Family Nursing, Ch. 2

Family Nursing: Focus, Evolution, and Goals

CONTENT OUTLINE

FAMILY NURSING: DEFINING THE SPECIALTY

Family as Context

Family as Sum of Its Members

Family Subsystem as Client

Family as Client

Family as a Component of Society

Defining Family Nursing

Distinguishing Family Nursing from Other Practice Areas

INCORPORATION OF FAMILY INTO STANDARDS OF CARE

FAMILY NURSING’S HISTORICAL LEGACY

CURRENT ISSUES IN FAMILY NURSING

FAMILY NURSING GOALS: LEVELS OF PREVENTION

PRIMARY PREVENTION: FAMILY HEALTH PROMOTION AND DISEASE PREVENTION

Factors Leading to Renewed Interest in Primary Prevention

Family Health Promotion

Impediments to Primary Prevention

Specific Preventive Measures

Risk Appraisal/Risk Reduction

Family’s Role in Primary Prevention

SECONDARY PREVENTION

TERTIARY PREVENTION

SUMMARY

LEARNING OBJECTIVES

Explain the differences in how the family is conceptualized in family nursing practice.

Compare how the family is incorporated into professional organizations’ standards of practice.

Distinguish between family nursing and (a) community health nursing, (b) family therapy.

Identify the four specialty areas in nursing that historically have been most ardently involved in family health care.

Discuss several current issues in family nursing.

Briefly describe the three levels of prevention.

Explain why health promotion is a predominant thrust within family nursing.

Discuss the primary factors leading to increased interest in health promotion and health maintenance today.

Identify factors that have impeded the growth of primary prevention.

Explain the difference between health promotion and disease prevention.

Explain the purpose of the three risk appraisal tools.

Describe the family nurse’s role in primary, secondary, and tertiary prevention.

This text is about family nursing and the basic knowledge base—consisting of theory, factual information, research, and clinical implications—needed to practice basic family nursing. The chapter begins the discussion of family nursing by addressing what family nursing encompasses, its evolution, and the incorporation of family into professional standards of care. Finally, the primary goal of family nursing, promotion and maintenance of family health, is analyzed by using Leavell and associates’ (1965) levels-of-prevention framework as a vehicle for discussing the family nurse’s role within the three levels of prevention. Particular emphasis is given to primary prevention, especially health promotion, because this focus is seen as the predominant thrust of family nursing. Discussions of family health, a healthy lifestyle, and risk appraisal and reduction are also elaborated upon as part of primary prevention. The family nurse’s role in secondary and tertiary prevention completes the discussion of the family nurse’s role in health and illness.

FAMILY NURSING: DEFINING THE SPECIALTY

Family nursing is a specialty area that cuts across the various other specialty areas of nursing. Although as a distinct specialty it is still relatively young, there is strong evidence that family nursing is a growing, dynamic specialty area of focus in practice, education, and research. Significant progress is being made in broadening nursing’s practice paradigm to include the family as client. Yet, a gap between conceptualization and practice still exists (Friedemann, 1989). Interestingly enough, there are several names of this specialty: family health care nursing (Bomar, 1996; Hanson, 2001); nursing of families or family systems nursing, depending on focus and the level of practice (Wright & Leahey, 2000); and system-focused or systemic family nursing (Friedemann, 1995).

When the first edition of this text was written in 1979 to 1980, there were no definitions of family nursing. Several texts discussed family nursing (Ford, 1979; Sobol & Robischon, 1975); family-centered community nursing (Reinhardt & Quinn, 1973); family-focused nursing (Janosik & Miller, 1980); and family health care (Hymovich & Barnard, 1979); but notions about a specialty called family nursing were absent. Today, texts, articles, and professional presentations in the area of family nursing are extensive. The specialty even has its own journal, The Journal of Family Nursing. This journal, begun in 1995, has been vital to the advancement of family nursing as it has given family nurses a place to share their thoughts and research.

