Learning Objectives
By the end of this section, you will be able to:
- Describe actions involved in the nursing assessment of the family
- Understand different nursing interventions to promote family health
- Verbalize how the nurse collaborates with interprofessional teams
The nurse’s role in caring for the family unit begins with a comprehensive family assessment, including therapeutic conversation techniques. An overview of family functioning also includes assessing individual roles within the family. Understanding the family values and behaviors allows the nurse to recognize specific needs and customize care plans for the family. Nurses will collaborate with other medical and social work professionals to create family care plans.
Nursing Assessment of the Family
The nursing assessment of the family involves direct assessment of an individual and their family members. This adds a further dimension to the nursing assessment by evaluating the individual through the lens of family interaction. This includes observing interactions between family members and between the family and other individuals, such as healthcare providers, friends, or community members. For nurses, keeping in mind the elements of therapeutic conversation will improve their ability to understand family dynamics. A detailed assessment of the individual and family helps the nurse uncover risk factors that may play a role in health and illness.
Observation
Observation is an ongoing assessment tool that is paramount for nurses. In caring for families, nurses will be alert to positive interpersonal and negative interactions among family members. Nurses will use their observation skills to identify the most prominent support persons and identify cultural values within the family that can affect healthcare access, compliance, and recovery and outcomes. Nurses can observe individuals interacting in person and notice how patients discuss their families. In cases of family dysfunction, the nurse must remain alert for any signs of abuse, neglect, or emotional trauma. Nurses who care for families on multiple occasions or repeatedly over a long duration can develop relationships with patients, allowing them to notice subtle changes within the family that may give clues to illness.
Therapeutic Communication
Therapeutic communication is crucial in all nurse-patient interactions (Table 37.5). In caring for families, nurses must maintain respect for family values and culture. Nurses can recognize verbal and nonverbal cues from family members. When families struggle with illness or health crises, keeping communication to the point may help them retain needed information and process it as a group. Families need time to discuss options, clarify plans, and create a shared experience around the health crisis. Nurses can use techniques in family discussions, such as beginning with broad topics and moving to more specific intervention and treatment discussions. Nurses should consider differing views and values within the family when discussing treatment options. The nurse should also consider the privacy of the patient. In most cases, the patient must request that a family member be present during an assessment or discussion about their health care. This includes telephone discussion and electronic communication methods. The nurse must be able to explain healthcare privacy rules to families clearly. This will vary depending on the age of the patient, child versus adult. This ensures that patients understand their privacy is respected and that family members understand their roles and rights with regard to family member health information.
| Therapeutic Techniques | Definition | Example |
|---|---|---|
| Acceptance | Acceptance acknowledges a patient’s emotions or message and affirms they have been heard. Patients who feel their nurses are listening to them and taking them seriously are more likely to be receptive to care. | Patient: “I hate taking all this medicine. It makes me feel numb.” Nurse (making eye contact): “Yes, I understand.” |
| Clarification | Clarification asks the family member to further define what they are communicating. It helps nurses ensure they understand what is actually being said and can help patients process their ideas more thoroughly. | Mother: “I feel useless to my child and my family.” Nurse: “I’m not sure I understand what you mean by useless. Can you give an example of a time you felt useless?” |
| Focusing | Focusing on a specific statement made by a patient that seems particularly important prompts them to discuss it further. Patients don’t always have an objective perspective on their situation or past experiences, but as impartial observers, nurses can more easily pick out important topics on which to focus. | Patient: “I grew up with five brothers and sisters. We didn’t have much money, so my mom was always working and never home. We had to fend for ourselves, and there was never any food in the house.” Nurse: “It sounds as if you experienced some stressful conditions growing up.” |
| Giving recognition | Giving recognition acknowledges and validates the family’s positive health behaviors. Recognition acknowledges behavior and highlights it without giving an overt compliment. | Nurse: “It sounds like you’ve been enjoying your time exercising together.” |
| Open-ended questions/ offering general leads | Therapeutic communication is most effective when patients direct the flow of conversation and decide what to talk about. Giving families a broad opening such as “What would you like to talk about?” is a good way to encourage clients to discuss what’s on their mind. | Father: “I’m unsure of what to do next.” Nurse: “Tell me more about your concerns.” |
| Reflecting | Reflecting asks patients what they think they should do, encourages them to be accountable for their own actions, and helps them come up with solutions. | Daughter: “Do you think I should encourage my mom to accept this new dementia treatment?” Nurse: “What do you think the pros and cons are for the new treatment plan?” |
| Making observations | Observations about the appearance, demeanor, or behavior of patients can help draw attention to areas that might pose a problem for them. | Nurse: “You look tired today.” Mother: “I haven’t been getting much sleep lately because of how worried I am about my daughter’s health.” |
| Offering hope | Offering hope encourages a family to persevere and be resilient. | Nurse: “I remember you shared with me how well your family adapted when your niece was diagnosed with diabetes.” |
Identify Risk Factors
Nurses who focus on therapeutic communication and have excellent listening skills will find that they can identify patient and family risk factors in nearly every patient interaction. The things that patients say, their visible interactions with others, and their subtle nonverbal communication will give clues to risk factors. In addition, identifying important aspects of the family history is crucial. Creating a sense of rapport with patients allows nurses to obtain detailed information in a safe atmosphere.
