Thinking Like a Nurse
Means Thinking About
the Family
Jane Ball, RN, DrPH
Ruth Bindler, RN, PhD
Kay Cowen, RN, MSN
Thursday, October 30, 2014
Jane Ball, RN, CPNP, DrPH
Ruth Bindler, RNC, PhD
Kay Cowen, RN-BC, MSN
“Often when nurse educators hear family-centered care, they
automatically think, "pediatric nursing", but a focus on the family is
important to nearly all patient populations. Furthermore, a familycentered clinical mindset is key to improving clinical reasoning and
judgment as it expands thinking beyond an individual point of care
moment to include broader considerations that may impact patient
care.”
OBJECTIVES
• define family-centered care and its importance in
caring for patients;
• provide examples of how family-centered care
considerations translates into general patient
care;
• demonstrate how population health concerns may
impact families and individual patients
• share patient teaching examples of how to
transition the adolescent patient with chronic
conditions to adult services;
• share active teaching strategies to reinforce
family-centered care across the curriculum
Defining “Family”
•Many definitions of family exist.
•A family is usually a self-identified group of
two or more persons joined together by
shared resources and emotional closeness.
•Family members may or may not be related
by blood, marriage, or adoption, and in
some cases they do not even live in the
same household.
•What is important is that family members
depend upon each other for emotional,
physical, and economic support.
•Families are guided by a common set of
values or beliefs about the worth and
importance of certain ideas and traditions.
•Examples include one parent families with
children, traditional families with two
parents, families with multiple generations
residing together, and gay or lesbian
couples with children.
Defining “Family-centered Care”
• Family centered care is a deliberate and dynamic approach to
building collaborative relationships between the nurse (or
other health professionals) and families.
• This approach must be respectful of the family’s diversity and
their beliefs about the nature of the child’s health conditions
and how to manage them.
• Family-centered care extends to all patients family care for:
– families with young children who are unable to participate in
decision making about the care they receive. Parents are
expected to be responsible for the care of children, but they
need guidance from health professionals to plan ways to provide
care at home in a manner that meets the needs of the child and
also fits within the family’s life and routines.
– Adults who are hospitalized for an acute illness or surgery and
are discharged early in the recovery process and need
monitoring and care when in the home – a family member is
usually expected to provide that care. The nurse needs to
develop a collaborative relationship with the family to ensure
proper care is given after the patient is discharged.
The Gonzalez Family
• The family emigrated from Mexico seven
years ago and all are now U.S. citizens.
• Family members:
– grandmother, Inez, who works in the fields at
times, but due to her age and frailty, often
remains home to do the cooking and
housework;
– mother and father, Julio and Maria, work in
the fields every day that they can, during the
winter there is little work but they make
cheese from their goats and work in various
jobs as available;
– 3 children – Gemma, a high school junior;
Ricardo, who is in 7th grade; and Isabella who
is in 2nd grade.
• Gemma does well in school but the school
nurse is concerned that she is quite
overweight. Gemma claims she does not like
the food that her grandmother makes, and
uses her spending money to buy fast food
as she walks to and from school. She rarely
exercises except in PE which she dislikes.
• The entire family became ill after consuming
homemade cheese made by Inez and wants
to know how to avoid that problem.
Family-centered Nursing Intervention
•
The school nurse meets with Gemma and learns that she wants to lose weight
but has little knowledge about how to do that.
– The nurse identifies an after school program with “fun” activities and healthy snacks that
appeals to Gemma.
– The nurse also assists the family in completing forms for reduced cost breakfast and
lunch, and Gemma becomes enrolled in the program. Gemma thought that if she got
school lunch her friends would know she was poor but the school has a card system that
keeps the payment option for each student private so she became receptive to eating
there and decreasing fast food snacks.
– The nurse also learns that the farmers have a gleaning program and allow the workers
to collect edible but slightly bruised fruits to take home to the family. She informs the
parents who take this opportunity and provide fruits for each child to take to school
daily.
•
Obesity in youth is almost always associated with eating and physical activity
patterns as well as family roles all must be considered. In this extended family,
the grandmother had a major role for preparing food, and the teen was, as
typical teens are, influenced by concerns about peer expectations. An
intersection of family needs, development, and cultural mores was important to
consider.
•
Also, there are several contaminants that can be present in homemade cheeses,
the major one which is Listeria. Several of the land grant universities in the west
have had classes and produced videos about how to prepare homemade cheese
safely. The school nurse worked with the community health nurse who provided
this information for the grandmother, Inez, and then showed it at a community
forum for many of the farmworker families.
The Marcos Family
• The Marcos family from the Denver area has multiple adults
and children living as an extended family, includes:
• the grandparents, the parents of Emmi, Mannie, and Zeke
who are 6, 9, and 12 years old, and the parents of Thomas,
Joseph, and Reina who are 7, 12, and 16 years old.
• Reina is pregnant and expecting a baby in 3 months. The
baby’s father is 18 years old and is attempting to make
efforts to assume responsibility for Reina and the baby.
• The parents of both sets of children work in a variety of
settings, such as food service, day care, home care for
seniors, and environmental services.
• The grandparents also work, and all family members
participate in food preparation for the family and jointly
caring for each other’s children.
• The family is also very active in their community church
and with other extended family in the area.
Family-centered Care Considerations
• The Denver area has been experiencing a pertussis
(whooping cough) epidemic in young infants and children
who have not been immunized.
