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 Filipinos. Additionally, families have
challenging health care needs that are not usually addressed by the health care system. Instead, the health
care system most frequently addresses the individual. This holds true for nursing interventions within the
health care system. This chapter endeavors to assist the nurse in understanding and addressing complex
issues that impact family health and suggests methods to improve family health.

Family nursing is not a new concept and has been taught in schools of nursing since Nightingale's "district
nursing" concept and Lillian Wald's principles on how to nurse families in the home. The National League for
Nursing (NLN) has emphasized the importance of family nursing in standard curriculum guides for schools of
nursing since 1917. Early NLN publications directed nurses in "household science" and later required that 10-
15 hours of study should be directed towards understanding the "modern family," in which the nurse must
consider the family as a unit. Modem nurse theorists such as Neuman, King, Orem, Roy, and others
extensively discuss the family and its importance to individuals and society.

Many disciplines are interested in the study of families; interdisciplinary perspectives and strategies are
necessary to understand the influence of the family on health and the influence of the broader social system
on the family. Traditionally, nursing, and even community health nursing, has relied heavily, if not solely, on
theoretical frameworks for intervention with families from the disciplines of psychology or social psychology,
which target individuals. This chapter addresses how community health nurses work with families within
communities to bring about healthy conditions for families at the family, social, and policy levels.

THE FAMILY

Many definitions of the family exist, from the definition by the National Statistical Coordination Board—"the
family is a group of persons usually living together and composed of the head and other persons related to the
head by blood, marriage or adoption. It includes both the nuclear and extended family"—to more inclusive
definitions. Sociologists tend to define family in terms of a "social unit interacting with the larger society".
Other professionals have classically defined family in terms of kinship, marriage, and choice: "a family is
characterized by people together because of birth, marriage, adoption, or choice". Friedman incorporated the
idea of many nontraditional definitions: "a family is two or more persons who are joined together by bonds of
sharing and emotional closeness and who identify themselves as being part of the family".

The community health nurse interacts with the community made up of different types of families. When faced
with great diversity in the community, the community health nurse must formulate a personal definition of
family and be aware of the changing definition of family held by other disciplines, professionals, and family
groups.
Single parenting is faced with greater risk associated with lesser social, emotional, and financial resources,
which affect the general well-being of children and families. In the Philippines, there were more than 2 million
overseas Filipino workers in 2010, with 1.07 million males and 0.98 million females (NSCB). This situation has
given rise to effectually single-parent families.
  The gay  or lesbian  family is made up of a cohabiting couple of the same sex in a sexual relationship.
The homosexual family may or may not have children. Because the Family Code of the Philippines
expressly states that marriage is a special contract of permanent union between a man and a woman
entered into in accordance with the law for the establishment of conjugal and family life, same-sex
marriage is not legally acceptable.

Functions of the family

The family fulfills two important purposes. The first is to meet the needs of society, and the second is to meet
the needs of individual family members. The family is the "buffer" between individuals and society.

"The basic unit (family) so strongly influences the development of an individual that it may determine the
success or failure of that person's life".
The family as a client

Regardless of the definition of family accepted or the form that it may take, what is evident is the importance
of the family unit to society. The family meets individual needs through provision of basic needs (food, shelter,
clothing, affection, and education). The family supports spouses or partners by meeting affective, sexual, and
socioeconomic needs.

Community health nursing has long viewed the family as an important unit of health care, with awareness that
the individual can be best understood within the social context of the family. Observing and inquiring about
family interaction enables the nurse in the community to assess the influence of family members on each
other.

Nursing assessment and intervention must not stop with the immediate social context of the family, but it
must also consider the broader social context of the community and society. Friedman suggest reasons it is
important for nurses to work with families:

 "The family is a critical resource." The importance of the family in providing care to its members has
already been established. In this caregiver role, the family can also improve individual members' health
through health promotion and wellness activities.

 "In a family unit, any dysfunction (illness, injury, separation) that affects one or more family members
will affect the members and unit as a whole." Also referred to as the "ripple effect," changes in one
member cause changes in the entire family. The nurse must assess each individual and the family unit.

 "Case finding" is another reason to work with families. While assessing an individual and family, the
nurse may identify a health problem that necessitates identifying risks for the entire family.

 "Improving nursing care." The nurse can provide better and more holistic care by understanding the
family and its members.
Freeman and Heinrich likewise point out that the family provides feedback and influences health services.
When the family informs the nurse that they do not utilize the services of a nearby health center, the nurse
must find out the reason. The family's reasons for nonutilization of services may provide the health center
personnel with clues as to how they can make services in keeping with the needs and expectations of the
catchment population. Beyond "improving nursing care," the family can help improve public health programs.

The family is not only a health resource in terms of providing care to its members and promoting health and
wellness activities. Decisions for personal care and health action are usually made in a family setting.
 
The family as a system

The general systems theory has been applied to the study of families. It is a way to explain how the family as
a unit interacts with larger units outside the family and with smaller units inside the family. Each member of
the system is, to a certain extent, independent of other members, yet, the members are in so many ways
dependent on each other. Thus, the family is certainly more than just the sum of its members. The family may
be affected by any disrupting force acting on a system outside the family (i.e., suprasystem). The family is
embedded in social systems that have an influence on health (e.g. education, employment, and housing), just
as it is affected by systems within the family (i.e., subsystems). Parke stated that there are three subsystems
of the family that are most important: parent-child subsystem, marital subsystem, and sibling-sibling
subsystem. Allmond compared the family as a system to a piece of a mobile crib toy suspended from the air
that is in constant movement with the other pieces of the mobile.

At any time, the family, like any piece of the mobile, may be caught by a gust of air and become unbalanced,
moving "chaotically" for a time; however, eventually, the stabilizing force of the other parts of the mobile will
reestablish balance. An understanding of systems theory is still important for the nurse working with families
today. Dunst and Trivette reviewed 20 years of systems theory and the importance to early childhood
interventions, adding that systems theory provides direction in understanding how health care providers can
expand family capacity by changing parenting, and therefore changing child behaviors.
 