Disease risk factors are present within the family history. The nurse asks questions that elicit information about the health status, age, and, if applicable, cause of death and age at the time of death of blood relatives (parents, grandparents, siblings, children, nieces, nephews). Questions to ask include the following:
- Tell me about the health of your blood relatives. Do they have any chronic or acute diseases (e.g., cardiac, cancer, mental health issues)?
- Have any of your blood relatives died? If so, do you know the cause of death? And at what age did they die?
Nurses also want to assess the health status of non-blood relatives and individuals that clients have had close encounters with or live with; this can be an essential part of the assessment, particularly in terms of communicable diseases. Questions to ask include the following:
- Tell me about the health status of those you live with. Has anyone been sick recently? If so, do you know the cause? What symptoms have they had?
- Have you been around anyone else who was sick recently (e.g., at work, at school, or in a location that involved a close encounter, such as a plane or an office)?
Nursing Interventions to Promote Family Health
Nurses must focus on individual patients and their families in providing care for families. Because many health habits, outcomes, risks, and diseases develop in the context of family habits and behavior, focusing on treating the whole family will improve outcomes for all. In addition, specific family interventions ensure that individuals with illness can recover within a supportive and healthful family environment. Researchers explain that health begins at home and that the family directly influences individuals’ health (Hanson et al., 2019). Nursing care for the family can focus on primary prevention and risk assessment, disease education, medication and treatment management, connections with community, and healthcare resources. In these interactions with families, nurses can consider aspects including the following (Hanson et al., 2019):
- family engagement: relationship patterns that support individual well-being
- family responsibility: caretaking ability and advocacy for family members
- family stability: the resilience of the family structure in the face of health crisis
- family diversity: varying family values and roles that affect health outcomes
Nurses can apply these considerations to various areas that are important in providing family-based interventions for patients.
Education
Family-directed education may be focused on individual patient education that incorporates the family as a support system. In caring for families, nurses encounter situations where education for the whole family is important, such as in family planning, prenatal care, and well-child care. These educational opportunities may arise at dedicated visits but may also be incorporated into other patient interactions as appropriate. One primary goal of family education is reducing health risks and preventing disease. Risk reduction considers family genetic history, disease history, lifestyle, cultural beliefs, and values about health care. Nurses need to assess each family member’s engagement and understand each family member’s responsibility within the group. Having an idea of family stability will also guide education, as a high-risk family may require more focus on high-risk concerns. In contrast, a stable family may be focused more on preventative measures to improve and maintain health. Understanding family diversity also helps the nurse personalize the education plan, create interventions that are appropriate and culturally sensitive, and offer treatments that have a high likelihood of follow-through.
Screening for Risk
A significant part of nursing care of the family relates to developing a plan for determining family risk. This may include risk factors that run in the family, such as cancers, cardiovascular disease, and diabetes. Nurses must discuss health risks with individual family members and enlist the help of other family members as necessary in putting together a family ecomap or genogram that may uncover genetic risk factors. Nurses can encourage families to take responsibility for minimizing risks, particularly modifiable ones. This will often include behavior modifications to improve lifestyle, which may consist of parents taking responsibility to avoid tobacco use, limit alcohol use, exercise with their children, and provide and role-model healthy eating habits. Other screening for families includes prenatal screening, autism screening, and genetic testing in families in which certain cancer types are prevalent. Nurses must be aware of family cultural values and beliefs about health care when recommending screening. Nurses can also be advocates for routine screening for depression and mental health disorders that are known to cause ripple effects through the family structure if not diagnosed and treated. A variety of screening tools are available to assess individuals for depression, for example. Nurses can also use family assessment tools to identify families at risk for addiction concerns, violence, economic strain, or abuse. Understanding these psychosocial risks within a family helps the nurse create a treatment plan that includes appropriate community resources.
