Family Nursing Process

Week 4
 Learning Objectives
• Conducting family interviews requires knowledge of family assessment and
intervention models, as well as skilled organizational communication techniques
so that the interaction will be effective and efficient for all parties.
• Determine the family genogram and ecomap are both assessment data-gathering
instruments. The therapeutic interaction that occurs with the family while
diagramming a genogram or ecomap is a powerful intervention in and of itself.
 Learning Objectives Cont’
• Discuss the need to approach assessment of family health literacy with sensitivity and understanding, because it is a crucial
element to successful outcomes.
• Examine the most critical aspects of family nursing is to encourage and seek family involvement in the decision-making
process to plan family care.
• Discuss the need to tailor their work with families based on the level of involvement preferred by the family, and the health
literacy needs of the family.
• Implement the working together and build on family strengths are in the best positions to determine and prioritize the family
needs, develop realistic outcomes, and design a plan of action that has a high probability of being implemented by the family.
• Determine what the families perceive as important is critical to successful planning and implementation.
• Nurses work with families to evaluate the ongoing family care plan and modify the course of action as needed.
• Examine the final step in the Family Nursing Process should always be for nurses to engage in critical, creative, and
concurrent reflection about the family, their work with the family, and professional self-reflection of their practice.
 Introduction
• The family genogram and ecomap are both assessment data-gathering instruments.
• The therapeutic interaction that occurs with the family while diagramming a genogram or
ecomap is a powerful intervention in and of itself.
• Nurses need to approach assessment of family health literacy with sensitivity and
understanding, because it is a crucial element to successful outcomes.
• One of the most critical aspects of family nursing is to encourage and seek family
involvement in the decision-making process to plan family care.
• Nurses need to tailor their work with families based on the level of involvement preferred by
the family, and the health literacy needs of the family.
 Introduction Cont’
• Families are complex social systems. Therefore, the use of logical,
systematic approaches to family clients is essential for several reasons:
(1) to assure that the needs of the family are met,
(2) to uncover any gaps in the family plan of action,
(3) to offer multiple supports and resources to the family.
• Nurses use a variety of assessment models to collect information about
families.
 Family Nursing Process

• Each step of working with families, whether applied to individuals within the family or the
family as a whole, requires a thoughtful, deliberate reasoning process.
• Nurses decide what data to collect and how, when, and where that data are collected.
• Nurses determine the relevance of each new piece of information and how it fits into the
emerging family story.
• Before moving forward, nurses decide whether they have obtained sufficient information on
problem and strength identification, or whether gaps exist that require additional data
gathering.
• Each family situation evolves as it is analyzed, and each item of new information must be
evaluated for accuracy, clarity, and relevance.
 The steps of the Family Nursing Process include:

• Assessment of the family story: The nurse gathers data from a variety of sources to see the
whole picture of the family experience.
• Analysis of family story: The nurse clusters the data into meaningful patterns to see how the
family is managing the health event. The family needs are prioritized using a Family
Reasoning Web.
• Design of a family plan of care: Together, the nurse and family determine the best plan of
care for the family to manage the situation.
• Family intervention: Together, the nurse and family implement the plan of care
incorporating the most family-focused, cost-effective, and efficient interventions that assist
the family to achieve the best possible outcomes.
• Family evaluation: Together, the nurse and family determine whether the
outcomes are being reached, partially reached, or need to be redesigned. Is the
care plan working well, does a new care plan need to be put into place, or does
the nurse/family relationship need to end?
• Nurse reflection: Nurses engage in critical, creative, and concurrent reflection
about the family and their work with the family.
 Assessment of the Family Story
• Every family has a story about how the potential or actual health event influences its individual members,
family functioning, and management of the health event.
• Nurses filter data gathered in the story through different views or approaches, which affects how they think
about the family as a whole and each individual family member.
• Nurses might use different strategies if the patient is in the acute hospital setting, is in an assisted living
center, or is living at home.
• Data collection, which is part of assessment, involves both subjective and objective family data that are
obtained through direct observation, examination, or in consultation with other health care providers (HCPs).
• The specific assessment strategies nurses use depend on the reason they are working with the family.
• In all cases, family assessment begins from the first moment that the family is referred to the nurse
 Making Appointments

