Chapter 20Family HealthCopyright © 2015, 2011, 2007, 2001, 1.docx

Chapter 20
Family Health
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders,
an imprint of Elsevier Inc.
Working with Families
Working with families has never been more complex or
rewarding than now.
Nurses understand the actual and potential impact that families
have in changing the health status of individual family
members, communities, and society as a whole.
Families have challenging health care needs that are not usually
addressed by the health care system.
2
.
How Do You Define a Family?
3

Definitions of a Family
Historical definitions:
The environment affecting individual clients
Small to large groups of interacting people
A single unit of care with definable boundaries
A unit of care within a specific environment of a community or
society
Current theorists:
Two or more individuals who depend on one another for
emotional, physical, and economic support. Members of family
are self-defined.
– Hanson & Kaakimen (2005)
The family is who they say they are.
– Wright & Leahey (2000)
4
Inclusive Definitions of Family
“Family” means any person(s) playing a significant role in an

individual’s life. This may include person(s) not legally related
to the individual. Members of “family” include spouses,
domestic partners, and both different-sex and same-sex
significant others. “Family” includes a minor patient’s parents,
regardless of gender of either parent … without limitation as
encompassing legal parents, foster parents, same-sex parent,
step-parents, those serving in loco parentis, and others
operating in caretaker roles.
– Human Rights Campaign ( 2009)
5
The Changing Family
Purposes of the family
To meet the needs of society
To meet the needs of individual family members
Examples of different family types
Traditional, nuclear family
Multigenerational family household
Cohabitating families
Single-parent families
Grandparent-headed families
Gay or lesbian families
Unmarried teen mothers
6

The “Sandwich” Generation
7
Figure 20-1 From Pew Research Center: Social and
Demographic Trends: The Sandwich Generation.
http://www.pewsocialtrends.org/2013/01/30/the-sandwich-
generation/. Accessed March 15, 2013.
Why Is It Important for the CHN to Work with Families?
The family is a critical resource.
Any dysfunction in a family unit will affect the members and
the unit as a whole.
Case finding can identify a health problem that leads to risks
for the entire family.
Nursing care can be improved by providing holistic care to the
family and its members.
– Friedman, Bowden, & Jones (2003)
8
Approaches to Meeting the Health Needs of Families
9
Moving from the Family to the Community
Moving from the Individual to the Family

Moving from the Individual to the Family
Family interviewing
Manners
Therapeutic conversations
Genogram and Ecomap
Therapeutic questions
Commending family or individual strengths
Issues in family interviewing
Many locations, family informant, family health portrait,
involvement of children
Intervention in cases of chronic illness
10
Moving from the Family to the Community
The health of communities is measured by the well-being of its
people and families.
Families are components of communities.
Cross-comparison of communities must include health needs as
well as resources.
Cross-compare the needs of the families within the community
and set priorities.
Delegation of scarce resources is essential.
A double standard in public health is tolerated.
11

Family Theory Approach
Any “dysfunction” that affects one member will probably affect
others and the family as a whole.
The family’s wellness is highly dependent on the role of the
family in every aspect of health care.
The level of wellness of the whole family can be raised by
reducing lifestyle and environmental risks by emphasizing
health promotion, self-care, health education, and family
counseling.
12
Family Theory Approach (Cont.)
Commonalities in risk factors and diseases shared by family
members can lead to case finding within family.
Individual is assessed within larger context of family.
Family is vital support system to individual member.
– Friedman (1994)
13
Systems Theory Approach
The family as a unit interacts with larger units outside the
family (suprasystem) and with smaller units inside the family
(subsystem).

– Friedman (1998)
14
Healthy Families
Members interact with each other; listen and communicate
repeatedly in many contexts.
Healthy families establish priorities. Members understand that
family needs are the priority.
Healthy families affirm, support, and respect each other.
Members engage in flexible role relationships, share power,
respond to change, support the growth/autonomy of others, and
engage in decision making that affects them.
– DeFrain (1999) and Montalvo (2004)
15
Healthy Families (Cont.)
The family teaches family and societal values and beliefs and
shares a religious core.
Healthy families foster responsibility and value service to
others.
Healthy families have a sense of play and humor and share
leisure time.
Healthy families have the ability to cope with stress and crisis
and grow from problems. They know when to seek help from
professionals.