Developmental stages of the family

Nurses are familiar with developmental states of individuals from prenatal through adult. Duvall, a noted
sociologist, is the forerunner of a focus on family development. In her classic work, she identified stages that
normal families traverse from marriage to death.

To assess the family, the community health nurse must comprehend these phases and the struggles that
families experience while going through them. The developmental categories are based on the stages of the
family life cycle of middle-class North American families and the tasks necessary for the family's resolution of
each stage.
Family health tasks

In addition to its developmental tasks, the family serves as an essential resource for its members by carrying
out health tasks. An important responsibility of the community health nurse is to develop the family's capability
in performing its health tasks.

The first family health task is providing its members with means for health promotion and disease prevention.
Breastfeeding an infant, a healthy diet for older family members, bringing a young child to the health center
for immunizations, and teaching a child about proper hand washing are a few examples of family health tasks.

The following are other health tasks of the family, according to Freeman and Heinrich:

 Recognizing interruptions of health or development . This is a requisite step the family has to take to be
able to deal purposefully with an unacceptable health condition.

 Seeking health care. When the health needs of the family are beyond its capability in terms of
knowledge, skill, or available time, the family consults with health workers.

 Managing health and nonhealth crises. Crisis, whether health-related or not, is a fact of life dial the
family has to learn to deal with. Crises may include maturational crises, which can be anticipated by
the family, or incidental crises, which may not be easily foreseeable. The family's ability to cope with
crises and develop from its experience is an indicator of a healthy family.

 Providing nursing care to sick, disabled, or dependent members of the family . In addition to care of the
very young and the very old, many minor illnesses, chronic conditions, and disabilities require home
management by responsible family members.

 Maintaining a home environment conducive to good health and personal development . In addition to a
safe and healthful physical environment, the home should also have an atmosphere of security and
comfort to allow for psychosocial development.

 Maintaining a reciprocal relationship with the community and its health institutions . Just as the family
utilizes community resources, the family also takes interest in what is happening in the community and,
depending on the availability of family members and the family's perception of its need and
appropriateness, gets involved in community events.

Characteristics of a healthy family

Otto and Pratt characterized healthy families as "energized families" and provided descriptions of healthy
families to guide in assessing strengths and coping. DeFrain and Montalvo helped to identify healthy families.
FAMILY NURSING AND THE NURSING PROCESS

Family nursing is the practice of nursing directed towards maximizing the health and well-being of all
individuals within a family system. Family nursing care may be focused on the individual family member, within
the context of the family, or the family unit. Regardless of the identified client, the nurse establishes a
relationship with each family member within the unit and understands the influence of the unit on the
individual and society.

Competencies in family nursing are useful to community health nurses: public health nurses, school nurses,
and occupational health nurses. The school nurse has a unique opportunity to compare the child in the school
system with the child in the family system. Astute assessment of children's needs within the context of their
families in interviews at school or in the home can lead to innovative interventions such as support groups for
children with chronic illness, learning or behavioral problems, and absenteeism.

The nurse in the occupational health setting also can use a family approach to improve the health of the
worker and contribute to overall productivity. For example, alcohol and chemical abuse account for much
absenteeism in the workplace. Effective intervention with these families has been demonstrated. Assessment
of occupational hazards may involve other family members, as toxic agents can also transfer to family
members from the workplace via clothes and equipment.

The nurse must remember, however, that as much as the nurse desires to help the family in health and
health-related matters, a primary consideration is the family's willingness to utilize nursing services. The family
members' expression of their desire not to utilize the services offered or their preference for another health
worker or agency should be respected. Nevertheless, exhaustive efforts should be taken in response to a
family's preference for folk healers, such as albularyo and magtatawas.

As in other fields of nursing practice, family nursing uses the nursing process.
 
Family health assessment

Assessment of the family helps practitioners identify the health status of individual members of the family and
aspects of family composition, function, and process. The nurse collects as much information about a family as
is feasible and practical. The process of family assessment is unceasing and requires objectivity and
professional judgment to attach practical meaning to the information being acquired. Thus, over time, tools
are developed to allow a more systematic and organized classification and analysis of data.

Often included in Family Health Assessment Guidelines is information about the environment, or community
context, and information about the family. The Family Health Assessment Form  is a guide in data collection for
this purpose. Since not all dimensions on the Family Health Assessment will be appropriate for every family,
the nurse should modify the content of the assessment guideline and adapt it as necessary to fit the individual
family. The guidelines should serve as a guide only, as a means to record pertinent information about the
family that will assist the nurse in working with the family. Several contacts with the family may be required to
complete the Family Health Assessment.

The nurse can obtain information for the Family Health Assessment through interviews with one or more
family members individually, interviews of subsystems within the family (e.g. dyads of mother-child, parent-
parent, and sibling-sibling), or group interviews with more than two members of the family. The nurse can
also obtain information through observation of individual family members, dyads, and the entire family and
observation of the environment in which the family lives, including housing, the neighborhood, and the larger
community. Physical examination and other health assessment techniques, such as anthropometry (e.g.
measurement of weight and height), may be used.

Secondary data can be derived from a review of records like charts, health center records, and/or other
agency records or from communication with other health workers or agencies who have worked with the
family.
In the Family Assessment Form, family is differentiated from household, which is a term applied to a social
unit consisting of a person living alone or a group of persons who the family home is a member of the
household, but is not a family member.

Many other tools also exist for the community health nurse in assessing the family. Reviewed here are the
genogram, family health tree, and ecomap.

Genogram

The genogram is a tool that helps the nurse outline the family's structure. It is a way to diagram the family.
Generally, three generations of family members are included in a family tree, with symbols denoting
genealogy. Children are pictured from left to right, beginning with the oldest child. In cases where the spouse
had a previous marriage or marriages, he or she must be positioned closer to his/her first partner, then the
second partner (if any), and so on.
The community health nurse may use the genogram during an early family interview, starting with a blank
sheet of paper and drawing a circle or a square for the person initially interviewed. The nurse tells the family
that he or she will ask several background questions to gain a general picture of the family. The nurse may
draw circles around family members living in separate households.

