Papel de la enfermeria en la Clínica de Universidad de Navarra en su Unidad de Terapia Familiar

1. UDITEF
UNIVERSITY HOSPITAL - UNIVERSITY OF NAVARRA
Nursing role in a Spanish
Family Therapy Unit
Beunza, M; Tricas, S;
Incera, S; Martín, R;
Cano, A;Aubá, E
University Hospital
University of Navarra, Spain
Reykjavik, June 2009

2. EUROPE-SPAIN

3. UDITEF
NAVARRE - SPAIN

4. UDITEF
UNIVERSITY HOSPITAL
Diagnosis and Family Therapy Unit

5. UDITEF
THE UNIVERSITY OF NAVARRE

6. UDITEF
MULTIDISCIPLINARY TEAM
NURSING
PSYCHIATRY
Maribel Beunza (Head Nurse)
Adrián Cano
Sandra Tricas (School of Nursing)
Enrique Aubá Seyla Incera: Master´s student
PSYCHOLOGY
Francisca Lahortiga COMMUNICATION
Raquel Martín

7. UDITEF
Chronic physical
illness
Mental illness
Marital or family
distress
Reykjavik, June 2009

8. UDITEF
REGULAR PROTOCOLE
1st contact:
Appointment First Assessment
Information about the case
Confidentiality
Case study: Report:
- Family interview - General information
- Personal interview - Reason for consultation
- Genograms - Questionnaires and RMICS results
Family
- Questionnaires - Interpretation Therapy
- RMICS - Therapeutic guidelines
Reykjavik, June 2009

9. NURSE ACTIVITY UDITEF
Psychiatric Nurse
(RMN) Cited by Either psychiatrist
coordination or RMN
1st contact:
Appointment First Assessment
Information about the case
Teamwork
Confidentiality (coordination, discussion,
consensus and dialogue)
Case study: Report:
- Family interview - General information
- Personal interview - Reason for consultation
- Questionnaires and RMICS results
Family
- Genograms
Genograms
- Questionnaires - Interpretation Therapy
- RMICS - Therapeutic guidelines
Oral and written interpretation
of family conflict or problem and
therapeutic orientation

10. UDITEF
THE 1st CONTACT
The first contact of the family is done with the nurse, who
coordinates the process and the appointments

11. UDITEF
FIRST ASSESSMENT INTERVIEW
It is carried out by the nurse or the psychiatrist
- General data of the family
- Information about the problem
- Need of a deeper assessment
- Family, couple intervention or therapy

12. UDITEF
MARITAL
9:00 - 11:30
INTERVIEW
SELF-REPORT
12:00 - 13:00 QUEST. GENOGRAM
SELF REPORT
13:00 - 14:00 GENOGRAM QUEST.
PERSONAL PERSONAL
16:00 - 18:00
INTERVIEW INTERVIEW
COMMUNICATION
18:30 - 19:00
RMICS

13. MARTIAL / FAMILY
ENTREVISTA
INTERVIEW
MARITAL / FAMILY INTERVIEW
• Video-recorded
• Informed consent (signed)
• Semi-structured interview
- Family cluster
- Family organization
- Constitution and development of the marriage
- Main problems
- Strengths
Reykjavik, June 2009

14. UDITEF
MARITAL
9:00 - 11:30
INTERVIEW
SELF-REPORT
12:00 - 13:00 QUEST. GENOGRAM
SELF REPORT
13:00 - 14:00 GENOGRAM QUEST.
PERSONAL PERSONAL
16:00 - 18:00
INTERVIEW INTERVIEW
COMMUNICATION
18:30 - 19:00
RMICS

15. GENOGRAM
GENOGRAM
I. Family structure design
II. Family information recording
III. Family relations design
Reykjavik, June 2009

16. SELF-REPORT
QUESTIONNAIRES
FAMILY ASSESSMENT QUESTIONNAIRES
• Marital Assessment
– Dyadic Adjustment Scale (DAS)
– Areas of Change Questionnaire (ACQ)
– Relationship Belief Inventory (RBI)
• Family Assessment
– Family Adaptability and Cohesion Evaluation Scale III
(FACES III)
– Parent-Adolescent Communication (PAC)
– Family Assessment Device (FAD)
– Family Environment Scale (FES)
Reykjavik, June 2009

17. UDITEF
MARITAL
9:00 - 11:30
INTERVIEW
SELF REPORT
12:00 - 13:00 QUEST. GENOGRAM
SELF REPORT
13:00 - 14:00 GENOGRAM QUEST.
PERSONAL PERSONAL
16:00 - 18:00
INTERVIEW INTERVIEW
COMMUNICATION
18:30 - 19:00
RMICS

18. PERSONAL
INTERVIEW
PERSONAL INTERVIEW
• Individual point of view on the problem
• Psychobiography
• Sexuality
• Previous relations
• Personality
• Psychopathological assessment
Reykjavik, June 2009

19. UDITEF
MARITAL
9:00 - 11:30
INTERVIEW
SELF REPORT
12:00 - 13:00 QUEST. GENOGRAM
SELF REPORT
13:00 - 14:00 GENOGRAM QUEST.
PERSONAL PERSONAL
16:00 - 18:00
INTERVIEW INTERVIEW
COMMUNICATION
18:30 - 19:00
RMICS

20. RMICS
Rapid Marital Interaction Coding System
(RMICS)
Richard Heyman and Dina Vivian
State University of New York at Stony Brook
Study of communication through the observation and
analysis of a 15-minute video-recorded conversation
Reykjavik, June 2009

22. UDITEF
ACTIVITY
To date, 326 families have been attended
• Most first assessments were done by the nurse
• All genograms were carried out by nursing staff
Nursing has an important role both in gathering
information through the genogram as well as in the
follow up of the families

