Family Health Nursing

Definition of Family

Family

Basic unit in society, and is shaped by all forces surround it.
- Values, beliefs, and customs of society influence the role and function of the family (invades every aspect of the life of the family)
Is a unit of interacting persons bound by ties of blood, marriage or adoption.
- Constitute a single household, interacts with each other in their respective familial roles and create and maintain a common culture.
An open and developing system of interacting personalities with structure and process enacted in relationships among the individual members regulated by resources and stressors and existing within the larger community (Smith & Maurer, 1995)
Two or more people who live in the same household (usually), share a common emotional bond, and perform certain interrelated social tasks (Spradly & Allender, 1996)
An organization or social institution with continuity (past, present, and future). In which there are certain behaviors in common that affect each other.

The Filipino Family

Based on the Philippine Constitution, Family Code with focus on religious, legal, and cultural aspects of the definition of family.

Section 1

The state recognizes the Filipino family as the foundation of the nation. Accordingly, it shall strengthen its solidarity and actively promote its total development

Section 2

Marriage, as an inviolable social institution, is the foundation of family and shall be protected by the state.

Section 3

The state shall defend –

the right of spouses to found a family in accordance with their religious convictions and the demands of responsible parenthood
the right of children to assistance including proper care and nutrition, and special protection from all forms of neglect, abuse, cruelty, exploitation and other conditions prejudicial to their development
the right of the family to a family living wage income
the right of families or family associations to participate in the planning and implementation of policies and programs of that affect them

Section 4

The family has the duty to care for its elderly members but the state may also do so through just programs of social security

The Filipino Family and its Characteristics

The basic social units of Philippine society are the nuclear family

Although the basic unit is the nuclear family, the influence of kinship is felt in all segments of social organizations
Extensions of relationships and descent patterns are bilateral
Kinship circles is considerably greater because effective range often includes the third cousin
Kin group is further enlarged by a finial, spiritual or ceremonial ties. Filipino marriage is not an individual but a family affair
Obligation goes with this kingship system
Extended family has a profound effect on daily decisions
There is a great degree of equality between husband and wife
Children not only have to respect their parents and obey them, but also have to learn to repress their repressive tendencies
The older siblings have something of authority of their parents.

Types of Family

There are many types of family. They change overtime as a consequence of BIRTH, DEATH, MIGRATION, SEPARATION and GROWTH OF FAMILY MEMBERS

A. Structure

NUCLEAR- a father, a mother with child/children living together but apart from both sets of parents and other relatives.
EXTENDED- composed of two or more nuclear families economically and socially related to each other. Multigenerational, including married brothers and sisters, and the families.
SINGLE PARENT-divorced or separated, unmarried or widowed male or female with at least one child.
BLENDED/RECONSTITUTED-a combination of two families with children from both families and sometimes children of the newly married couple. It is also a remarriage with children from previous marriage.
COMPOUND-one man/woman with several spouses
COMMUNAL-more than one monogamous couple sharing resources
COHABITING/LIVE-IN-unmarried couple living together
DYAD—husband and wife or other couple living alone without children
GAY/LESBIAN-homosexual couple living together with or without children
NO-KIN- a group of at least two people sharing a relationship and exchange support who have no legal or blood tie to each other
FOSTER- substitute family for children whose parents are unable to care for them

FUNCTIONAL TYPE:

FAMILY OF PROCREATION- refers to the family you yourself created.
FAMILY OF ORIENTATION-refers to the family where you came from.

B. Decisions in the family (Authority)

PATRIARCHAL – full authority on the father or any male member of the family e.g. eldest son, grandfather
MATRIARCHAL – full authority of the mother or any female member of the family, e.g. eldest sister, grandmother
EGALITARIAN- husband and wife exercise a more or less amount of authority, father and mother decides
DEMOCRATIC – everybody is involve in decision making
AUTHOCRATIC-
LAISSEZ-FAIRE- “full autonomy”
MATRICENTRIC- the mother decides/takes charge in absence of the father (e.g. father is working overseas)
PATRICENTIC- the father decides/ takes charge in absence of the mother