There is, however, disagreement over what family nursing actually encompasses (Hanson, 2001; Wright & Leahey, 2000), and how it differs from community health nursing (Friedman, 1986) and family therapy (Gilliss, Rose, Hallburg, & Martinson, 1989; Wright & Leahey, 1994). A review of the family nursing literature reveals that within the definition of family nursing family nursing practice is described in different ways. The way family nursing is practiced depends on how the family nurse conceptualizes the family and works with it. The degree of family-centeredness also is dependent on the philosophy of the system within which the nurse works. The work environment (what leadership rewards and negatively reinforces) is also a major determinant of behavior. Each of the following five ways of thinking about the family shape family nursing practice, education, research and theory development.

FAMILY AS CONTEXT

The first way family nursing is conceptualized is as a field where the family is viewed as context to the client or family member (Bozett, 1987; Robinson, 1995) (Figure 2-1). Nursing care is individually focused. The family, as typically the client’s most important primary group, is visualized typically as a resource to the client although in some cases is viewed as a stressor. The family is the background or secondary focus and the individual, the foreground or primary focus relative to assessment and intervention.

Figure 2-1. Five ways of viewing the family, all shaping family nursing.

The nurse may involve the family to varying degrees. In some cases the nurse may assess the family as part of the client’s social support system, but with little incorporation of the family into the client’s plan of care. In other cases, the nurse may extensively involve the family in the client’s care. The family’s tangible and socioemotional impact on the client is assessed and integrated into the treatment plan.

Most nursing theories conceptualize the family’s role in this light. Most specialty areas also view the family as a crucial social environment of the client and hence a primary social support resource. A case in point is the definition of family-centered care promulgated by the interdisciplinary Association for the Care of Children’s Health (ACCH). They explain that family-centered care is a philosophy of pediatric health care that considers and treats the child in the context of the family and recognizes the family as the primary and continuing provider of care for the child. This organization stresses that the family is “the constant” in the child’s life (Shelton & Stepanek, 1995).

FAMILY AS SUM OF ITS MEMBERS

In the second type of family nursing practice, the family is seen as an accumulation or sum of the individual family members. When care is made available to or provided for all the family members, family health care is seen as being provided. This is a model that is implicit to much of practice within family primary care and community health nursing. In this type of family nursing practice, the foreground is each of the clients, seen as separate rather than interacting units.

FAMILY SUBSYSTEM AS CLIENT

In the third type of family nursing practice, family subsystems are the focus and recipient of assessment and intervention. Friedemann (1993b) and Robinson (1995) refer to this model as being the basis for interpersonal family nursing. Family dyads, triads, and other family subsystems are the unit of analysis and care. Parent-child relationships, marital interactions, caregiving issues, and bonding-attachment concerns are examples of the nursing foci here.

FAMILY AS CLIENT

In the fourth type of family nursing conceptualization, the entire family is viewed as client or as the primary focus of assessment and care. The family is now in the foreground, with the individual family members in the background or context. The family is viewed as an interactional system. The focus is on internal family dynamics and relationships, the family’s structure and functions, as well as the relationships of family subsystems with the whole and of the family with its outer environment. It is in this latter type of conceptualization of family that the unique contributions of family nursing are evident.

When systems theory and cybernetics, especially the notions of interaction, circularity, and reciprocity, become the prevailing way the family is viewed and analyzed, Wright and Leahey (2000) call this family systems nursing. Here the connections between illness, family members, and the family are assessed within this interactional perspective and incorporated into the treatment plan. This type of practice involves using a different paradigm or epistemological framework for assessment and care, one characterized by holism and circular causation. Family systems nursing utilizes advanced clinical assessment and intervention skills based on an integration of nursing, family therapy, and systems theory (Wright & Leahey, 1994). It represents advanced nursing practice, as its concentration is simultaneously on not only the whole family as the unit of care, but on multiple systems, such as the individual, the family, and larger systems (Bell, 1996).

