nurturance; authoritative discipline; avoidance of hostile parental conflict o Communication: Clarity, open emotional expression, and collaborative problem solving o financial management: Sound money management, family warmth despite financial problems o time together: Makes the most of togetherness with daily tasks o mutual recreational interests: Develops child social and cognitive skills; cohesion and adaptability o routines and rituals: Embedded activities that promote close family relationships; maintenance even during family crisis o social support: Individual, familial, and community networks to share resources; especially important for families in poverty -

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The family resilience model is increasingly recognized in family assessment and therapy, although the deficit and individualist views still seem to be the predominant approaches Family services that accentuate the positive qualities of families, such as teaching relationship patterns, interpersonal skills, and competencies, have been shown to build and maximize family resilience positive affirmative approaches in interactions with families through a process of identifying and developing strengths, then using those strengths in planning care. Awareness of community resources is instrumental in the search for hidden family resources and linkages that may prove to be protective and recovery factors. If assistive family resources are not identified in the community, the family nurse is called to serve as an advocate to create resiliency-building networks and reduce the risks especially inherent in vulnerable families.

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Registered Nurses’ Association of Ontario. (2015). Person-and-family-centered care. Toronto, ON: Registered Nurses’ Association of Ontario. Practice Recommendations. Retrieved from http://rnao.ca/sites/rnaoca/files/FINAL_Web_Version_0.pdfExternal tool ....Please read pages 23-41

 Empowerment of all participants within the therapeutic relationship is one of the goals of person- and family-centred care  Promoting the person as an active partner means recognizing and valuing their potential and their strengths, sharing power with them, and working with them to create a plan for their health Behaviours That Encourage Empowerment ■ Demonstrate an interest in the whole person as an individual. ■ Intentionally start with what matters most to the person. ■ Be respectful of each person’s diversity and their evolving capacity to manage their health. ■ Encourage the person to tell their story so that you can come to know and draw out information regarding what helps or hinders the person’s achievement of health. ■ Facilitate choice and support the person’s autonomy and demonstrate a belief in the person’s ability to make decisions for their health. ■ Encourage the person to participate to their preferred level of involvement. ■ Demonstrate sympathetic presence when the person expresses emotion 

The person’s perspective informs the health-care provider of the context for the person’s care needs. When interacting with health-care providers, people find it most meaningful when: o they are viewed from a holistic perspective (i.e., not seen just in the context of their disease or illness), o their experience of health is legitimized, o they are acknowledged as the expert on themselves and their life, and o they work in partnership with health-care providers

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Health literacy impacts overall health, so nurses must explore with the person their understanding of their health and their needs to self-manage care. Nurses must document the information obtained on the meaning and experience of health to the person using the person’s own words. This information will be used to diagnose, plan, coordinate, and implement health care and services. When planning care and services, health-care providers should engage with the person in a participatory model of shared decision making, respecting autonomy; their preferred interventions for their health. A participatory model of decision making respects the person’s right to choose the interventions for care that meet their health-care goals. A participatory model includes: o collaborating with the person to identify their priorities and goals for health care, o sharing information to promote an understanding of available options for health care so the person can make an informed decision, and o respecting the person as an expert on themselves and their life.

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The pt must be given information on evidence-based treatment options in a way that enables them to decide. Sharing decisions on health care requires a mutual understanding that the person is the expert on themselves and their life situation, and that health-care providers are the experts on evidence-based practices and legislation in health care When there is a difference in the person’s and the health-care provider’s expectations for care, collaboration can assist in: o exploring the person’s perspective;

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o exploring the health-care provider’s and organization’s perspective; o accepting there is a difference of opinion, without judgment; o creating a shared understanding of what everyone is willing to do; and o arriving at a mutually agreed-to solution and plan for the delivery of care and services  

An evaluation of care must start from the perspective of the person receiving care. Members of the health-care team should seek feedback from the person regarding their level of satisfaction with care in order to monitor the outcomes of person- and family-centred care Health-care providers should participate in professional development opportunities that support the development of their knowledge and ability to apply the following person- and family-centred-care attributes in practice.

Var coe,C.&Doan,H.G.( 2018) .Rel at i onal nur si ngandf ami l ynur si ngi nCanada.I nJ.R.Kaaki nen,D.P.Coehl o, R.St eel ,&M.Robi nson,( 6t hed. ) ,Fami l yheal t hcar enur si ng:Theor y ,pr act i ceandr esear ch( BC1BC19) . Phi l adel phi a,PA:F. A.Davi sCompany .

 Thus, relational inquiry focuses very specifically on how health is a socio-relational experience that is strongly    

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shaped by contextual factors. One of the few predictable characteristics of families is diversity. By understanding and intentionally attending to diversity when providing care, family nurses in Canada are prepared to take into account the contextual nature of families’ health and illness experiences and how their lives are shaped by their circumstances. Contexts are literally embodied in people; both nurses and families live their contexts and circumstances. For family nurses in Canada to work responsively with a range of different families, it requires understanding the particular families. Understanding the families entails taking a stance of inquiry, listening and paying attention to the specific experiences of particular families, reflexively attending to one’s own understandings, and continuously developing new knowledge and cultural awareness. This process embraces the complexity of family nursing care and provides more relational, and thereby more appropriate and successful, care for families. Family nurses in Canada must optimize family care within a structure that limits out-of-hospital care and limits access to care in rural communities. Family nurses need to collaborate with other providers and resources to help families optimize their health and long-term health outcomes.