For example, family order across generations can be illustrated and specific personal characteristics can be
noted in the drawing. Conditions or factors affecting members of the Marcial family are noted down by the
nurse, as these need to be considered in the plan for nursing interventions. At times, the usefulness of the
genogram is limited by how freely the family member relates significant information such as separations and
remarriages, or family health concerns. Other families may be sensitive to the sharing of such information,
particularly when it is shown to recur with each generation. For example, a family history of alcohol or
substance abuse or depression may be a sensitive issue, for other families, the development of the genogram
is an excellent opening to the discussion of family history or hereditary health problems. It can also highlight
the need for health education and promotion.
Family health tree

The family health tree is another tool that is helpful to the community health nurse. Based on the genogram,
the family health tree provides a mechanism for recording the family's medical and health histories. The nurse
should note the following points on the family health tree:

 Causes of death of deceased family members

 Genetically linked diseases, including heart disease, cancer, diabetes, hypertension, allergies, asthma,
and mental retardation

 Environmental and occupational diseases

 Psychosocial problems, such as mental illness and obesity

 Infectious diseases

 Familial risk factors from health problems

 Risk factors associated with the family's methods of illness prevention, such as having periodic physical
examinations, Pap smears, and immunizations

 Lifestyle-related risk factors (i.e., by asking what family members do to "handle stress" and "keep in
shape")

The family health tree can be used in planning positive familial influences on risk factors such as diet, exercise,
coping with stress, or pressure to have a physical examination. Questions to ask family members about
common diseases and questions that suggest health promotion activities are also included. When completed,
the "family tree" can be printed. This tool could be incorporated into the family assessment and utilized by the
nurse to plan family interventions to improve health. Although initiated by the US. Surgeon General, the tool
may be helpful to Filipinos as well.

Ecomap

The ecomap  is another classic tool that is used to depict a family's linkages to its suprasystems. As originally
stated by Hartman:

"The eco-map portrays an overview of the family in their situation; it depicts the important nurturant or
conflict-laden connections between the family and the world. It demonstrates the flow of resources, or the
lacks and deprivations. This mapping procedure highlights the nature of the interfaces and points to conflicts
to be mediated, bridges to be built, and resources to be sought and mobilized."

As with the genogram, the nurse can fill out the ecomap during an early family interview, noting people,
institutions, and agencies significant to the family. The nurse can use symbols used in attachment diagrams to
denote the nature of the ties that exist. The ecomap shows contacts that occur between the family and the
suprasystems. It suggests that the Marcial family does not actively participate in the community organization
and does not utilize services of the nearby barangay health station. The community health nurse may use the
ecomap to discuss with the Marcial family the types of resources in the community and the types of
relationships they want to establish with them.
The nurse can use these tools for family assessment with families in every health care setting. These tools
help increase the nurse's awareness of the family within the community and help guide the nurse and the
family in the assessment and planning phases of care.
 
Family interviewing

In addition to using the interview as an assessment tool, Wright and Leahey suggest family interviewing as a
medium for providing family intervention. In the family interview, the community health nurse uses general
systems and communication concepts to conceptualize the health needs of families and to assess families'
responses to events such as birth, retirement, or chronic illness. Intervention is straightforward, as in helping a
pregnant woman prepare for childbirth, or making a referral to another health professional, if the level of
intervention is beyond the preparation of the nurse. Wright and Leahey identify the following critical
components of the family interview: manners, therapeutic questions and conversation, family genogram (and
ecomap when indicated), and commendations. With experience, they believe that the family interview can be
accomplished in 15 minutes.

Manners

Manners are common social behaviors that set the lone for the interview and begin the development of a
therapeutic relationship. Wright and Leahey believe that erosion of these social skills prevents the family nurse
from collecting essential data. Many nurses argue that too much formality establishes artificial barriers to
communication; however, studies identify that the essentials of a therapeutic relationship begin with manners.
The nurse introduces himself or herself to the client by name and title, always addresses the client (and family
members) by name and title (i.e., Mr., Mrs., or Ms., unless otherwise directed by the client or using Filipino
titles such as Mang or Ate), keeps appointments, explains the reason for the interview or visit, and brings a
positive attitude. Other behaviors (manners) that invite rapport include being honest with the client and
checking attitude (the nurse's) before each client encounter.
 
Therapeutic questions

Therapeutic questions are key questions that the nurse uses to facilitate the interview. The questions are
specific for the context or family situation but have the following basic themes: family expectations of the
interview or home visit; challenges, concerns, and problems encountered by the family at the time of the
interview; and sharing information (e.g. who will relate the family history or information).
 
Therapeutic conversations

The third key element in the interview is the therapeutic conversation. This type of conversation is focused
and planned and engages the family. The nurse must listen and remember that even one sentence has the
potential to heal or help a family member. The nurse encourages questions, engages the family in the
interview and assessment process, and commends the family when strengths are identified. Every encounter,
whether brief or extended, has "healing potential." Therapeutic conversation may initiate further discussion
that brings the family together on issues.

Genogram and ecomap

The genogram and ecomap constitute the fourth element. These tools provide essential information on family
structure and are an efficient way to gather information, such as family composition, background, and basic
health status, in a way that engages the family in the interview process.
 
Commending family or individual strengths

The fifth element of the family interview is commending the family or individual strengths. Wright and Leahy
suggest identifying at least two strength areas and, during each family interview, sharing them with the family
or individual. Sharing strengths reinforces immediate and long-term positive relationships between the nurse
and family. Interviews that identify and are built upon family strengths tend to progress toward more open
and trusting relationships and often allow the family to reframe problems, thereby increasing problem solving
and healing.

Family data analysis

As can be seen in the foregoing text, a thorough family assessment yields a large volume of data. The nurse
organizes data into clusters (data synthesis) and sets aside data that may be considered irrelevant at this
point. Seemingly inaccurate or conflicting data are validated with the family respondent(s).