Fortunately, there is a growing effort in family primary care to see the family unit as the focus of care (Doherty & Campbell, 1988; Campbell, 2000), but with cost-containment efforts and lack of reimbursement for family care, these efforts are not widespread.

FAMILY AS A COMPONENT OF SOCIETY

There is a fifth conceptualization of family described by Hanson (2001b), that is, as a component of society. Here, the family is visualized as one subsystem within a larger system—the community, society. The family is seen as one of basic societal institutions, such as the educational, welfare, or religious institutions are. This view of the family is discussed in the structural-functional theory chapter (Chapter 4), the systems theory chapter (Chapter 6), and the family environmental data chapter (Chapter 9).

DEFINING FAMILY NURSING

Family nursing encompasses all the five models described above, even though the fourth model is considered uniquely family nursing. In family nursing, nurses work simultaneously with individuals, subsystems, the whole family, and the family-society (other systems in the community) interface. In this text we emphasize the unique aspects of family nursing (i.e., working with the whole family as an interactional system) but recognize that working with family members individually or as dyads/triads, or working with family and their relationship to other interacting systems, is also quite important. As Hanson (2001b) notes, it is important to keep all family perspectives in mind when working with families.

Family nursing practice is defined in this text as “the provision of nursing care to families and family members in health and illness situations.” Hence, families and family members may be healthy and/or may be experiencing health problems. The goal of family nursing is to assist families to help themselves achieve a higher level of functioning or wellness within the context of their particular aims, aspirations, and abilities. Family nursing may be rendered to all forms of families in any health setting and in other settings where families are being served (e.g., educational and multipurpose service centers). The nursing process serves as the framework for providing care.

It is practice that is informed by nursing, family, social science, and family therapy theories. (Refer to Chapter 3 for more in-depth discussion of theoretical foundations.) The emphasis of family nursing practice should be health oriented, incorporating holistic, systemic, and interactional perspectives and drawing on and drawing forth family strengths (Bell, 1996; Friedemann, 1995; Wright & Leahey, 2000). (See Table 2-1.)

TABLE 2-1 Family Nursing Entails:

Provision of nursing care to families

Use of the nursing process applied to the family

Working with families within a health and/or illness context

Working with families in many settings—wherever families are being served

Working with all forms of families

Being guided by theories and research from family social science, family therapy, and nursing

Emphasizing a health orientation, a holistic and an interactional perspective, and the importance of family strengths

DISTINGUISHING FAMILY NURSING FROM OTHER PRACTICE AREAS

Because family nursing historically has been aligned primarily with community health nursing (Whall, 1986a), some confusion exists between what is community health or public health nursing and family nursing. Whereas family nursing focuses on the family as its target or recipient of care, community health nursing’s target of service is the community (Williams, 1996). The health of the community rather than the health of the family is the ultimate goal of community health nursing. It is through families that community health nurses improve and preserve the health of communities. The difference here is a matter of ultimate goals and priorities. The implications of this difference are that in rendering personal health services to a family—for example, a single-parent family of mother and young children—the “non-community-oriented” family nurse would be concerned with the family’s unique problems first, and second with the community health problems common to young families (the first commitment being a client and family). In a community health setting, the nurse would be cognizant of the pressing maternal-child health problems in the community that were relevant to the client family, such as immunizations and family planning, and prioritize these needs along with the unique health needs of the family.

Another point of confusion is the difference between family nursing and family therapy (Gilliss et al., 1989) or family systems nursing. In Wright and Leahey’s text, Nurses and Families (2000), they distinguish nursing of families from family therapy and family systems nursing. Wright and Leahey believe that advanced preparation is needed to practice as a family systems nurse clinician. However, nursing of families, consisting of basic family nursing assessment and intervention, should be part of baccalaureate nursing education. The nurse here is able to complete family assessments of healthy/functional and dysfunctional families. The family nurse or interviewer intervenes using educative-supportive strategies that are direct and straightforward. In family systems nursing or family therapy, the nursing interventions include more complex and indirect psychosocial interventions (Wright & Leahey) and the clinician works with multiple systems simultaneously (Bell, 1996).

