Family Health Care Nursing Theory Practice 5th Edition by Joanna Rowe Kaakinen, Deborah Padgett Coehlo

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Chapter 3

Theoretical Foundations for the Nursing of Families

Theoretical Foundations for the Nursing of Families reviews how theories are used in family nursing, highlighting five foundational theories drawn from sociology, family therapy, and nursing. This chapter focuses on using theory to develop critical and creative thinking to support and implement family interventions in a health event. This chapter also describes how to select and evaluate a family theory for use and how to integrate more than one theory into nursing practice. It provides models and tools for assessment of families and for developing family care plans. Chapter 3 lays the groundwork for theory-guided, evidence-based family nursing practice.

Critical Concepts

· Theories inform the practice of nursing. Practice informs theory and research. Theory, practice, and research are interactive, and all three are critical to the profession of nursing and family care.

· The major purpose of theory in family nursing is to provide knowledge and understanding that improve the quality of nursing care of families.

· By understanding theories and models, nurses are prepared to think more creatively and critically about how health events affect family clients. Theories and models provide different ways of comprehending issues that may be affecting families and offer choices for action.

· The theoretical and conceptual frameworks and models that provide the foundations for nursing of families have evolved from three major traditions and disciplines: family social

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Instructor’s Guide

science, family therapy, and nursing.

· No single theory, model, or conceptual framework adequately describes the complex relationships of health events on family structure, function, and process.

· Nurses who use an integrated theoretical approach build on the strengths of families in creative ways. Nurses who use a singular theoretical approach to working with families limit the possibilities for families they serve. By integrating several theories, nurses acquire different ways to conceptualize problems, thus enhancing thinking about interventions.

Review of Key Terms

Bioecological systems theory: Developmental psychologist Urie Bronfenbrenner advanced this theory, which focuses on the interaction and interdependence of humans (as both biological and social entities) with the environment. It combines systems and developmental theory to understand individual and family growth better in the context of the larger environment of society, which is divided into levels.

Chronic illness framework: Rolland’s conceptual framework involving multiple factors of chronic illness, which have implications for both the affected individual and family functioning over time.

Concepts: Concepts, mental images, or abstract representations of phenomena are building blocks of theory that represent the main ideas the theory expresses, sometimes termed variables. They exist on a continuum from empirical (concrete) to abstract. Examples of concrete concepts are sex and age; examples of abstract concepts are family and health.

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Conceptual model or framework: The terms model and framework are sometimes used interchangeably to mean a set of interrelated concepts that symbolically represent and convey a mental image of a phenomenon. They are more abstract and more comprehensive than a theory. They integrate concepts into a meaningful configuration or pattern. They are less predictive than a theory and symbolize only that there is a relationship among the concepts in the framework. For example, nursing models are not considered stringent enough to be theories because they are not predictive.

Developmental theory: According to developmental theory, human beings have specific tasks at specific periods in their life span, and successful achievement of the tasks at one stage of life leads to happiness and success with later tasks. Failure to achieve tasks leads to unhappiness, disapproval, and difficulty in achieving later tasks.

Family assessment and intervention model: Developed by Berkey and Hanson (1991) as an extension and modification of Neuman’s health care systems model to expand the focus from care of an individual to family health nursing care. It focuses specifically on what issues cause family stress and how families react and respond to these stressors. One critical concept is for nurses to help families identify their strengths and build on them to create problem-solving strategies. The Family Systems Stressor-Strength Inventory (FS³I) is an assessment and measurement instrument designed according to this model.

Family life cycle theory: This is a descriptive developmental theory about the tasks and processes of families. Stages are based on the age of the oldest child of a nuclear family. Duvall developed the most common family life cycle theory. It has been criticized for not being applicable to nontraditional families. However, similar theories have now been developed for divorced and blended families.

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Instructor’s Guide

Family social science theories: These are a set of theories about how families work that are based in the social science theories, especially sociological theories.

Family systems theory: In the family systems theory, families are viewed as an organized whole, and individuals in the family are interdependent and interactive. Every family system has features designed to maintain stability or homeostasis, although these features may be adaptive or maladaptive. At the same time, the family changes constantly in response to stresses and strains from the external environment, as well as from the internal family environment. Theories: Theories are abstract, general ideas subject to rules of organization, composed of concepts and the relationships among concepts. They are selected and organized as abstract representations of phenomena. They are a set of statements that tentatively describe, explain, or predict relationships among concepts. Examples of theories are family systems theory and family development theory.

Quiz and Exam Questions

1. Which of the following statements about theories is accurate?

1. Theories are subject to rules of organization.

1. Theories are statements about how some part of the world works.

1. Theories represent logical and intelligible patterns that make sense of observations.

1. All of the above

2. The conceptual and theoretical frameworks that provide the foundation for family nursing

have evolved from the following three major traditions and disciplines:

___________________________, __________________, and ___________________.

Answer: family social science, family therapy, and nursing

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Instructor’s Guide

3. Theory and research inform family nursing practice, but in turn, practice does not inform theory development or research. Is this a true or false statement? Why?