Data analysis is done by comparing findings with accepted standards for individual family members and for the
family unit. Current information should be compared with previous information if available. In addition, the
nurse correlates findings in the different data categories and checks for significant gaps in the information or
the need for more details related to a finding.

The following is a system of organizing family data:

 Family structure and characteristics are reflected in data on household membership and demographic
characteristics, family members living outside the household, family mobility, and family dynamics
(emotional bonding, authority and power structure, autonomy of members, division of labor, and
patterns of communication, decision making, and problem and conflict resolution). Data on family
 structure can be visualized clearly through graphic tools such as genogram, ecomap, and/or family
health tree.

 Socioeconomic characteristics include data on social integration (ethnic origin, languages and/or

dialects spoken, and social networks), educational experiences and literacy, work history, financial
resources, leisure time interests, and cultural influences, including spirituality or religious affiliation.

 Family environment refers to the physical environment inside the family's home/residence and its
neighborhood.

 Family health and health behavior  take into account the family's activities of daily living, self-care, risk
behaviors, health history, current health status, and health care resources (home remedies and health
services).

Family nursing diagnosis

Nursing diagnoses may be formulated at several levels: as individual family members, as a family unit, or as
the family in relation to its environment/community. Specific diagnoses as proposed by NANDA - International
serve as a common framework of expressing human responses to actual and potential health problems.

An alternative tool for nursing diagnosis is the Family Coping Index. This tool is based on the premise that
nursing action may help a family in providing for a health need or resolving a health problem by promoting the
family's coping capacity. The Family Coping Index provides a system of identifying areas that may require
nursing intervention and areas of family strengths that may be used to help the family deal with health needs
and problems. Rather than identifying problems, the index focuses on identifying coping patterns of the family
in nine areas of assessment. The family is treated as a unit. Thus, if a family member is unable to cope in a
particular category, but other family members are able to compensate, the family is still rated as adequately
coping. It is suggested that the family be rated numerically very much as in a 5-point Likert scale, then
justifying the score given by the nurse by writing down observations that support the rating given in the area.

The following are the nine areas of assessment of the Family Coping Index:

1. Physical independence refers to the family members' mobility and ability to perform activities of daily
living, such as feeding themselves and performing activities necessary for personal hygiene.

2. Therapeutic competence  is the family's ability to comply with prescribed or recommended procedures
and treatments to be done at home, which include medications, dietary recommendations, exercises,
application of wound dressings, and use of prosthetic devices and other adaptive appliances such as
wheelchairs and walkers,

3. Knowledge of health condition means understanding of the health condition or essentials of care

according to the developmental stages of family members. Examples are the degree of knowledge of
responsible family members in terms of communicability of a disease and its modes of transmission or
that a disease is genetically transmitted, as in the case of diabetes mellitus.

4. Application of principles of personal and general hygiene  includes practice of general health promotion
and recommended preventive measures.

5. Health care attitudes refer to the family's perception of health care in general. This is observed in the
family's degree of responsiveness to promotive, preventive, and curative efforts of health workers.
 6. Emotional competence is concerned with the degree of emotional maturity of family members
according to their developmental stage. This may be observed in behaviors such as how the family
members deal with daily challenges, their ability to sacrifice and think of others, and acceptance of
responsibility,

7. Family living patterns  refer to interpersonal relationships among family members, management of
family finances, and the type of discipline in the home.

8. Physical environment  includes home, school, work, and community environment that may influence the
health of family members.

9. Use of community facilities is the ability of the family to seek and utilize, as needed, both government-
run and private health, education, and other community services.

Formulating the plan of care

Planning involves priority setting, establishing goals and objectives, and determining appropriate interventions
to achieve goals and objectives. The nurse has to remember that the plan is for the family's benefit and must
never lose sight of the fact that the family has the right to self-determination. In the end, family decisions
regarding health care have to be respected. As suggested by Stanhope and Lancaster (2010), the nurse's role
at this stage consists of offering guidance, providing information, and assisting the family in the planning
process.

Priority setting

Priority setting is determining the sequence in dealing with identified family needs and problems. Priority
setting is necessary because the nurse cannot possibly deal with all identified family needs and concerns all at
once. To guide the nurse in priority setting, the following factors need to be considered:

 Family safety. A life-threatening situation is given top priority. Likewise, the occurrence of a
communicable disease requires immediate attention to promote healing and, more importantly, to
prevent the spread of the communicable disease to the susceptible members of the household and the
community.

 Family perception. Next to life-threatening emergencies, priority is given to the need that the family
recognizes as most urgent and/or important. The nurse may strive towards patient and family
education in instances where the family fails to recognize issues that may affect family safety, as in
communicable cases.

 Practicality. Together with the family, the nurse looks into existing resources and constraints. Are the
resources required to address a particular need available to the nurse and the family? Does the nurse
have the necessary competence to deal with the situation? If the nurse does not have the necessary
competence, how feasible is referral to another health worker or agency? What are the constraints that
the family and the nurse have to deal with?

 Projected effects. The immediate resolution of a family concern gives the family a sense of
accomplishment and confidence in themselves and the nurse. Providing a clear-cut intervention during
a family-nurse contact raises the family's level of trust in the nurse. Also, the nurse thinks of the
prospect of preventing serious problems in the future by resolving an existing family concern.

Establishing goals and objectives

A goal is a desired observable family response to planned interventions in response to a mutually identified
family need. The goal is the end that the nurse and the family aim to achieve. Setting realistic goals within the
limits of the resources of the family, the nurse, and the health agency is of utmost importance. Aside from
limitation of resources, another factor to be taken into consideration is the family's perception of its needs.
The likelihood of attainment of a goal is higher if the family "owns" the goal and if it is achievable within the
existing family situation.