• As soon as the family is identified, nurses begin to collect data about the family story.
• Sources of data that can be collected before contacting a family for a home or clinic appointment, such
information:
 The reason for the referral or requested visit
 The family knowledge of the visit or referral
 Specific medical information about the family member with the health problem
 Strategies that have been used previously
 Insurance sources for the family
 Family problems identified by other health providers
 The need for an interpreter
• Before contacting the family to arrange for the initial appointment, the nurse
decides whether the most appropriate place to conduct the appointment is in the
family’s home or the clinic/office.
• The type of agency where the nurse works may dictate this decision. For instance,
home health agencies provide nursing in the home, or mental health agencies
require family meetings to occur in the neighborhood clinic office.
 Setting up Family Appointments

• Introduce yourself.
• State the purpose of the requested meeting, including who referred the family to the agency.
• Do not apologize for the meeting.
• Be factual about the need for the meeting but do not provide details.
• Offer several possible times for the meeting, including late afternoon or evening.
• Let the family select the most convenient time that allows the majority of family members to
attend.
• Offer services of an interpreter, if required.
• Confirm date, time, place, and directions.
 Using Interpreters With Families

• It is critical for the nurse to determine whether an interpreter is needed during the
family meeting.
• Language barriers have been found to complicate many aspects of patient care,
including comprehension, adherence to plans of care, adverse health outcomes,
compromised quality of care, avoidable expenses, dissatisfied families, and
increased potential for medical mistakes.
• The types of interpreters that nurses solicit to help work with families have the
potential to influence the quality of the information exchanged.
 Family Meeting

• During the initial interaction with families, it is critical for nurses to introduce themselves
to the family, meet all the family members present, learn about the family members not
present, clearly state the purpose for working with the family, outline what will happen
during this session, and indicate the length of time the meeting will last.
• By introducing themselves, nurses set the tone for a therapeutic nurse family client
relationship, and send the message that all family members are important and affected by
the health event(s) (Wright & Leahey, 2009).
• The nurse needs to develop a systematic plan for the first and all reoccurring family
meetings.
 Family Meeting Cont’
• Nurses who use a therapeutic approach to family meetings have found that their focus on family centered
care increased, and that their communication skills with families became more fluid with experience.
• When nurses use therapeutic communication skills with families, the families report feeling a stronger
rapport with the nurse, an increased frequency of communication between families and the nurse occurs,
and families perceive these nurses to be more competent.
• Conducting family interviews not only requires skilled communication strategies but also requires
knowledge of family assessment and intervention models.
• Nurses use a variety of data collection and assessment instruments to help gather information in a
systematic and efficient manner.
• Therefore, it is important that the instruments be carefully selected so they are family friendly and render
information pertinent to the purpose of working with the family.
 Selecting Family Assessment Instruments
• Because there are approximately 1,000 family focused instruments that have been
developed and used in assessing family-related variables (Touliatos, Perlmutter, &
Straus, 2001), the selection of the appropriate instrument can be complex.
• Sometimes, a simple questionnaire or instrument can be completed in just a few
minutes. One such example is the Patient/Parent Information and Involvement
Assessment Tool (PINT),which is an instrument that Sobo (2004) designed to assess
the family’s perspective on shared decision making. Other times, more
comprehensive family assessment instruments are necessary, such as the Family
Systems Stressor-Strength Inventory (FS 3 I) (Berkey-Mischke & Hanson, 1991;
Hanson, 2001; Kaakinen & Hanso
 Selecting Family Assessment Instruments
Cont’
• The FS 3 I is an instrument designed by nurses to provide quantitative and qualitative data
pertinent to family stressors, family strengths, and intervention strategies.
• To select the most appropriate short assessment instrument, be sure the instrument has the
following characteristics:
■ Written in uncomplicated language at a fifth grade level
■ Only 10 to 15 minutes in length
■ Relatively easy to score
■ Offers valid data on which to base decisions
■ Sensitive to sex, race, social class, and ethnic background
• No matter which assessment/measurement instrument is used, families should
always be informed of how the information gathered through the instruments will
be used by the HCPs.
• Two family data-gathering instruments that must always be used in working with
families are the family genogram and the family ecomap.
• Both are short, easy instruments and processes that supply essential family data
and engage the family in therapeutic conversation.
 Family Genogram and Family ECOMAP
• Genograms and ecomaps actively engage families in their own care and provide care providers with visual diagrams of the current family story
and situation.
• The information gathered from both the genogram and ecomap help guide the family plan of action and the selection of intervention strategies.
• One of the major benefits of working with families with these two instruments is that they can feel and visualize the amount of energy they are
expending to manage the situation, which in itself is therapeutic for the family.