Answer: False. Theory and research inform nursing practice, and practice informs

theory development and research.

For questions 4 through 8, match the right word from Set A with one of the definitions in Set B. Set A

1. theories

1. concepts

1. propositions

1. hypotheses

1. conceptual frameworks

Set B

4. Statement of expected relationships between concepts ___________________

5. Set of propositions that integrate concepts into a meaningful pattern ________

6. Statements about the relationship among two or more concepts ____________

7. Abstract ideas that are subjects to rules of organization __________________

8. Words that are mental images or abstract representations of phenomena _____

Answers: 4 (d), 5 (e), 6 (c), 7 (a), 8 (b)

For questions 9 through 11, match the different theories from Set A with their professional origins listed in Set B.

Set A

1. developmental life cycle theory

1. family systems theory

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c. ecological theory
Set B
9. Family therapy ________________
10.	Nursing ______________________
11.	Family social science____________
		Answers: 9 (b), 10 (c), 11 (a)

Reflection Questions

1. Is it important for nurses to integrate conceptual and theoretical frameworks when working with families? Why or why not? (Support your answers.)

Important points: Families are complex, small groups in which multiple processes and dynamics occur simultaneously. Families do not function in one way alone. Today, no single theory or conceptual framework from family social science, family therapy theory, or nursing fully describes the dynamics of family life. Nurses who use only one theoretical approach to working with families are limiting the possibilities for families. Integrating theories allows nurses to view the family from a variety of perspectives, which increases the probability the family will implement the interventions selected, because they fit the family’s structure, processes, and style of functioning. Instead of fragmented knowledge and piecemeal interventions, nursing practice is then based on an organized, realistic conceptualization of families. Nurses who use an integrated theoretical approach build on the strengths of families in creative ways.

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Instructor’s Guide

2. Find an example from your clinical practice that illustrates the use of theory (perhaps to guide your nursing care planning and interventions). Who chose the particular theory and why? Are there other theories that could be used in the same family situation?

3. Reflecting on health issues in your own family, compare and contrast how each theory presented in this chapter could inform a family nursing care plan (family systems theory, Family Developmental Theory, bioecological systems theory, chronic illness framework, and family assessment and intervention model).

Student Learning Activities

1. Have students find and select a research article that investigates a question or describes family function. Review it to determine the conceptual framework or theoretical approach(es) used to support the study and the findings. How did the theoretical concepts the authors studied contribute or limit the findings about families? How will this knowledge assist nurses in caring for families?

2. Have students select one of the theories presented in this chapter. Briefly identify the key person or people the theory is associated with, the primary focus of the theory (e.g., individual, family, organization, or society), and the key concepts associated with the theory. Have the students reference where they found the information about the theory (lecture, text, film, computer, journal articles, edited book, etc.). Have the students summarize the theory by answering the following questions:

1. What is the main problem the theory attempts to explain?

1. What explanation does the theory offer?

1. What solution does the theory suggest?

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Instructor’s Guide

1. What is the main weakness or criticism of this theory?

1. How can this theory be applied? Use an actual case example, outlining how the problem could be addressed using the theory for individuals, families, or society. Use the theory to explain why the problem occurs.

Case Study

The following case study of the Jones family is used throughout the rest of this chapter to demonstrate how different assessments, interventions, and options for care vary given the particular theoretical perspective chosen by nurses caring for this family.

Figure 3-3. Jones family genogram.

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Instructor’s Guide

Figure 3-4. Jones family ecomap.

Setting: Inpatient acute care hospital

Nursing Goal: Work with the family to assist them in preparation for discharge that is planned to occur in the next 2 days

Family Members:

· Robert: 48 years old; father, software engineer, full-time employed

· Linda: 43 years old; mother, stay-at-home homemaker

· Amy: 19 years old; oldest child, daughter, freshman at university in town 180 miles away

· Katie: 13 years old; middle child, daughter, sixth grade, usually a good student

· Travis: 4 years old; youngest child, son, all-day preschool

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Jones Family Story

Linda was diagnosed with multiple sclerosis (MS) at age 30, when Katie was 3 months old. Pregnancy often masks the symptoms of MS; therefore, a pregnant woman who experiences development of MS during pregnancy will show symptoms after the birth of the child. After she was diagnosed with MS, Linda had a well-controlled, slow progression of her illness. Travis was a surprise pregnancy for Linda at age 39, but he is described as “a blessing.” Linda and Robert are devout Baptists, but they did discuss abortion, given that Linda’s illness might progress significantly after the birth of Travis. Their faith and personal beliefs did not support abortion. They made the decision to continue with Linda’s pregnancy knowing the risks, namely that it might exacerbate and speed up her MS. Linda had an uncomplicated pregnancy with Travis. She felt well until 3 months postpartum with Travis, when she noted a significant relapse of her MS.