• Many adults who might have been immunized with the
pertussis vaccine as children no longer have active immunity
as the vaccine effect has diminished. In recent years an
adult formulation of the tetanus- diphtheria vaccine was
developed that also includes the acellular pertussis vaccine.
Many adults only receive a tetanus injection in association
with an injury.
• The nurse caring for Reina at the OB clinic is interested in
helping Reina to protect her newborn from developing
pertussis which can be life threatening at that age.
Guidelines from the CDC recommend that adolescents and
adults who are likely to have close contact with an infant
aged <12 months old should receive a single dose of Tdap to
protect against pertussis if they have not previously received
this vaccine, optimally at least 2 weeks before the baby’s
birth.
Family-centered Nursing Interventions
• The nurse asks Reina to find out information about the
immunization status of her parents and grandparents. If
they have not received the Tdap vaccine, she encourages
Reina to ask them to get the vaccine.
• Reina soon learns that the grandparents and 2 of the
parents have not been immunized. Reina reports this
information to the nurse on her next visit, and the nurse
then informs Reina that the vaccines can be obtained at a
local pharmacy or health department clinic.
• Reina’s OB nurse practitioner provides a signed prescription
for each family member needing the vaccine to make it
easier for them to obtain it.
• This family-centered care strategy illustrates the
importance of adult immunizations and their role in
protecting all members of the family.
Transitioning the Adolescent
Patient
•
•
•
•
•
•
•
Mark is 17 years old and a junior in high school has cystic fibrosis living with his mother, stepfather, and 2 sisters, one of whom also has cystic fibrosis.
Mark has been fortunate to live in a city with a cystic fibrosis specialty clinic at the university
hospital. Mark’s mother worked carefully with the health professionals in the CF clinic to provide
all the recommended treatments and find ways to fit them into a schedule that made sense for
Mark’s school day and family activities.
For respiratory therapy, he uses a bronchodilator and inhaler to moisten secretions, followed by a
oscillating vest 3 times a day to loosen secretions that he must cough up.
Mark’s mother is very much engaged in ongoing management of Mark’s condition and has
provided the high caloric diet and other medications needed to keep his condition under control.
Mark has a gastrostomy tube to ensure that he receives the extra calories needed for his
adolescent growth spurt and to promote his resistance to infection.
His pediatrician worked collaboratively with the cystic fibrosis clinic to provide routine health care
as well as treatment for respiratory infections that frequently develop and wants to transfer Mark
to an adult primary care physician when he is 18.
At this time, it is not known if or when Mark will be expected to live independently after he
graduates from high school and looks for a job. Mark has relatively frequent episodes of
respiratory infections, and he will be limited to finding a job that does not require much physical
effort.
The nurse in the CF clinic has begun working with Mark and his mother on a transitional health
plan that includes identifying a new primary care physician, but he will continue to receive some
specialty care through the CF clinic. This transition process is likely to take several visits over a
year. Mark needs a plan to take total responsibility for his care. When you have an individual
with a life-limiting condition, what is the role of the family? How challenging will it be for his
mother to stand back and serve as Mark’s consultant rather than the manager of his care?
Family-centered Care Questions:
Transitioning Adolescent Patients
• When you have an individual with a life-limiting
condition, what is the role of the family?
• How challenging will it be for his mother to stand
back and serve as Mark’s consultant rather than the
manager of his care?
• What happens when Mark has an acute episode
related to CF or diabetes mellitus?
• Will Mark’s mother still be available to assist him
during the recuperation?
• What if Mark develops a significant relationship with
someone and moves out of the family home?
• How would that new family member become
educated and integrated into Mark’s care plan?
Family-centered Care based Active
Teaching Strategy #1
• Have students follow a family for their entire curriculum or for a
semester or two.
• If a child has asthma, the student can study the pathophysiology of
the condition, the medications and other treatments, and can attend
healthcare visits with the child.
• The student also should interview everyone in the family with
questions such as history of allergy in family members, use of
tobacco products (either in or outside of the home), adult
employment and exposure to contaminants on clothing.
• Questions for the student to have answered:
– Can parents get away from work when necessary to seek care for the
child?
– Do family resources allow for insurance coverage of treatment and for
getting to appointments?
– Where does the family live?
– Does that increase the chances of asthma occurring?
– What environmental factors can be altered and which cannot?
• Seeing the trajectory of the illness, the influence of the family
situation on the illness, and the influence of the illness on the family
are powerful learning opportunities.
Family-centered Care based Active
Teaching Strategy #2
• Healthy People 2020 provides clear data and objectives for
many conditions. Have your students seek out the leading
health indicators for oral health for example.
• Oral Health (OH) Objective 7 states “Increase the proportion
of children, adolescents, and adults who used the oral
health care system in the past year.”
• Using the data from the HP2020 website, the student will
learn that only 44.5% of children meet that objective, but
the nation is striving to increase this number to the goal of
49%. Students can then research ways that families access
oral health care, find resources in their communities, and
learn about the relationship of poor oral health to other
diseases. Tie the HP2020 goal to the student’s goal or
objective for care in their nursing care plan. Linking HP2020
to families, your own communities, and pathophysiology ties
all of these factors together for students.
Family-centered Care based Active
Teaching Strategy #3
• Have your nursing students work in a
group with students in pharmacy, physical
therapy, occupational therapy, social work
and medicine.
• Assign a Team Challenge such as the
scenario involving a child with asthma who
wants to complete a local 5 mile fun walk.
• Write the scenario so that each profession
can contribute their specialty's unique
knowledge about asthma and how the goal
can be met.