FAMILY GENOGRAM
• The family genogram is a format for drawing a family tree that records information about family members and their relationships over at least
three generations.
• This diagram offers a rich source of information for planning intervention strategies because it displays the family visually and graphically in a
way that provides a quick overview of family complexities.
• Family genograms help both nurses and families to see and think systematically about families and the impact of the health event on family
structure, function, and processes.
 Family Genogram and Family ECOMAP
Cont’
• The three-generational family genogram had its origin in Family Systems Theory According to family systems,
people are organized into family systems by generation, age, sex, or other similar features.
• How a person fits into his or her family structure influences his or her functioning, relational patterns, and what type
of family he or she will carry forward into the next generation.
• Bowen incorporates Toman’s (1976) ideas about the importance of sex and birth order in shaping sibling
relationships and characteristics.
• Furthermore, families repeat themselves over generations in a phenomenon called the transmission of family
patterns.
• What happens in one generation repeats itself in the next generation; thus, many of the same strengths and problems
get played out from generation to generation.
• These include both psychosocial and physical and mental health issues.
 Family Genogram and Family ECOMAP
Cont’
• Nurses establish therapeutic relationships with families through the process of
asking questions while collecting family data.
• Families become more engaged in their current situation during this
interaction and as their family story unfolds.
• Both the nurse and the family can see the “big picture” historically on the
vertical axis of the genogram and horizontally across the family.
• The process can help families see connectedness, and help identify potential
and missing support people.
 Family Genogram and Family ECOMAP
Cont’
• The diagramming of family genograms must adhere to specific rules and symbols to assure all parties involved have
the same understanding and interpretations.
• It is important not to confuse family genograms with a family genetic pedigree.
• A family pedigree is specific to genetic assessments, whereas a genogram has broader uses for family HCPs.
• The health history of all family members (e.g., morbidity, mortality, and onset of illness) is important information for
family nurses and can be the focus of analysis of the family genogram. An example of a family genogram developed
from one interview.
• Most families are cooperative and interested in completing their genogram, which becomes a part of their ongoing
health care record.
• The genogram does not have to be completed at one sitting. As the same or a different nurse continues to work with
a family, data can be added to the genogram over time in a continuing process. Families should be given a copy of
their own genogram.
 Family Genogram Interview Data Collection
1. Identify who is in the immediate family.
2. Identify the person who has the health problem.
3. Identify all the people who live with the immediate family.
4. Determine how all the people are related.
5. Gather the following information on each family member.
 Age
 Sex
 Correct spelling of name
 Health problems
 Occupation
 Dates of relationships: marriage, separation, divorce, living together, living together/committed
 Dates and age of death
 Family Genogram Interview Data Collection Cont’