Over the past 4 years, Linda has experienced development of progressive relapsing MS, which is a progressive disease from onset, with clear acute relapses without full recovery after each relapse. Continuing progression of the disease characterizes the periods between her relapses. Because of her increased weakness, Robert and Linda are having sexual issues with decreased libido and painful intercourse for Linda. Both are experiencing stress in their marital roles and relationship.

Currently, Linda has had a serious relapse of her MS. She is hospitalized for secondary pneumonia from aspiration. She has weakness in all limbs, left foot drag, and increasing ataxia. Linda will be discharged with a wheelchair (this is new because she has used a cane until this admission). She has weakness of her neck muscles and cannot hold her head up steady for long periods. She has difficulty swallowing, which probably was the cause of her aspiration. She has

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numbness and tingling of her legs and feet. She has severe pain with flexion of her neck. Her vision is blurred. She experiences vertigo at times and has periodic tinnitus. Constipation is a constant problem together with urinary retention that causes periodic urinary tract infections.

Health Insurance

Robert receives health insurance that covers the whole family through his work. Hospitalizations are covered 80/20, so they have to pay 20 percent of their bills out-of-pocket. Although Robert is employed full-full-time, this adds heavily to the financial burden of the family. Robert has shared with the nurses that he does not know whether he should take his last week of vacation when his wife comes home or save it for a time when her condition worsens. Robert works for a company that offers family leave, but he would have to take family leave without pay.

Family Members

Robert reports being continuously tired with caring for his wife and children, as well as working full-time. He asked the doctor for medication to help him sleep and decrease his anxiety. He said he is afraid that he may not hear Linda in the night when she needs help. He is open to his mother moving in to help care for Linda and the children. He began counseling sessions with the pastor in their church.

Amy is a freshman at a university that is 180 miles away. Her mother is proud of Amy going to college on a full scholarship. Amy does well in her coursework but travels home on weekends to help the family and her mother. Amy is considering giving up her scholarship to transfer home to attend the local community college. She has not told her parents about this idea yet.

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Katie is in the sixth grade. She is typically a good student, but her latest report card showed that she dropped a letter grade in most of her classes. Katie is quiet. She stopped having friends over to her home about 6 months ago, when her mother began to have more ataxia and slurring of speech. Linda used to be very involved in Katie’s school but is no longer involved because of her illness. Katie has been involved in Girl Scouts and the youth group at church.

Travis just started going to preschool 2 months ago for half days because of his mother’s illness. This transition to preschool has been difficult for Travis because was home full-full-time with Linda until her disease got worse. He is healthy and developmentally on-target for his age.

Linda’s parents live in the same town. Her parents, Tom and Sally, both work full-time and are not able to help. Robert’s widowed mother, Elise, lives by herself in her own home about 30 minutes out of town and has offered to move into the Jones home to help with the care of Linda and the family.

Discharge Plans: Linda will be discharged home in 2 days.

Case Study Discussion Questions and Activities

1. Have small groups of students select one or two family theories to use to assess this family, considering the present and the multigenerational patterns or the past.

2. Develop a care plan using the selected theories.

3. Compare and contrast the different care plans different students developed using different combinations of theories.

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Chapter 4

Family Nursing Assessment and Intervention

Family health care nursing uses assessment, clinical judgment, creativity, critical thinking, evaluation, and reflective processes. This complexity is necessary to provide adequate care for increasingly diverse family populations. Building on what students know about using the nursing process for an individual client’s care, Chapter 4 provides an overview of family nursing assessment models and instruments that nurses can use when working with families as clients. The models described in this chapter include the family assessment and intervention model (Berkey-Mischke & Hanson, 1991), the Friedman Family Assessment Theory and Model (Friedman et al., 2003), and the Calgary Family Assessment Model (Wright & Leahey, 2013).

Approximately 1,000 family-focused instruments and tools exist for the nurse to select from, and selection of an appropriate instrument for the family situation can be complex. This chapter features the following tools and instruments for use in designing family health care according to the nursing process:

1. The Family Systems Stressor-Strength Inventory (FS³I) (Berkey-Mischke & Hanson, 1991; Hanson, 2001; Kaakinen, Hanson, & Denham, 2010)

2. The family genogram and ecomap

3. The Family Reasoning Web (Tabacco & Kaakinen, 2010)

4. North American Nurses Diagnosis Association (NANDA) classification system (2007)

5. Beliefs and Illness Model (Wright & Bell, 2009)

6. Patient/Parent Information and Involvement Assessment Tool (PIINT; Sobo, 2001)

Note: The Handbook of Family Measurement Techniques (Touliatos, Perlmutter, & Strauss, 2001) can augment this list of tools and is useful in identifying family variables.