– DeFrain (1999) and Montalvo (2004)
16
Structural-Functional Conceptual Framework
Internal structure
Family composition, gender, rank order, functional subsystem,
and boundaries
External structure
Extended family and larger systems (work, health, welfare)
Context: ethnicity, race, social class, religion, environment
Instrumental functioning (routine ADLs)
Expressive functioning
Emotional, verbal, nonverbal, circular communication; problem
solving; roles; influence; beliefs; alliances and coalitions
17
Developmental Theory
Family life cycle (Duvall & Miller, 1985)
Leaving home
Beginning family through marriage or commitment as a couple
relationship
Parenting the first child
Living with adolescent
Launching family (youngest child leaves home)
Middle-age family (remaining marital dyad to retirement)
Aging family (from retirement to death of both spouses)

18
Family Health Assessment Tools
Genogram
A tool that helps the nurse outline the family's structure
Family health tree
Family’s medical and health histories
Ecomap
Depicts a family’s linkages to their suprasystems
19
Family Health Assessment Tools
Family Health Assessment
Addresses family characteristics, including structure and
process and family environment
Information obtained through interviews with one or more
family members, subsystems within the family, or group
interviews of more than two members of the family
Additional information obtained through observation of family
and their environment

20
Genogram
21
Figure 20-2 Redrawn from Genopro Software: Symbols used in
genograms, 2009: www.genopro.com.
Ecomap
22
Figure 20-4 Redrawn from Hartman A: Diagrammatic
assessment of family relationships, Soc Casework 59:496, 1978.
Social and Structural Constraints
Identify what prevents families from receiving needed health
care or achieving a state of health
Usually based on social and economic causes
Literacy, education, employment
If disadvantaged, often unable to buy health care from private
sector
Hours of service, distance and transportation, availability of

interpreters, and criteria for receiving services (age, sex,
income barriers)
23
Family Health Interventions
Institutional context of family therapists
Ecological framework: A blend of systems and developmental
theory that focus on the interaction and interdependence of
families within the context of their environment
Social Network Framework: Involves all connections and ties
within a group; social support
Transactional model: A system that focuses on process as
opposed to a linear approach
24
Applying the Nursing Process
Knowledge of self, previous life experiences, and values is
crucial in planning home visits
Gather referral information, review assessment forms, and
gather intervention tools (e.g., screening materials, supplies)
before going to the home
Flexibility is important in working with families
25

Chapter Twelve: Personal Loss: Bereavement and Grief
Terms Critical to Understanding Loss
Bereavement
Uncomplicated bereavement
Grief
Complicated grief/prolonged grief
Traumatic grief
Disenfranchised grief
Loss
Primary loss
Secondary loss
Ambiguous loss
Mourning
Dynamics of Bereavement
Cultural Dynamics
Culture
3 patterns of response:
Death accepting
Death defying

Death denying
Sociocultural Mores
Spirituality and Religion
Conceptual Approaches to Bereavement
Stage/Phase Models
Kubler-Ross’s Stages
Bowlby’s Attachment Theory
Schneider’s Growth Model
Counterpart to Traditional Models
Dual Process Model
Loss orientation
Restoration orientation
Adaptive Model
Int
Assessment Tools
Texas Revised Inventory of Grief (TRIG)
Current Grief
Past Disruption
Grief Experience Inventory (GEI)
Nine clinical scales
Hogan Grief Reaction Checklist (HGRC)
Can discriminate variability in the grieving process as a
function of cause of death and time elapsed since death

Inventory of Complicated Grief (ICG)
Targets symptoms of grief that are distinct from bereavement-
related depression and anxiety, and predicts long-term
functional impairments
Types of Loss
Death of a Spouse
One of the most emotionally stressful and disruptive events in
life
More widows than widowers
Loss Due to Caregiving
Death of a Child
Perhaps the ultimate loss for a person to endure regardless of
the age of the child
Types of Loss Cont.
Bereavement in Childhood
Toddlers
Primary school age
Middle school age
Intervention and treatment
Bereavement in Adolescence
Value of connectedness
Intervention and treatment