Objectives, on the other hand, define the desired step-by-step family responses as they work toward a goal.
Mutually agreed upon objectives provide the family and the nurse direction for alternatives and selection of
family and nursing actions. They are used to measure family achievement for monitoring and evaluation.
Workable, well-stated objectives should be:

 Specific; The objective clearly articulates who is expected to do what, i.e., the family or a target
family member will manifest a particular behavior.

 Measurable: Observable, measurable, and whenever possible, quantifiable indications of the family's
achievement as a result of their efforts toward a goal provide a concrete basis for monitoring and
evaluation.

 Attainable: The objective has to be realistic and in conformity with available resources, existing
constraints, and family traits, such as style and functioning.

 Relevant: The objective is appropriate for the family need or problem that is intended to be
minimized, alleviated, or resolved.

 Time-bound: Having a specified target time or date helps the family and the nurse in focusing their
attention and efforts toward the attainment of the objective.

Determining appropriate interventions

Depending on the identified family needs and the goals and objectives, interventions may range from the
simple or immediate, such as offering information about external health resources available to the family, to
the complicated or prolonged, such as providing care to a family with a member newly diagnosed with
pulmonary tuberculosis.

Freeman and Heinrich categorize nursing interventions into three types:

 Supplemental  interventions  are actions that the nurse performs on behalf of the family when it is
unable to do things for itself, such as providing direct nursing care to a sick or disabled family member.

 Facilitative interventions  refer to actions that remove barriers to appropriate health action, such as
assisting the family to avail of maternal and early child care services.

 Developmental  interventions aim to improve the capacity of the family to provide for its own health
needs, such as guiding the family to make responsible health decisions. This type of intervention is
directed toward family empowerment.

Interventions may be a mix of two or all three of these categories, with the nurse making sure that they are
appropriate to the family situation. For example, overuse of supplemental interventions may hold back
development of self-reliance.

Since the plan is aimed to benefit the family, the expected outcomes of interventions are observable changes
in the family. The plan should therefore be based on the principle of mutuality. This means that the family is
given the opportunity to decide for itself how they can best deal with a health situation, just as the nurse
takes into consideration his or her own resources— competence, material resources, time—as well as the
resources and policies of the health agency. The plan has to be mutually agreed upon by the nurse and the
family based on their limitations individually or as a group.

The principle of personalization requires that the nursing care plan fits the unique situation of a family: its
needs, style, strengths, and patterns of functioning. Families with similar concerns do not necessarily require
the same nursing actions, nor can the nurse expect the family to act in the same manner as another family
confronted with a similar situation. A related principle is consideration of family values and health care beliefs,
which are the basis for family health behavior.

Coordination  with the other members of the health team and other agencies involved in the care of the family
maximizes resources by preventing duplication of services. On the part of the family, harmonizing services also
prevents confusion and promotes performance of desirable behaviors such as availing of early child care
services.

Finally, a prerequisite to designing an effective family care plan is the nurse's capacity of defining self. Many
times, the demands of family health care will be greater than the resources available to the nurse and the
family. The nurse has to delineate the purpose, resources (competencies, time, and material resources), and
limitations. This process affords a realistic view of the situation, allowing the nurse to be more effective and
avoiding disappointments or frustrations. Also, having clearly defined values and beliefs allows the nurse to
work with the family in an ethical and considerate manner.
 
Implementing the plan of care

Implementation is the step when the family and/or the nurse execute the plan of action. The pattern of
implementation is determined by the mutually agreed upon goals and objectives and the selected courses of
action. When appropriate, it involves providing direct nursing care, helping family members do what is
necessary to meet health needs and problems, or referring the family to another health worker or agency. The
nurse should be conscious of possible barriers to implementing planned strategies, which may be family-
related or nurse-related. Family-related barriers include apathy and indecision. Seeming apathy may be a
manifestation of the family's feelings of hopelessness and powerlessness. Indecision may result in the family
allowing events to just happen. In these instances, the nurse has to exert effort to find out what is actually
happening to the family to be able to effectively deal with the situation.

Barriers may also arise from the nurse's behavior, such as imposing ideas, negative labeling, overlooking
family strengths, and neglecting cultural and gender implications of family interventions. The nurse who
imposes ideas on the family keeps the family from taking responsibility for decision making and appropriate
action. The nurse may label a family as stubborn (matigas ang ulo) if it is unable to comply with instructions,
or it may lead the nurse to label himself or herself as ineffective. Overlooking family strengths usually results
from the tendency of the nurse to focus on family problems and weaknesses. The nurse who fails to consider
cultural differences and gender issues in implementing interventions risks making the plan unacceptable to the
family.

Defining self, as described earlier in this text, promotes the nurse's awareness of own behaviors. Recognition
of having an idea or behavior that may affect effectiveness, allows the nurse to address the issue
appropriately.

Evaluation

To evaluate is to determine or fix the value. In family nursing, evaluation is determining the value of nursing
care that has been given to a family. The product of this step is used for further decision making: to
terminate, continue, or modify the intervention(s). Well-formulated goals and objectives in the nursing care
plan serve as the framework for evaluation.

Formative evaluation  is judgment made about effectiveness of nursing interventions as they are implemented.
This is ongoing and continuing while family nursing care is being implemented and family-nurse interactions
are taking place. Results of formative evaluation guide the nurse and the family in updating plans as
necessary. Summative  evaluation  is determining the end results of family nursing care and usually involves
measuring outcomes or the degree to which goals have been achieved.

Aspects of evaluation that are useful in family health care are summarized as follows:

 Effectiveness  is determination of whether goals and objectives were attained. It answers the question,
"Did we produce the expected results?" or "Did we attain our objectives? “

 Appropriateness  refers to the suitability of the goals/objectives and interventions to the identified
family health needs. An accurate assessment of family health needs is the basis for appropriate
goals/objectives and interventions. It answers the question, " Are our goals/objectives and interventions
correct, in relation to the family health needs we intend to address? "
 Adequacy  means the degree of sufficiency of goals/objectives and interventions in attaining the desired
change in the family, It answers the question, "Were our interventions enough to bring about the
desired change in the family?"
 Efficiency is the relationship of resources used to attain the desired outcomes. It answers the question,
"Are the outcomes of family nursing care worth the nurse's time, effort, and other resources? "

FAMILY-NURSE CONTACTS
 
The family-nurse relationship is developed through family-nurse contacts, which may take the form of a clinic
visit, group conference, telephone contact, written communication, or home visit. The nurse uses the type of
family-nurse contact that is most suitable to the purpose or situation at hand.