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Schr oeder ,W. ,( 2014,November ,25) .Howt odr awecomaps[ Vi deofil e] .Ret r i evedf r om ht t ps: / / www. yout ube. com/ wat ch?v=eRHsRCl uXWI &f eat ur e=yout u. be

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Module 5 – CFAM PPT. Highlights Essential Steps of Family Nursing Care 1. Assessment of the family story 2. Analysis of the family story 3. Design of a family plan of care 4. Family intervention 5. Family evaluation 6. Nurse reflection 7. Family Assessment Models Family Assessment and Intervention Model - Friedman Family Assessment Model - Calgary Family Assessment Model (CFAM) - Introduction to CFAM & CFIM - Developed by Wright and Leahey in 1984 - Integrated, multidimensional framework - 3 major assessment categories in CFAM: Structural, Developmental, and Functional 1. Nurses can assess all 3 areas and their subcategories for a macroview 2. OR can use one specific part of the model for a microview CFAM: Foundational Concepts 3. A family system is part of a larger suprasystem and is also composed of many subsystems 4. The family as a whole is greater than the sum of its parts 5. A change in one family member affects all family members 6. The family is able to create a balance between change and stability 7. Family members’ behaviours are best understood through circular rather than linear causality CFAM: Structural Assessment 1. Internal Structure: a. Family composition b. Gender c. Sexual orientation d. Rank order e. Subsystems f. Boundaries 2. External Structure: a. Extended family b. Larger systems 3. Context: a. Ethnicity b. Race c. Social class d. Religion and/or spirituality e. Environment  Genogram & Ecomap

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CFAM: Developmental Assessment 1. Stages: developmental stage of the family, as per Developmental Life Cycle Theory 2. Tasks: developmental tasks associated with family stage 3. Attachments: relatively enduring, unique emotional ties between two specific people CFAM: Functional Assessment - Instrumental Assessment: activities of daily living - Expressive Assessment: 1. Emotional communication 2. Verbal communication 3. Nonverbal communication 4. Circular communication 5. Problem-solving 6. Roles 7. Influence & power 8. Beliefs 9. Alliances/coalitions Calgary Family Intervention Model - CFIM is a companion to CFAM - Strengths- and resiliency-based model - Provides a framework for choosing the most appropriate intervention(s) for a family - Interventions can be in one of three domains: 1. Cognitive 2. Affective 3. Behavioral - Interventions can promote, improve, or sustain family functioning CFIM: Interventive Questions - Can be part of cognitive, affective, or behavioral interventions - Either linear or circular questions 1. Linear questions inform the nurse and gather information  Example: “When did you notice a change in your daughter’s eating habits?” 2. Circular questions aim to reveal explanations about problems, effect change, and generate new understanding  Example: “How do you express your concern about your daughter’s anorexia?” Cognitive Domain - Cognitive interventions offer new ideas, opinions, beliefs, info, or education on a health problem or risk - Treatment goal/desired outcome: change the way a family perceives its health problems, so members can discover new solutions - Types of interventions in cognitive domain: 1. Commending family and individual strengths 2. Offering information and opinions

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Affective Domain - Aims to increase or decrease intense emotions that may be blocking problem-solving efforts - Types of interventions in affective domain: 1. Validating, acknowledging, or normalizing emotional responses 2. Encouraging the telling of illness narratives 3. Drawing forth family support Behavioural Domain - Helps family members to interact with and behave differently in relation to one another - Types of interventions in behavioural domain: 1. Encouraging family members to be caregivers and offering caregiver support 2. Encouraging respite 3. Devising rituals

Kaakinen, J. (2018). Family nursing assessment and intervention. In J. R. Kaakinen, D. P. Coehlo, R. Steel, & M. Robinson, (6th ed.), Family health care nursing: Theory, practice and research (pp.113-146). Philadelphia, PA: F.A. Davis Company.  People are both influenced by their context and live within contexts.  Through relational inquiry lens of family nursing, nurses look for how people, situations, contexts, environments, and processes are integrally connecting with and shaping each other. o Through this process nurses connect across differences and work with the family by providing options and choice to help them determine the best decisions for them and their family in this situation at this point in time. o RI is important for family assessment and family tailored interventions  Illness story differs from the medical story o The medical story is about the pt who has the disease or health problem and includes S&S, meds, tx, prognosis or trajectory of illness. o The family illness story is how the family and each member live through the experience of the illness or health event.  Goal of family centered care is to increase mutual benefit of health care provision for all parties with a focus on improving the satisfaction and outcomes of health care for families. Family Nursing Assessment  Nurses must be aware that “common” interpretations of data may not be the “correct” interpretations in any given situation:  The family nursing assessment includes: 1. Assessment of family story – gathers data from variety of sources to see whole picture of family’s experience 2. Analysis of family story – nurse clusters data into meaningful patterns to see how the family is managing the health event. 3. Design of a family plan of care – nurse/family determines the best plan of care for the family to manage the situation

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4. Family intervention – nurse/family implement the plan of care incorporating the most familyfocused, cost-effective, and efficient interventions that assist the family to achieve the vest possible outcomes 5. Family evaluation – nurse/family determine whether the outcomes are being reaches, are being partially reached, or need to be redesigned. 6. Nurse reflection – nurses engage in critical, creating, and concurrent reflection about themselves and their own family experiences the family client and their work with the family. Making community-based appointments The nurse needs to know the following:  Reason for the referral or requested visit  Family knowledge of the visit or referral  Specific medical information about the family member with the health problem  Strategies that have been used previously  Insurance sources for the family  Family problems identified by other health providers  Family demographic data  Need for an interpreter 

Family assessments in acute care settings • Families need the help of nurses to learn how to: ‒ Provide effective post-discharge care tasks ‒ Engage in shared decision making with health care providers ‒ Unders...