23. UDITEF
Health care system in Spain is
–like in many other countries–
Primary oriented to the individual
However, as Bell & Wright (2009), says:
“Illness is a family affair”

24. UDITEF
Nurses have an essential role with
families in the Family Therapy Unit.
We believe that this role can be extended
to other clinical areas

25. UDITEF
Adult and Child Medical Departments Oncology
Psychiatry
Paediatrics
Surgery
Acute Psychiatric Ward FAMILY ASSESSMENT
AND INTERVENTION
Family Therapy Ambulatory Inpatient Outpatient

26. UDITEF
Change in the culture of health care to include
families and encouraging a belief that nurses have
the competence and confidence to soften illness
suffering in families
Janice M Bell (J FAM NURS 2008)

27. UDITEF
Working with families in UDITEF extended
our point of view from patient to family and
encouraged us to introduce nursing family
assessment in the inpatient unit

28. UDITEF
Mental illness is hard to be accepted by patients
and their families. They need special attention
and information
Psychiatric hospitalisation is very often
“traumatic” for the families
Lack of information and family care may
increase families’ and patients’ suffering

29. UDITEF
Too many families, specially spouses,
report being ignored or made to feel
invisible by health professionals during
their illness experience
(Wright, LM J Fam Nurs 2005; 11; 344)
One of the causes can be the insufficient education in this complex area

30. UDITEF
Introduction of Genograms in an acute
psychiatric unit as a way of changing nursing
activity from patient centre care to care centred
in the family

31. UDITEF
Genograms are useful tools in the assessment of individual
patients, they give the nurse a global vision of the family and
the environment of the patient, giving important information
about the family functional and dysfunctional family
patterns. They can also strengthen the therapeutic
relationship with the nurse

32. UDITEF
Possible future benefits of the use of Genograms
• More satisfaction in nurses
• Acquisition of new knowledge. Better education in family
assessment
• Relevant information gathered by the nurse. Facilitates teamwork
• Better therapeutic relationship patient-nurse-family. More
confidence
• Quality of care. The nurse knows the family and the patient and can
help them better. Enhance the therapeutic relationship with the
patient and the family.
• More confidence of the patient and the family with the nurse
• It may decrease relapses
• Will change the traditional individualistic role of the nurse,
involving patients and their families in care

33. GENOGRAMS
The Use of Genograms in UDITEF
Beunza, M; Tricas, S
Cano, A; Martin, R

34. GENOGRAMS
What is a GENOGRAM?
Graphical and descriptive representation of
the family throughout time and of the relationships
within its members.

35. GENOGRAMS
How we do apply GENOGRAMS?
Each of the spouses (individually)
About 45-60 minutes per interview

36. GENOGRAMS
Information provided by GENOGRAMS
1. Family structure
2. Dysfunctional and Recurring
Transgenerational (DART) Patterns

37. GENOGRAMS
1. Family Structure
- Horizontal: nuclear family and extended family
- Vertical: usually includes three generations
- Type of Relationships among members: close, distant,
conflictual, friendly
- Events and relevant problems (e.g.: deaths, suicides,
psychiatric disorders, abortions, stressful life events,
adoptions)
- Patterns inherited from other generations

38. GENOGRAMS
2. Dysfunctional and Recurring Transgenerational
(DART) Patterns
- Transgenerational recurrence of dysfunctional patterns of:
Disease
Behaviour
Relation
Structure
- Psychosocial characteristics
- Multigenerational patterns of perception of success or failure

39. GENOGRAMS
DYSFUNCTIONAL AND RECURRING PATTERNS
Alcoholism
Incest (Mc Goldrick et al, 1999)
Physical symptoms
Violence
Suicide
- Mental disorder, suicide
- Divorce/ Separation
- Substance abuse, Alcoholism
- Impulse control disorder
- Violence, Physical and Sexual abuse

40. GENOGRAMS
PSYCHIATRIC DISEASE 230
Significant differences between
families: sociocultural status,
values, expression of emotion.
Husband’s family: appearances
matter, authoritarian and rigid.
Wife’s family: father’s death,
excessive interdependence
between her mother and brother.
Affective disorder. Mother
perceives herself as fragile.

41. GENOGRAMS
IMPULSE-CONTROL DISORDER 238
Temporary separation
Husband: explosive and
verbal aggressiveness,
stressed at work, dependent
on his father, anxious, little
time at home, recurrent
pattern from his father.
Wife: her father was
alcoholic,
authoritarian and verbal
aggressiveness. She bears
all the responsibilities at
home.

42. GENOGRAMS
DIVORCE/SEPARATION 16
Wife attends our unit alone.
Divorce, fighting for the
children’s custody.
Physical, psychological and
sexual abuse.
Husband’s personality and
similar disorders identified in
her father.
Wife: experienced her parents ‘
separation at 12 years old. Her
mother suffered from
depression, but still she
assumed the responsibility of
the family and children.
She wants to avoid her children
experiencing a similar
situation.

43. GENOGRAMS
ALCOHOLISM 78

44. GENOGRAMS
OUR EXPERIENCE
• Practical, “easy” way of obtaining information on family
dynamics
• Non aggressive way of obtaining intimate and personal
information
• Completes information obtained in the interviews and
questionnaires
• Easy to apply, once the team is familiar with the procedure

45. GENOGRAMS
OUR EXPERIENCE
• Information gathered relevant both for the assessment of the
family as well as subsequent family treatment.
• Important: good communication and co-ordination between
team members.
• Process that can be improved, particularly in order to carry out
further research.

46. Thanks for your attention