Family nurse researchers working as a special interest group under the auspices of the Family Nursing Continuing Education Project, Oregon Health Sciences University (Kirschling et al., 1989), were also interested in clarifying what family nurses actually do. To address this question they conducted a national survey of 263 nurses who identified themselves as being family nurses, asking them about their practice and interaction with their clients. From this data, the researchers identified unique characteristics of family nursing practice. The following four major themes emerged when participants were queried as to what they did differently when they cared for families rather than individuals:

Recognition and integration of family concepts

Application of a broader perspective as identified in the nurses’ approach to nursing care, primarily by assessing the family

A focus on family interaction and family dynamics

Involvement of family members in care, particularly in areas of decision making and caregiving

INCORPORATION OF FAMILY INTO STANDARDS OF CARE

Ideally, family nursing should be a reality in all clinical areas of nursing practice. In some settings and specialty areas, however, incorporating the family as client is more difficult to achieve than in others. For instance, in episodic settings—especially in intensive care units and emergency departments, where immediate lifesaving measures are needed—a predominant patient focus is understandable.

Evidence of what specialty areas believe to be the appropriate standards and scope of their practice are found in publications from the American Nurses Association (ANA), which is responsible for defining and establishing the scope of nursing practice and standards in both the general field and in areas of specialization. The Association for the Care of Children’s Health and the National Organization of Nurse Practitioner Faculties developed documents addressing standards of care in pediatrics and primary care, respectively.

We reviewed the ANA’s Social Policy Statements (1980; 1995a) and Standards of Clinical Nursing Practice (general standards) (ANA, 1998), and standards/scope of practice statements in seven specialty areas to see the extent to which the family was incorporated into standards of care documents. Standards from psychiatric-mental health nursing (ANA, 2000), gerontological nursing (ANA, 1995b), public health nursing (ANA, 1999), and home health nursing (1999); pediatric clinical nursing (ANA, 1996); and rehabilitation nursing (ANA, 1988) and primary health care nurse practitioner (ANA, 1987) were reviewed. This survey revealed that the family as context was recognized, that is, as an important resource to the individual client in all standards documents. All these standards—with the exception of rehabilitation nursing— also stated that the client may be an individual, family, group, or community. However, when specific descriptions of standards and scope of practice were delineated, the family was clearly not considered as client in some of the specialties. The standards documents, with the exception of rehabilitation nursing, following the general Standards of Clinical Nursing Practice lead, used the nursing process framework to describe their standards of practice. Hence, the same basic framework, the nursing process, was used in all standards of care, but the description of practice varied widely with respect to family inclusion.

In the ANA’s important social policy statements of 1980 and 1995, the association described the family, along with the individual client and community, as nursing’s recipient of care. The family was also identified as a necessary unit of nursing services. The generic standards of clinical practice also stated that the family is a client along with individuals, groups, and communities.

In the psychiatric-mental health nursing standards (ANA, 2000), family psychotherapy was discussed as an intervention appropriate for a psychiatric-mental health nurse functioning at an advanced practice level (master’s prepared advanced practice nurse).

In the Standards of Public Health Nursing Practice (ANA, 1999) and Standards of Home Health Nursing Practice (1999), the nursing process was utilized to assess, plan, diagnose, intervene, and evaluate families. Collaboration with families is stressed. Family nursing care was promulgated as a vital component of practice.

In the Standards of Pediatric Clinical Nursing Practice (ANA, 1996), family was heavily identified and integrated throughout the standards. For instance, the standards stated that nurses assist families to achieve health promotion and to cope with health problems and role transitions.