C. Decent (cultural norms, which affiliate a person with a particular group of kinsman for certain social purposes)

PATRILINEAL – Affiliates a person with a group of relatives who are related to him though his father
BILATERAL- both parents
MATRILINEAL – related through mother

D. Residence

PATRILOCAL – family resides / stays with / near domicile of the parents of the husband
MATRILOCAL – live near the domicile of the parents of the wife

Ackerman States that the Function of Family are:

Insuring the physical survival of the species
Transmitting the culture, thereby insuring man’s humanness
- Physical functions of the family are met through parents providing food, clothing and shelter, protection against danger provision for bodily repairs after fatigue or illness, and through reproduction
- Affect ional function – the family is the primary unit in which he child test his emotional reactions
- Social functions – include providing social togetherness, fostering self esteem and a personal identity tied to family identity, providing opportunity for observing and learning social and sexual roles, accepting responsibility for behavior and supporting individual creativity and initiative.

Universal Function of the Family by Doode

REPRODUCTION – for replacement of members of society: to perpetuate the human species
STATUS PLACEMENT of individual in society
BIOLOGICAL and MAINTENANCE OF THE YOUNG and dependent members
Socialization and care of the children;
Social control

The Family as a Unit of Care

Rationale for Considering the Family as a Unit of Care:

The family is considered the natural and fundamental unit of society
The family as a group generates, prevents, tolerates and corrects health problems within its membership
The health problems of the family members are interlocking
The family is the most frequent focus of health decisions and action in personal care
The family is an effective and available channel for much of the effort of the health worker

The Family as the Client

Characteristics of a Family as a Client

The family is a product of time and place-

- A family is different from other family who lives in another location in many ways.
- A family who lived in the past is different from another family who lives at present in many ways.

The family develops its own lifestyle

- Develop its own patterns of behavior and its own style in life.
- Develops their own power system which either be:
  - Balance-the parents and children have their own areas of decisions and control.
  - Strongly Bias-one member gains dominance over the others.

The family operate as a group

- A family is a unit in which the action of any member may set of a whole series of reaction within a group, and entity whose inner strength may be its greatest single supportive factor when one of its members is stricken with illness or death.

The family accommodates the needs of the individual members.

- An individual is unique human being who needs to assert his or herself in a way that allows him to grow and develop.
- Sometimes, individual needs and group needs seem to find a natural balance;
  1. The need for self-expression does not over shadow consideration for others.
  2. Power is equitably distributed.
  3. Independence is permitted to flourish.

The family relates to the community

- Family develops a stance with respect to the community:
  1. The relationship between the families is wholesome and reciprocal; the family utilizes the community resources and in turn, contributes to the improvement of the community.
  2. There are families who feel a sense of isolation from the community.
    - Families who maintain proud, “We keep to ourselves” attitude.
    - Families who are entirely passive taking the benefits from the community without either contributing to it or demanding changes to it.

The family has a growth cycle

- Families pass through predictable development stages (Duvall & Miller, 1990)
- STAGES:
  - Stage 1: MARRIAGE & THE FAMILY
    - Involves merging of values brought into the relationship from the families of orientation.
    - Includes adjustments to each other’s routines (sleeping, eating, chores, etc.), sexual and economic aspects.
    - Members work to achieve 3 separate identifiable tasks:
      1. Establish a mutually satisfying relationship
      2. Learn to relate well to their families of orientation
      3. If applicable, engage in reproductive life planning
  - Stage 2: EARLY CHILDBEARING FAMILY
    - Birth or adoption of a first child which requires economic and social role changes
    - Oldest child: 2-1/2 years
  - Stage 3: FAMILY WITH PRE-SCHOOL CHILDREN
    - This is a busy family because children at this stage demand a great deal of time related to growth and development needs and safety considerations.
    - Oldest child: 2-1/2 to 6 years old
  - Stage 4: FAMILY WITH SCHOOL AGE CHILDREN
    - Parents at this stage have important responsibility of preparing their children to be able to function in a complex world while at the same time maintaining their own satisfying marriage relationship.
    - Oldest child: 6-12 years old
  - Stage 5: FAMILY WITH ADOLESCENT CHILDREN
    - A family allows the adolescents more freedom and prepare them for their own life as technology advances-gap between generations increases
    - Oldest child: 12-20 years old
  - Stage 6: THE LAUNCHING CENTER FAMILY
    - Stage when children leave to set their own household-appears to represent the breaking of the family
    - Empty nests
  - Stage 7: FAMILY OF MIDDLE YEARS
    - Family returns to two partners nuclear unit
    - Period from empty nest to retirement
  - Stage 8: FAMILY IN RETIREMENT/OLDER AGE
  - Stage 9: PERIOD FROM RETIREMENT TO DEATH OF BOTH SPOUSES