The clinic visit takes place in a private clinic, health center, barangay health station, or in an ambulatory clinic
during a community outreach activity. The major advantage of a clinic visit is the fact that a family member
takes the initiative of visiting the professional health worker, usually indicating the family's readiness to
participate in the health care process. It also allows the nurse to maximize resources (time, other health care
providers to whom the client can be referred as needed, and material resources, such as supplies and
equipment). Also, because the nurse has greater control over the environment, distractions are lessened.
There are conditions, however, when a clinic visit presents an obvious hardship for the family, such as when
the family is unable to transport the family member requiring nursing care. Precisely because the nurse is in
control of the situation, the family may feel less confident to discuss family health concerns.

A group conference, such as a conference of mothers in the neighborhood, provides an opportunity for initial
contact between the nurse and target families of the community. It may take place at a health facility or in the
community. This type of family-nurse contact is appropriate for developing cooperation, leadership, self-
reliance, and/or community awareness among group members. The opportunity to share experiences and
practical solutions to common health concerns is a strength of this type of family-nurse contact. However,
attendance in a group conference usually requires motivation and availability of target family members. The
nurse, therefore, may not be able to reach the families in greatest need of help through a group conference.

If the resources are available, the telephone (landline or mobile/cell) provides easy access between the
nurse/health worker and the family. The wide reach of mobile/ cell phone communication services in the
country provides the nurse and the family with opportunities to contact each other through calls or short
messaging service (text messaging). Encouraging the family to communicate with the clinic or health center
when they feel the need for it cultivates the family's confidence in the health agency. However, information
transmitted through the telephone is limited. Accurate assessment of family conditions usually requires face-
to-face contact.

Written communication is used to give specific information to families, such as instructions given to parents
through school children. Although there is a potential for reaching many families, being a one-way method and
requiring literacy and interest, the nurse cannot be certain that the information will reach the intended
recipient.
 
Home visit

A home visit is a professional, purposeful interaction that takes place in the family's residence aimed at
promoting, maintaining, or restoring the health of the family or its members. It is a family-nurse contact
where, instead of the family going to the nurse, the nurse goes to the family. The nurse makes a home visit
upon the family's request, as a result of case finding, in response to a referral, or to follow-up clients who
have utilized services of a health facility such as a health center, lying-in clinic, or hospital.

A home visit has the following advantages:

 It allows firsthand assessment of the home situation: family dynamics, environmental factors affecting
health, and resources within the home.

 The nurse is able to seek out previously unidentified needs.

 It gives the nurse an opportunity to adapt interventions according to family resources.

 It promotes family participation and focuses on the family as a unit.

 Teaching family members in the home is made easier by the familiar environment and the recognition
of the need to learn as they are laced by the actual home situation.

 The personalized nature of a home visit gives the family a sense of confidence in themselves and in the
agency.

The major disadvantage relates to efficiency: the cost in terms of time and effort. Also, because the nurse is
unable to control the environment, there are more distractions in the home. The nurse's safety may also be a
concern.

Phases of a home visit

The home visit has three phases: previsit, in-home, and postvisit phases.
 
Previsit phase
During the previsit phase, if possible, the nurse contacts the family, determines the family's willingness for a
home visit, and sets an appointment with them. A plan for the home visit is formulated during this phase.

The planning process for a home visit is essentially the same as the planning phase of the nursing process. For
purposes of clarity, the following are specific principles in planning for a home visit:

Being a professional contact with the family, the home visit should have a purpose. Although the nurse is a
guest in the family's home, the visit is not for social reasons and should be therapeutic. A home visit may have
one or more of the following purposes:

 To have a more accurate assessment of the family's living conditions and adapt interventions
accordingly.

 To educate the family about measures for health promotion, disease prevention, and control of health
problems.

 To prevent the spread of infection among family members and within the community.

 To provide supplemental interventions for the sick, disabled, or dependent family member and,
whenever possible, guide the family on how to give care in the future.

 To provide the family with greater access to health resources in the community by establishing a close
relationship with them, providing information, and making referrals as necessary,

 Use information about the family collected from all possible sources , such as records, other personnel
and/or agency, or previous contacts with the family. All available information is used to determine and
analyze the family situation.

 The home visit plan focuses on identified family needs, particularly needs recognized by the family as
requiring urgent attention. Based on information about the family, the nurse considers what is
expected of him or her, such as care of a postpartum and her newborn baby or care of a sick or
disabled family member.

 Continuing care for a client who needs it will be provided by the client and/or responsible family
members. Therefore, the client and the family should actively participate in planning for continuing
care.
 It is seldom that the nurse has up-to-date, accurate, and all necessary information about the client and
the family. The plan should be practical and adaptable,  considering the actual family situation and the
resources available to the nurse and the family. Flexibility is important in working with families because
the nurse will not know the family's priority needs until the home visit.

Before leaving the health facility, the nurse should check the contents of the nursing bag and other articles
she needs in order to carry out the home visit efficiently and safely. It is important that the nurse comply with
practices and policies for personnel safety, such as informing the other personnel of his or her itinerary. The
"buddy system" is suggested for nursing students and personnel new to the service. The buddy may be
another student, health professional, or a member of the community such as a barangay health worker. The
nurse should inform the family to be visited of this practice, if possible, before the visit.

In the absence of a buddy, however, it is important that the nurse makes a spot map of the house for visiting
and identify with other members of the health team of the time that one is expected to be back to the health
care facility. This will assist the colleagues in determining whereabouts of the nurse in case she is not back as
indicated.