In the gerontology nursing practice standards (ANA, 1995b) and rehabilitation nursing standards (ANA, 1988), the family was clearly seen as a resource to the individual client. Finally, in the standards of practice for primary care nurse practitioners (ANA, 1987), there was no mention of family. The ANA 1985 scope of practice document mentioned family in the introductory section, stating primary care’s orientation “to the family and/or broader systems of which the individual is a part” (p. 3). The National Organization of Nurse Practitioner Faculties (NONPF), in contrast to the ANA document on primary care nurse practitioner scope of practice, clearly described the nurse practitioner’s role in working with families.

As seen in the Standards of Pediatric Clinical Nursing Practice, this specialty emphasizes a family-centered philosophy and approach in clinical practice. The best example of this “family-centerdness” is found in a document from the Association for the Care of Children’s Health in which they list the following key elements of family-centered care:

Incorporating into policy and practice the recognition that the family is the constant in a child’s life, whereas the service systems and support personnel within those systems fluctuate

Facilitating family/professional collaboration at all levels of hospital, home, and community care

Exchanging complete and unbiased information between families and professionals in a supportive manner

Incorporating into policy and practice the recognition and honoring of cultural diversity, strengths, and individuality within and across all families

Recognizing and respecting different methods of coping and implementing comprehensive policies and programs that provide developmental, educational, emotional, environmental, and financial supports to meet the diverse needs of families

Encouraging and facilitating family-to-family support and networking

Ensuring that hospital, home, and community services and support systems for children needing special health and developmental care and their families are flexible, accessible, and comprehensive in responding to diverse family-identified needs

Appreciating families as families and children as children, recognizing that they possess a wide range of strengths, concerns, emotions, and aspirations beyond their need for specialized health and developmental services and support (Shelton & Stepanek, 1995)

FAMILY NURSING’S HISTORICAL LEGACY

“The concept of family nursing has always been with us in nursing” (Ford, 1979, p. 4). It has, however, seen decline and regrowth.

In the preindustrialized, colonial era, when family members worked at home in cottage industries or farming, family care predominated. Then came industrialization, with family members moving into factories to work. Health care gradually moved from the home to the hospital.

In England, Florence Nightingale was aware of the importance of the family and home environment in the care of the sick. She mentions the needs of family members in military camps and the need “to keep whole families out of pauperism by nursing the breadwinner back to health” (Beard, 1915, as cited in Whall, 1986a, pp. 242-243).

During the 1800s and early 1900s in the United States, public health nurses and their equivalents in England served families in the home (initially the poor, but later also those with communicable diseases). With bureaucratization in society, specialization in medicine grew (obstetrics, pediatrics, surgery, etc.). Nursing also became specialized, and family medicine and family-oriented nursing practice fell into disuse. Insurance coverage limitations, private and public reimbursement policies and referrals, and lack of preventive funding also were policies that later mitigated against family-focused care (Ford, 1979).

Public health nursing, maternal-child health, and midwifery managed to bridge the gap in some instances and stand as examples of both family-centered and fractionalized care. For instance, obstetrics limits care to the mother, with care of baby left to a different provider, and little interest in other family members; and communicable disease public health nursing services typically include the family only with regard to case finding. An example of where family nursing continued was in the Frontier Nursing Service. Here, the Frontier Nursing Service provided both midwifery and public health nursing services to families.

The four specialty groups in nursing that have been the most ardent in focusing on the family have been community health nursing, which sees the family as client; parent-child nursing, which sees the family as context and client; psychiatric-mental health nursing, which sees extensive family involvement within the family therapy specialization; and the family primary care or nurse practitioner specialty, which sometimes sees the family as a sum of its members, but also views the family as context.

Each of these specialty groups has been informed by both specific developments in its own area of specialization and by more general developments within nursing, social science, and society. For instance, in community health nursing, the legacy was to consider the family as a focus of service. But not until the 1970s was there much substantive content within nursing programs that addressed family theory, assessment, and intervention. In the 1970s we saw texts focusing on family theory and its application to family-centered community health nursing. In community health nursing, sociological and cultural theories of family behavior (such as family socialization, poverty, roles, values, dynamics, and cultural diversity) were important in influencing the field.