6. Seek the same information for the family members on the same
generational level and
for those in the preceding generational level.
7. Add any additional information relative to the situation, such as
geographic location and
interaction patterns.
 FAMILY ECOMAP
• A family ecomap provides information about systems outside of the immediate nuclear
family that are sources of social support or that are stressors to the family.
• The ecomap is a visual representation of the family unit in relation to the larger community in
which it is embedded.
• The ecomap is thus an overview of the family in its current situation, picturing the important
connections among the nuclear family, the extended family, and the community around it.
• A simplified version of the family is placed in the center of the larger circle to complete the
ecomap.
• This circle marks the boundary between the family and its extended external environment.
 FAMILY ECOMAP Cont’
• The smaller outer circles represent significant people, agencies, or institutions with whom the family
interacts.
• Lines are drawn between the circles and the family members to depict the nature and quality of the
relationships, and to show what kinds of energy and resources are moving in and out of the immediate
family.
• Straight lines show strong or close relationships; the more pronounced the line or greater the number of
lines, the stronger the relationship is.
• Straight lines with slashes denote stressful relationships, and broken lines show tenuous or distant
relationships.
• Arrows reveal the direction of the flow of energy and resources between individuals, and between the family
and the environment.
 Analysis of the Family History
• One of the challenges of data collection is organizing the individual pieces of
information so that the “big picture” or whole family story can be understood.
• To understand the family picture, the nurse must consolidate the data that were
collected into meaningful patterns or categories so that the relationships between and
among the patterns of how the family is managing the situation can be visualized.
• Diagramming the family and the relationships between the data groups assists in the
identification of the most pressing issues or problems for the family.
• If the family and nurse focus on solving these major family problems, the outcome will
have a ripple effect by positively influencing the other areas of family functioning.
 Analysis of the Family History Cont’
• The Family Reasoning Web is an organizational tool to help cluster individual
pieces of data into meaningful family categories.
• The components of the Family Reasoning Web are:
1.Family routines of daily living (i.e., sleeping, meals, child care, exercise)
2.Family communication
3.Family supports and resources
4.Family roles
5.Family beliefs
 Analysis of the Family History Cont’
6.Family developmental stage
7.Family health knowledge
8.Family environment
9.Family stress management
10.Family culture
11.Family spirituality
 Analysis of the Family History Cont’
• Once the data have been placed into the categories of the Family Reasoning Web template, the nurse assigns
a family nursing diagnosis to each category. “A nursing diagnosis is defined as a clinical judgment about
individuals, families, or community responses to actual or potential health problems/life processes.
• Nursing diagnoses link information to care planning. Nursing diagnoses provide the basis for selecting
nursing interventions to help achieve outcomes for which nurses are accountable”(Doegnes, Moorhouse, &
Murr, 2008, p. 10).
• NANDA Nursing Diagnoses Relevant to Family Nursing: Risk for impaired parent/infant/child attachment;
Caregiver role strain; Risk for caregiver role strain; Parental role conflict; Compromised family coping;
Disabled family coping; Readiness for enhanced family coping; Dysfunctional family processes: alcoholism;
Readiness for enhanced family processes; Interrupted family processes; Readiness for enhanced parenting;
Impaired parenting; Risk for impaired parenting; Relocation stress syndrome; Ineffective role performance;
Ineffective family therapeutic regimen management.
 Designing a Family Plan of Care
• The family plan of care is designed by the nurse and the family to focus on the concerns
that were identified in the family reasoning web as the most pressing or causing the family
the most stress.
• One of the most crucial aspects of family nursing is encouraging and seeking family
involvement in planning care and in the decision-making processes.
• Universal needs of families include consistency, clarity, comprehensive information, and
involvement in shared decision making with HCPs.
• Shared decision making requires that HCPs tailor their communication, accommodate their
talk to the level of the family, and present information in a way that allows the family to
make informed choices.
 Shared decision making includes the following steps as outlined by
Makoul and Clayman (pp. 305–306):

• The family and HCP must define and agree on the health problem that is confronting the family member.
• The HCP presents and discusses options of care in a way that invites family questions.
• The family and HCP discuss pros and cons of options, including cost benefits, convenience, and financial costs.
• The family and HCP discuss values and preferences including ideas, concerns, and outcome expectations.
• The family and HCP discuss ability and confidence to follow through with steps or regimen for each option.
• Both the HCP and family should check and clarify for understanding the discussion and information shared.
• Both the HCP and family should reach a decision or defer decisions until an agreed-on, specified time.
• The HCP should follow up to track the outcome of the decision.
 Family Intervention
• Nurses help families in the following ways: (1) providing direct care, (2) removing
barriers to needed services, and (3) improving the capacity of the family to act on its own
behalf and assume responsibility.
• One of the important aspects of working with the family is the nurse-family relationship,
which is an intervention in and of itself.
• The nurse can assume the role of teacher, role model, coach, counselor, advocate,
coordinator, consultant, and evaluator in helping the family to implement the plan of the
care they were intimately involved in creating.
• The types of interventions are limitless because they are designed with the family to meet
their needs in the context of their family story.
 Family Evaluation

• In making clinical judgments, nurses engage in critical thinking to determine whether and to what extent they have
met an outcome.
• Working with the family, decisions are made about whether to proceed as originally planned, to modify the family
action plan, or to revisit the family story in total.
• As indicated previously, the Family Nursing Process is not linear. In practice, a constant flow occurs between the
components of the Family Nursing Process model.
• If not meeting expected outcomes, nurses should consider whether family apathy and indecision are the barriers.
• Family apathy may occur because of value differences between the nurse and the family.
• The family may be overcome with a sense of hopelessness, may view the problems or bureaucracy as too
overwhelming, or may have a fear of failure.
• Nurses also should consider whether they themselves imposed barriers. A more detailed list of possible barriers to
family outcomes.
 Barriers to Family Outcomes

• Family apathy
• Family indecision about the outcome or actions
• Nurse-imposed ideas
• Negative labeling
• Overlooking family strengths
• Neglecting cultural or gender implications
• Family perception of hopelessness
• Fear of failure
• Limited access to resources and support
• Limited finances
• Fear and distrust of health care system