12 Behaviors Indicating a Well Family

Able to provide for physical emotional and spiritual needs of family members
Able to be sensitive to the needs of the family members
Able to communicate thought and feelings effectively
Able to provide support, security and encouragement
Able to initiate and maintain growth producing relationship
Maintain and create constructive and responsible community relationships
Able to grow with and through children
Ability to perform family roles flexibly
Able to help oneself and to accept help when appropriate
Demonstrate mutual respect for the individuality of family members
Ability to use a crisis experience as a means of growth
Demonstrate concern of family unity, loyalty and interfamily cooperation

Family Health Task

Health task differ in degrees from family to family
TASK- is a function, but with work or labor overtures assigned or demanded of the person
Duvall & Niller identified 8 task essential for a family to function as a unit:

Eight Family Tasks (Duvall & Niller)

Physical maintenance- provides food shelter, clothing, and health care to its members being certain that a family has ample resources to provide
Socialization of Family– involves preparation of children to live in the community and interact with people outside the family.
Allocation of Resources- determines which family needs will be met and their order of priority.
Maintenance of Order– task includes opening an effective means of communication between family members, integrating family values and enforcing common regulations for all family members.
Division of Labor – who will fulfill certain roles e.g., family provider, home manager, children’s caregiver
Reproduction, Recruitment, and Release of family member
Placement of members into larger society –consists of selecting community activities such as church, school, politics that correlate with the family beliefs and values
Maintenance of motivation and morale– created when members serve as support people to each other

5 Family Health Tasks (Maglaya, A., 2004)

Recognizing interruptions of health development
Making decisions about seeking health care/ to take action
Dealing effectively health and non-health situations
Providing care to all members of the family
Maintaining a home environment conducive to health maintenance

Family Roles

Nurturing figure– primary caregiver to children or any dependent member.
Provider – provides the family’s basic needs.
Decision maker– makes decisions particularly in areas such as finance, resolution, of conflicts, use of leisure time etc.
Problem-solver– resolves family problems to maintain unity and solidarity.
Health manager– monitors the health and ensures that members return to health appointments.
Gate keeper-Determines what information will be released from the family or what new information cam be introduced.

Theoretical Approaches to Family Health Care (family apgar)

Family Models

the use of family model provides a perspective of focus for understanding the family
have categorized according to their basic focus as developmental, interactional structural-functional, and systems model

Developmental Models

Duvall’s and Stevenson’s Family development model

Evelyn Duvall’ (1977) family developmental framework provides guide to examine and analyze the basic changes and developmental tasks common to most families during their life cycle. Although each family has unique characteristics normative patterns of sequential development are common to all families
These stages and developmental tasks illustrate common family behaviors that may be expected at specific times in the family life cycle. The stages are marked by the age of the oldest child however some overlapping occurs in families with several children.

STAGES OF DEVELOPMENT

BASIC FAMILY TASK

Beginning FamiliesEarly childbearing

Families with preschoolers

Families with school children

Families with teen-agers

Launching center families

Middle-aged families

Aging Families

Physical maintenance

Allocation of resources

Division of labor

Socialization of members.

Reproduction, recruitment and release of Members

Maintenance of order

Placement of members in larger community Maintenance of motivation and morale

Duvall’s developmental model is an excellent guide for assessing, analyzing and planning around basic family tasks developmental stage, however, this model does not include the family structure or physiological aspects, which should be considered for a comprehensive view of the family. This model is applicable for nuclear families with growing children and families who are experiencing health-related problems.