Bereavement in the Elderly
Present more somatic problems than psychological problems
No indication that the intensity of grief varies significantly with
age
Grief among older people may be more prolonged than among
younger people
Tend to be lonelier and to have far longer periods of loneliness
than younger people
Types of Loss Cont.
HIV/AIDS
Job Loss
Separation and Divorce
Death of a Pet
Complicated Grief
Traumatic grief
Being There for Grievers
Empathic Presence
Gentle Conversation
Providing Available Space
Eliciting Trust

Fitting Technique to Style of Grief
The Dual Process Model
The griever sometimes confronts and sometimes avoids the
stressors of both orientations
Adaptive Model
Affective
Behavioral
Cognitive
Spiritual
Fitting Technique to Style of Grief Cont.
Cognitive-Behavioral Approaches
Most commonly used therapies for those who suffer from
complicated grief
Narrative Therapy
Reconstructs the relationship with the deceased rather than
abandoning it
Attachment Theory and Therapy
One of the oldest theories that deals with grief and loss
“Coherent narrative”
Case Examples for Dealing with Loss

Sudden Death of a Spouse
Stuart
Traumatic Death of a Child
Helen and Brad
Bereavement in Childhood
Makeena
Separation and Divorce
Nancy
Case Examples for Dealing with Loss Cont.
Death of a Pet
The Thompsons
Bereavement in Elderly People
Lenore
Bereavement in an HIV-Infected Client
Clint
Complicated Grief: Death of a Mother
Ann Marie
The Crisis Worker's Own Grief
Emotional investment in the client
Bereavement overload
Countertransference
Emotional replenishment

Facing one’s own mortality
Sense of power
Tendency to rescue
Chapter 9
Case Management
Case Management …
“… is a collaborative process of assessment, planning,
facilitation, care coordination, evaluation and advocacy for
options and services to meet an individual’s and family’s
comprehensive health needs through communication and
available resources to promote quality cost-effective outcomes.”
– The Case Management Society of America (2009)
2
Nursing Case Management …
… is “a dynamic and systematic collaborative approach to

provide and coordinate health care services to a defined
population. The framework includes five components:
assessment, planning, implementation, evaluation and
interaction.”
– American Nurses Credentialing Center, ANA
3
Care Management
Overall goal: Improve the coordination of services provided to
clients who are enrolled in a care management program.
A collaborative process
An emerging concept that is…
evidence based
patient centered
clinical care focused
4
Care Coordination
Target chronically ill persons at risk for adverse outcomes and
expensive care
Identify full range of problems that increase patients’ risk of
adverse health events
Educate in self-care, optimization of treatment, and integration
of care

Monitor patients for progress and early signs of problems
Hope to raise quality of care, improve health outcomes, and
reduce need for costly hospitalizations and medical care
5
Patient-Centered Medical Homes
Seven characteristics:
Patient’s relationship with primary care physician
Physician-led, team-based care
“Whole persons” require comprehensive care at various stages
of life
Integration and coordination of care
Quality and safety
Improved access to care
Payment system that accurately reflects the efforts and care
provided by the team
6
Purposes of Case Management
Client centered
Help the client through a complex, fragmented, and often
confusing health care delivery system and achieve specific
client-centered goals.
System-centered
Recognizes that resources are finite
Promote cost-effective, high-quality care
7

Possible Case Management Functions
Identifying the target population
Determining screening and eligibility
Arranging services
Monitoring and follow-up
Assessing
Planning care
Reassessing
Helping clients through a complex, fragmented health care
system
Care coordination and continuity
8
Case Managers
Must have appropriate educational background
A minimum skill level is needed to ensure success in the role
Certification as a case manager is available
Case Management Association of America (CMSA)
American Nurses Credentialing Center (ANCC)
9

Role Functions of Case Managers (CMSA, 2002)
Essential activities of case management
Assessment
Planning
Facilitation
Advocacy
Collaboration
10
Case Management in Community Health
Community case management models
Public health clinic settings
Occupational health settings
High-risk clinic settings
Clients with chronic diseases
Home health and hospice
Case management research
International settings
11

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