In-home phase

This phase begins as the nurse seeks permission to enter and lasts until he or she leaves the family's home.
The in-home phase consists of initiation, implementation, and termination.

Initiation: It is customary to knock or ring the doorbell and, at the same time, in a reasonably loud but
nonthreatening voice say, "Tao po. Si Jenny po ito, nurse sa health center," or a similar greeting in the
vernacular or some other language common to the nurse and the family.

On entering the home, the nurse acknowledges the family member(s) with a greeting and introduces himself
or herself and the agency he or she represents. At this point, the nurse observes the environment for his or
her own safety and sits as the family directs him or her to sit. To establish rapport, the nurse initiates a short
social conversation. He or she then states the purpose of the visit and the source of information.

Implementation: Implementation involves the application of the nursing process— assessment, provision of
direct nursing care as needed, and evaluation.

Assessment consists of techniques such as interview, physical examination, and simple diagnostic
examinations that can be done at home, like capillary blood glucose determination. It includes observation of
family dynamics and the family's physical environment. The Family Assessment Form is used as a guide for
this purpose.

Physical care, health teachings, and counseling are provided to the family as needed or according to plan. If
the family needs further services that the nurse and his or her agency cannot provide, the nurse explores with
the family other community facilities that the family can be referred to.
Since the nurse performs assessment and physical care of clients, it is important that he or she observes
aseptic practices such as hand washing before and after touching family members and proper disposal of
soiled materials and body secretions. Coupled with explanations, this is an opportunity for the nurse to teach
the family by visual demonstration practical methods of preventing the spread of infection.

Some of the objectives of the home visit may be evaluated towards the end of the visit, while some objectives
require further family-nurse contacts. As much as possible, the nurse evaluates with the family what they have
accomplished during the visit.

Termination: This consists of summarizing with the family the events during the home visit and setting a
subsequent home visit or another form of family-nurse contact such as a clinic visit. If necessary, the nurse
may also use this time to record findings, such as vital signs of family members and body weight.
 Postvisit phase

The postvisit phase takes place when the nurse has returned to the health facility. This involves
documentation of the visit during which the nurse records events that transpired during the visit, including
personal observations and feelings of the nurse about the visit. This will help the other members of the health
team to understand the family, providing for a more effective intervention. If appropriate, a referral may be
made. If a subsequent visit has been set, planning for the next visit is done at this time.
 
The Nursing Bag
The nursing bag, frequently called the PHN bag, is a tool used by the nurse during home and community visits
to be able to provide care safely and efficiently. The contents of the bag depend upon agency policies and the
type of services expected of the nurse while he or she is in the community or in the client's home. Besides its
obvious function of providing a receptacle for items needed for nursing care, which would usually not be
available in the home, the bag serves as a reminder of the need for hand hygiene and other measures to
prevent the spread of infection. It also supports the idea that the nurse must be prepared for a variety of
situations while in the field.

The nursing bag usually has the following contents:

 Articles for infection control: soap in a covered soap dish and linen or disposable paper towels for hand
washing, apron, bottles of antiseptics, and hand sanitizer.

 Articles for assessment of family members: body thermometer(s), measuring tape, newborn weighing
scale, portable diagnostic aids such as glucometer (if available), or items for Benedict's test (Benedict's
solution, medicine dropper, test tube, test-tube holder, alcohol lamp). Note that the stethoscope and
sphygmomanometer are carried separately.

 Articles for nursing care

 Sterile items: dressings, cotton balls, cotton tip applicators, syringes (2 and 5 ml) with needles,
surgical gloves, cord clamp, one pair surgical scissors, sterile pack with kidney basin, two pairs
of forceps (straight and curved).

 Clean articles: adhesive tape, bandage scissors.

 Pieces of paper: for lining the soap dish if the home sink is used and for lining the bag (a
washable rubber protector may also be used for this purpose), and folded paper to be used as
waste receptacle if needed.

The following are the general principles in the use of the nursing bag (bag technique):

 Bag technique helps the nurse in infection control. The proper use of the bag allows the
practice of medical aseptic technique during the home visit where the family members and the
articles in the home are considered potential sources of infection. The nurse protects himself or
herself and the nursing bag and its contents from contamination. The nurse uses the bag
technique as a live demonstration to the family of practical methods of infection control, such
as hand washing, one of the most important steps that anyone can take to avoid the spread of
infection.

 Bag technique allows the nurse to give care efficiently. It saves time and effort by
ensuring that the articles needed for nursing care are available. It is important for the nurse to
check the contents of the bag for completeness and for proper functioning (as needed) before
leaving the health facility for a home visit. The traditional nursing bag is constructed to allow
the efficient arrangement of its contents. Articles piled on top of each other must be arranged
according to use, with the article to he used first placed on top. For example, articles for hand
washing should be placed on top of the center of the bag.

 Bag technique should not take away the nurse's focus on the patient and the family.
It is simply a tool in providing care.

 Bag technique may be performed in different ways. There may be variations in using the
bag technique because of agency policies and the home situation. However, principles of
asepsis are of the essence and should be practiced at all times.
For infection control, the following activities should be practiced during home visits and as part of bag
technique:

 Remember to proceed from "clean" to "contaminated." For example, provide nursing care first to the
newborn, then the postpartum. If the nurse schedules several home visits within the day, the sequence
should be the family with a postpartum and newborn first, then the family with a communicable case.

 The bag and its contents should be well protected from contact with any article in the patient's home.
Consider the bag and its content clean or sterile, while articles that belong to the patients as dirty and
contaminated.

 Line the table/flat surface with paper/washable protector on which the bag and all of the articles to be
used are placed.

 Wash your hands before and after physical assessment and physical care of each family member.

 Bring out only the articles needed for the care of the family. Those that will not be used should remain
in the bag. This practice is facilitated when the contents of the bag are arranged according to the
nurse's convenience to avoid confusion and promote efficiency.

 Do not put any of the family's articles on your paper lining/washable protector.

 Whenever possible and as necessary, wash your articles before putting them back into the bag. If this
is not possible, wrap them properly to prevent contaminating the bag and its contents.