Stevenson’s Family Developmental Model

Joanne Stevenson (1977) describes the basic tasks and responsibilities of families in four stages.

STAGES	HEALTH TASKS
Emerging family (from marriage for 7 to 10 years)	Couple strives for independence from their parents and to develop a sense of responsibility for family life.
Crystallizing family (with teenage children)	To assume responsibility for growth and development of individual members and outside organizations
Interacting family(children grown and small grandchildren)	Assumption of responsibility for “continued survival and enhancement of the nation.”
Actualizing family (aging couple alone again)	Assume the responsibility for sharing the wisdom of age, reviewing life and putting affairs in order

She views family tasks as maintaining a common household rearing children and finding satisfying work and leisure. It also includes sustaining appropriate health patterns and providing mutual support and acculturation of family members.
This model is useful for nuclear families because it examines psychosocial patterns to specific stage of development, however, it also does not include family structure, nor it addresses health promotion and health-related concerns that the family may face.

Structural- Functional Model

Friedman’s Structural- Functional Family Model

Was developed from sociological frameworks and systems theory by Marilyn Friedman (1986)
The family is the focus of this model as it interacts with supra-systems in the community and with individual family members in the subsystem.

Friedman’s Family Model Components

STRUCTURAL COMPONENTS	FUNCTIONAL COMPONENTS
Family composition	Affective
Value systems	Physical necessities and care
Communication patterns	Economic
Role structure	Reproductive
Power structure	Socialization and social placement Family coping

Structural component examines the family unit, how it is organized and how members relate to one another in terms of values, communication network, role system and power while functional components refers to the interaction outcomes resulting from family organizational structure.
The structural-functional components and parts all intimately interrelate and interact; the others affect each component and part.
This model provides a broad framework for examining the interactions among family and within the community. This incorporates physical, psychosocial and cultural aspects of the family along with interacting relationships.
This model is very applicable to any type of family and their health-related problems

Systems Model

Calgary’s Family Model (system’s model)

Is an integrated conceptual framework of several theorists.
Model is based on three major categories: family structure, function and development. Each is further subdivided into parts that interacts with others and changes the whole family configuration.

Calgary Family Model

Family Structure Family Development Family Functions
Internal developmental stage daily living activities
Family composition developmental tasks allocation of tasks
Rank order of member’s attachments
Subsystems in family
Boundaries of familyExternal Expressive
Culture Communication
Religion Problem-solving
Social class status Roles
And mobility Control
Environment Beliefs
Extended family Alliances/coalitions

This model is comprehensive and incorporates three major areas, namely, the structure, function and development of the family.
It is complex, with too many sub concepts for the health worker to explore and focus.
It can be applied to any type of family with any health-related problems.

Family Apgar Questionnaire (SMILKESTEIN, 1978)

	ALWAYS (2 PTS.)	SOMETIMES (1 pt.)	HARDLY EVER (0 PT.)
I am satisfied with the help I receive from my family when something is troubling me.
I am satisfied with the way my family discovers items of common interest and shares problem-solving with me.
I find that my family accepts my wishes to take on new activities or make changes in my lifestyle.
I am satisfied with the way my family expresses affection and responds to my feelings such as anger, sorrow and love
I am satisfied with the way my family and I spend time together.

Scoring:
Check one of the three choices:
Total Score:

7-10 = suggests a highly functional family
4-6 = moderately dysfunctional family
0-3 = severely dysfunctional family

Health as a Goal of Family Health Care

HEALTH DEFICIT- this refers to conditions of health breakdowns or advent of illness in the family
HEALTH THREAT- these are the conditions that make it more likely for accidents, disease or failure to thrive or develop to occur.
FORESEEABLE CRISIS- these are anticipated periods of unusual demand on the family in terms of time or resources
WELLNESS POTENTIAL- this refers to states of wellness and the likelihood for health maintenance or improvement to occur depending on the desire of the family