Psychiatric-mental health nursing, in contrast, was more heavily influenced by the theories and clinical writings within the family therapy movement. Since these nurses work with troubled families, this knowledge base was more important to assist them in assessing and intervening with dysfunctional families. Family therapy theories and practice models, however, are only one psychotherapeutic modality in mental health. Hence, family nursing assessment and intervention are not widespread throughout the whole specialty area.

Maternal or parent-child nursing has a long history of family involvement—beginning with the early days of midwifery and visiting of mothers and children in the home. It has long been recognized that when caring for mothers and children, the family is crucial. Familycentered texts in pediatrics and maternity are the norm. Most texts primarily see the family as context. Parent-child family-focused nursing has been particularly influenced by growth and development, mother-child bonding, role, and socialization theories.

Family and pediatric nurse practitioners are the fourth specialty area identified as being family focused. In the 1960s it was recognized among health care planners and legislators that specialization in medicine was not meeting the primary health care needs of the whole population in the United States. Federal monies were granted to medical schools to open up family practice programs. The nurse-practitioner movement grew on the coattails of this larger movement concerned with cost-effective, accessible care to all sectors of society. Nurse-practitioner programs have also been heavily federally funded. Family nurse practitioners care for the whole family, but their predominant focus is to see the family as a sum of its members. Both pediatric and family nurse practitioners view the family as context to the individual client. This is changing, however, as some nurse-practitioner programs are incorporating advanced family nursing content into their curricula to attempt to broaden services and to help students “think family” (Wright & Leahey, 2000) or to “think interactionally” (Wright & Leahey).

In addition to the more specific influences each of these specialty areas experienced, certain more general factors have enhanced the growth of family nursing. These include:

The increased recognition in nursing and society of the need for health promotion and a health focus, rather than the practically exclusive disease orientation

Our aging population and the growth of chronic illness, which have brought self-care and the needs of family caregivers into prominence

The widespread awareness concerning the pervasiveness of troubled families in our communities

The promulgation and general acceptance of certain interpersonal and family-based theories, such as attachment and bonding theory, general systems theory, and family stress and coping theories

The marriage and family therapy movements and the growth in child guidance, marriage, and family clinics and services

The growth of family research and the significance of its findings. Two cases in point are:

The extensive and influential family communication research in the 1950s and 1960s, which showed that troubled parents, particularly mothers and their communication patterns, were associated with troubled children

The growing number of family nursing research studies that demonstrate the impact of health stressors and coping on family health outcomes and the effectiveness of family-centered interventions

CURRENT ISSUES IN FAMILY NURSING

From our review of the literature and professional discussions with colleagues in family nursing, eight issues appear to be salient issues in family nursing today:

Practice Issue: The significant gap between theory and research and actual clinical practice. The gap between extant knowledge and the application of this knowledge is clearly a problem in all fields and specialties in nursing, although this gap may be more striking in family nursing. Family-centered nursing also remains a stated ideal rather than prevailing practice. Wright and Leahey (2000) believe that the most important factor creating this gap is “how a nurse conceptualizes health and illness problems. It is the ability to ‘think interactionally’: from an individual to a family (interactional) level” (p. 15). Other authors point out that technology, economic trends such as downsizing services and staff, the greater diversity within the client population (Bowden, Dickey, & Greenberg, 1998), lack of good comprehensive family assessment tools and intervention strategies, nursing’s ties to the medical model (individualistic and disease oriented), and our charting system and nursing diagnostic systems (Hanson, 2001) make incorporation of family-focused care difficult to realize.

Practice Issue: The need to make family nursing more feasible to incorporate into practice. In recent years there has been a dramatic restructuring of health care, which includes the rapid growth of managed care systems wherein complex, multiunit, multilevel systems of health care delivery are being established. Part of this restructuring also involves the trend of patients going home “sicker and quicker” and the downsizing of hospitals, the downsizing of services and staff, and the growth of community-based services. These changes have led to increased job stress and a sense of work