Pharmacological Management
While pharmacological management is primarily focused on individual care, it becomes the family’s responsibility in situations where family members are also caregivers, such as with children. Other conditions in which a family member may be responsible for medication management include the following:
- developmental delays
- dementia
- debilitating mental health disorders
- physical disabilities
Nurses evaluate the need for family interventions regarding medication education, administration, and long-term management. Family stability and engagement are important in medication management because creating an appropriate medication regimen is crucial for adherence as well as the efficacy of medication therapy. The teach-back method is the gold standard for education about health-related treatments and medications. This is particularly important for medications administered through injection, such as insulin. This method can be adapted to include family members engaged in medication administration and assistance. Consulting family members is also an effective way to help determine the response and effectiveness of the medication, particularly in cases of mental health disorders and behavioral health disorders.
Referrals to Community Resources
Nurses will find themselves frequently making referrals to various community resources for families. These resources may be directly related to a chronic or acute health conditions. In addition, community resources are available to help families obtain and maintain basic needs. These resources may include the following:
- housing assistance
- state Medicaid services
- nutrition services
- family planning clinics
- mental health support services
- autism support services
- home safety services
- educational services, such as HeadStart
- substance use support services
- youth homes
- disease-specific support groups
- WIC (Women, Infants, and Children)
Life-Stage Context
Autism Screening
Autism spectrum disorder (ASD) is a prevalent and fast-growing bio-neurological developmental disability. It is most often diagnosed in childhood, although adolescent and adult diagnoses of less severe cases may occur. Nurses can be alert for specific risk factors that may indicate that screening for ASD is warranted. These risk factors include the following:
- genetic disorders
- sensory integration dysfunction
- sleep disorders
- autoimmune disorders
- speech delay
- anxiety disorders
- behavior concerns
- feeding problems
Nurses must focus on identifying risk factors and referring for screening. Screening is essential, as early diagnosis and intervention are the keys to limiting the impact of ASD on the individual and the family (National Autism Association, n.d.).
Collaborate with Interprofessional Team
Nurses collaborate with professionals from many other specialties when caring for families. Depending on the type of needs of the family or individual within the family, the nurse may collaborate with the following:
- physical therapists
- occupational therapists
- speech therapists
- mental health professionals
- spiritual advisors
Therapists
Family therapists and counselors will focus primarily on the health of the family as a whole and interactions among the family members. Nurses may refer patients and families to therapists to address long-standing issues and develop coping strategies for acute health crises. In addition, mental health concerns within the family, past trauma, death and grief, divorce, stress, sudden change, and other dysfunctional dynamics are triggers for therapy referral. Common types of counseling for families include the following (Cleveland Clinic, 2022):
- functional family therapy: focuses on behavior, communication, and parenting skills
- relationship counseling: focuses on communication and problem-solving for couples in a long-term or romantic relationship
- strategic family therapy: focuses on making structural and behavioral changes to improve the overall family environment
- structural family therapy: focuses on interpersonal relationships among family members
- systemic family therapy: focuses on family issues within the context of their wider system, such as cultural, religious, and socioeconomic status
Nurses must understand that families are dynamic, and therapy may be needed for a long or short duration depending on the individual family dynamics.
Social Workers
Nurses and social workers share similar goals for family care and work hand-in-hand to create healthy environments for families. While nurses make referrals to medical specialists, ancillary specialists, and disease-specific specialists, social workers help address the many environmental constraints and burdens on a family. Nurses ensure that families in health crises can access social work services to help address these and other logistical concerns. Some social workers are trained in mental health counseling as well. They help families navigate complicated family and healthcare dynamics. They also apply their knowledge of family dynamics to create individualized care plans that address factors such as the following (Tadic et al., 2020):
- prevention and health promotion
- home visits
- lifestyle counselling
- financial advocacy
- housing assistance
- substance use recovery
- employment guidance
- interpersonal relationship
- communication counseling
- crisis intervention