Roles of Health Care Provider in Family Health Care

HEALTH MONITOR
PROVIDER OF CARE
COORDINATOR
FACILITATOR
TEACHER
COUNSELOR

Family Health Care Process

DATA COLLECTION: METHODS AND TOOLS
DATA ANALYSIS or INTERPRETATION
PLANNING
IMPLEMENTATION
EVALUATION PHASE

ASSESSMENT PHASE

first major phase of nursing process in family health nursing
Involves a set of action by which the nurse measures the status of the family as a client. Its ability to maintain wellness , prevent, control or resolve problems in order to achieve health and wellness among its members
Data about present condition or status of the family are compared against the norms and standards of personal , social, and environmental health, system integrity and ability to resolve social problems.
The norms and standards are derived from values, beliefs, principles, rules or expectation.

TWO MAJOR TYPES

FIRST LEVEL ASSESSMENT- a process whereby existing and potential health conditions or problems of the family are determined (WS, HT, HD, SP or FC)
SECOND LEVEL ASSESSMENT- defines the nature or type of nursing problem that family encounters in performing health task with respect to given health condition or problem and etiology or barriers to the family’s assumption of the task

DATA COLLECTION METHODS: SELECT APPROPRIATE METHOD

OBSERVATION

- done through use of sensory capacities
- The nurse gathers information about the family’s state of being and behavioral responses
- the family’s health status can be inferred from the s/sx of problem areas
  - a. communication and interaction patterns expected ,used, and tolerated by family members
  - b. role perception / task assumption by each member including decision making patterns
  - c. conditions in the home and environment

** Data gathered though this method have the advantage of being subjected to validation and reliability testing by other observers

PHYSICAL EXAMINATION

- significant data about the health status of individual members can be obtained through direct examination through IPPA, Measurement of specific body parts and reviewing the body systems
- data gathered from P.A form substantive part of first level assessment which may indicate presence of health deficits (illness state )

INTERVIEW

- Productivity of interview process depends upon the use effective communication techniques to elicit needed response PROBLEMS ENCOUNTERED:
  - How to ascertain where the client is in terms of perception of health condition or problems and the patterns of coping utilized to resolve them
  - Tendency of community health worker to readily give out advice, health teachings or solutions once they have identified the health condition or problems.
- Provisions of models for phrasing interview questions utilization of deliberately chosen communication techniques for an adequate nursing assessment.
- confidence in the use of communication skills
- Being familiar with and being competent in the use of type of question that aim to explore, validate, clarify, offer feedback, encourage verbalization of thought and feelings and offer needed support or reassurance.

TYPES:

completing health history of each family member
- Health history determines current health status based on significant PAST HEALTH HISTOI\RY e.g. developmental accomplishment, known illnesses, allergies, restorative treatment, residence in endemic areas for certain diseases or sources of communicable diseases.
- FAMILY HISTORY e.g. genetic history in relation to health and illness.
- SOCIAL HISTORY e.g. intra-personal and inter-personal factors affecting the family member social adjustment or vulnerability to stress and crisis
Collecting data by personally asking significant family members or relatives questions regarding health, family life experiences and home environment to generate data on what wellness condition and health problem exist in the family ( first level assessment) and the corresponding nursing problems for each health condition or problem ( 2nd level assessment)

RECORDS REVIEW

- Gather information through reviewing existing records and reports pertinent to the client
- Individual clinical records of the family members, laboratory and diagnostic reports, immunization records reports about home and environmental conditions

LABORATORY/ DIAGNOSTIC TEST

ANALYZE DATA TO IDENTIFY NEEDS AND PROBLEMS

CRITERIA FOR ANALYSIS:
PROCESS FOR ANALYSIS:
- SORTING OF DATA
- CLUSTERING OF RELATED CUES
- DISTINGUISHING RELEVANT FROM IRRELEVANT CUES
- IDENTIFYING PATTERNS
- COMPARING PATTERNS
- INTERPRETING RESULTS OF COMPARISON
- MAKING INFERENCES AND DRAWING CONCLUSIONS

Health Needs and Problems of the Family

A situation which interferes with the promotion and / or maintenance of health
It is a health problem when it stated as the family’s failure to perform adequately specific health task to enhance the wellness state or manage a health problem