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Chapter 4 assists students in comprehending the variety and complexity of variables that affect the selection of tools for family assessment, intervention, and evaluation. It helps students differentiate between tools for screening and assessment, testing or measurement and outcome parameters, and quantitative versus qualitative data collection methods. This chapter illuminates the value of using both the traditional nursing process and newer nursing process models, emphasizing the creativity involved in family health care nursing. A case study that uses the steps of the nursing process as well as provides various models and tools for further understanding is included.

Critical Concepts

· Families are complex social systems with which nurses interact in many ways and in many contexts; the use of a logical systematic family nursing assessment approach is important.

· In the context of family nursing, the creative nurse thinker must be aware of possibilities, be able to recognize the new and the unusual, be able to decipher unique and complex situations, and be inventive in designing an approach to family care.

· Nurses determine through which theoretical and practice lens(es) to analyze the family event.

· Knowledge about family structures, functions, and processes informs nurses in their efforts to optimize and provide individualized nursing care, tailored to the uniqueness of every family system.

· Nurses begin family assessment from the moment of contact or referral.

· Family stories are narratives that nurses construct in framing, contextualizing, educating, communicating, and providing interpretations of their family clients’ needs as they exercise clinical judgment in their work.

· Interacting with families as clients requires knowledge of family assessment and intervention

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Instructor’s Guide

models, as well as skilled communication techniques so that the interaction will be effective and efficient for all parties.

· 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 itself a powerful intervention.

· Families’ beliefs about health and illness, about nurses and other health care providers, and about themselves are essential for nurses to explore to craft effective approaches to family interventions and promote health literacy.

· Families determine the level of nurses’ involvement in their health and illness journeys, and nurses seek to tailor their work and approach accordingly.

· Nurses and families who work together and build on family strengths are in the best position to determine and prioritize specific family needs; develop realistic outcomes; and design, evaluate, and modify a plan of action that has a high probability of being implemented by the family.

· The final step in working with families 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.

Review of Key Terms

Assessment: A continuously evolving process of data collection in which the nurse, drawing on the past and the present, is able to predict or plan the future. Client story: The problem the family is currently experiencing.

Data: Pieces of information collected in a study to answer research questions.

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Desired outcomes: To determine whether the outcome is being achieved, the nurse identifies tests or measures that will provide information about the resolution of the problems. Nurses make decisions about which nursing interventions are most appropriate for the family. Ecomap: A diagrammatical assessment procedure (drawing) that portrays the family’s relationships to other systems in the community in which the family is imbedded, that is, work, school, and church, among others.

Family-centered care (FCC): According to the Institute for Patient- and Family-Centered Care (IPFCC, 2013), the core principles are respect and dignity, information sharing, participation, and collaboration. The goal of FCC is to increase the mutual benefit of health care provision for all parties, with a focus on improving the satisfaction and outcome of health care for families (IPFCC, 2013).

Family Reasoning Web: The process of gathering data by asking about organizational categories and placing information into meaningful groups so that nurses can identify relationships and make accurate family diagnoses.

Genogram: A format for diagramming a family that illustrates family structure. Other information that is included on the drawing is family constellation, health history, and family relationships.

Judgment: The decision the nurse makes to evaluate client progress toward the desired

outcomes.

Nursing diagnosis: A clinical judgment about individual family or a community response to actual and potential health problems or life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. Although NANDA is the most global nursing classification system, not all family situations will

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match those in existence that are specific to family. Nurses are encouraged to create a family nursing diagnosis that captures the essence of a family issue or problem.

Nursing process: An orderly, systematic manner of determining the client’s problems, making plans to solve them, initiating the plan or assigning others to implement it, and evaluating the extent to which the plan was effective in resolving the problems identified. Prevention: (1) Primary: focuses on preventing the occurrence of health problems; (2)

secondary: designed to identify and treat health problems early; (3) tertiary: aimed at correcting health problems and preventing further deterioration.

Reflection: A strategy nurses use to review and learn from clients to enhance and expand their practice base.

Shared decision making: The process of building a therapeutic relationship to allow shared decision making with family members and health care providers to develop an effective action plan or care plan.

Quiz and Exam Questions

1. Assessment can be defined as:

1. a continuously evolving process of data collection to assist nurses in using information from the past and present to predict the future.

1. the process of assigning numbers or symbols to variables to assist nurses in measuring particular characteristics of family members.

1. an instrument family nurses use to give a quantifiable result when examining a particular attribute.

1. a tool nurses use to obtain important family information in less than 15 minutes.

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