 After using an article such as an apron or washable protector, confine the contaminated surface by
folding the contaminated side inward.

 Wash the inner cloth lining of the bag as necessary.

APPLICATION OF THE NURSING PROCESS

 
Jenny Reyes is a public health nurse at the Rural Health Unit. She met 26-year-old Rina Yap, married, 6
months pregnant with her first child, in a Garantisadong Pambata (outreach health services) visit at an
ambulatory clinic in the barangay where the Yap family was residing.
 
Assessment

Jenny found out that Rina never had a prenatal consultation. She also noted that Rina was underweight, with
a weight of only 48 kg and a height of 55 cm. When Jenny asked her where she plans to deliver her baby, she
replied that she would probably have a home delivery under the care of the local "hilot" because professional
attendance would be too expensive for them. Rina explained that she came to the ambulatory clinic upon the
prodding of her husband who heard about the health workers' visit to the barangay. To assess the Yaps' home
situation and to teach Rina health practices related to her pregnancy, Jenny asked Rina if she could make a
home visit. Seemingly pleased with Jenny's attention, Rina agreed with Jenny on a home visit schedule,
stating that she wanted to learn more from Jenny to prevent problems with her pregnancy and delivery.
When Jenny made the home visit, she noted that Rina lived with her 32-year-old husband Mario, who was at
work at the time of the visit. He was the sole breadwinner of his family - a construction worker earning the
daily minimum wage. Rina described her husband as hardworking. They lived in a rented shack of mixed
materials with a bedroom, a bathroom and toilet, and a small multipurpose room (living and dining room and
kitchen). Rina's activities consisted mainly of household chores. Sometimes, Rina would spend time at the
homes of some friends and relatives residing in the neighborhood.

In the course of the interview, Jenny found out that Rina had inadequate knowledge about community health
services, prenatal nutrition, preparation for childbirth, and infant care. Rina said that she and her friends and
relatives sometimes talk about such matters, but the information given was confusing and conflicting. Aside
from palmar pallor and underweight, other findings during physical examination were normal. When asked
about her diet, Rina told Jenny that, she limited her food intake because she did not. want to have a
caesarean section, which may be needed if the baby grew too big .
Individual level

Diagnosis

Jenny was able to identify the following nursing diagnoses for Rina Yap:

 Deficient knowledge regarding community health services, prenatal nutrition, preparation for delivery,
and infant care related to lack of familiarity with right sources of information.

 Risk-prone health behavior related to inadequate understanding of available health resources.

 Imbalanced nutrition: less than body requirements related to misinformation regarding prenatal
nutrition.

Planning

Goal

 Rina will deliver her baby full-term without evidence of maternal or fetal complications.

Objectives

 Rina will gain at least 2 kg per month before delivery.

 Rina will visit the health center or barangay health station for prenatal services within a month after
the home visit.

 Rina will engage in activities in preparation for delivery within a month after the home visit.

 Rina will decide on facility-based delivery, as in a lying-in clinic.

Interventions

 Explore with Rina possible motivations for participating in teaching-learning activities. Reinforce
positive motivations such as the desire to promote her baby's and her own health and to prevent
health problems associated with pregnancy.

 Assess in detail Rina's level of knowledge, skills, and attitudes relevant to the situation.

 Based on the results of assessment of Rina's level of knowledge, provide information/guidance on

activities for health promotion and prevention of maternal and fetal problems, with emphasis on:
  Regular prenatal consultation (high priority)

 Prenatal nutrition (high priority)

 Preparation for delivery

 Accessible, affordable community health services, including facilities for delivery

 Set an appointment at the health center or make a referral to Rina's health agency of choice.

 Invite Rina to attend mothers' classes on hygiene of pregnancy, preparation for delivery, and infant
care including breastfeeding at the health center.

Evaluation

With Jenny's guidance, Rina was able to make a sample meal plan for 3 days, taking into consideration her
food preferences and the family's food budget. When Rina expressed her reluctance to have professional
attendance during delivery because of its cost, Jenny explained the procedure and expected expenses at the
most accessible government-run lying-in clinic. Before the home visit ended, Rina and Jenny set an
appointment for a visit to the health center where a mothers' class is held on Mondays.

Rina went for her first prenatal clinic consultation at the health center as scheduled and attended a mothers'
class.
 
Family level

Diagnosis

 Readiness for enhanced family coping related to availability of developmental support for needs during
pregnancy and delivery.

Planning

Goal

 The couple will express confidence in their ability to cope with Rina's pregnancy and upcoming delivery.

Objectives

 The couple will express their feelings about the changes in their family life brought about by Rina's
pregnancy and forthcoming delivery during the initial family-nurse contact.

 The couple will utilize resources (e.g. family strengths, outside support systems such as their relatives
in the neighborhood and accessible health professionals and facilities) to cope with the demands of
pregnancy, delivery, and parenting.

Interventions
 Establish a relationship of trust with Rina and Mario (if the opportunity presents itself).

 Encourage Rina and Mario (if the opportunity presents itself) to express their feelings about the
changes in their lives brought about by the pregnancy and forthcoming delivery.

 Guide the couple in the identification and utilization of resources, both within and outside the family,
which will help them cope with their health needs.
  During the mothers' class, allow the women to share experiences with each other.

 Provide experiences that will help them prepare for:

 Delivery

 Infant care

Evaluation

Jenny was able to establish a relationship of trust with Rina during the first home visit, but had yet no
opportunity to talk with Mario. During the mothers' class, Rina participated in a discussion and demonstration
on newborn care, including breastfeeding. One of the resource speakers in the mothers' class was a midwife in
the lying-in clinic. After talking of advantages of facility-based delivery and preparations the women had to
make to avail of their services, the midwife answered questions including the estimated expense of childbirth
at their facility. Rina later said that she was convinced that delivery at the lying-in clinic would be good for her
and the baby and that she would tell Mario about her experiences at the health center and the mothers' class.