Comprehensive family nursing, as one of the functions of public health nursing, is a complex process. But in spite of this complexity, a systematic approach to nursing in the family situation brings about positive and measurable changes in the treatment of disorders, in the prevention of disease, and in the promotion of health. Freeman describes in detail the way family health nursing may be done. * The Community Service Society of New York City gives succinct evidence of the value of a logical and organized approach to family nursing in their service. 2
Basic to the practice of nursing in any environment is that the service appropriate to the specific situation cannot be rendered until the situation is evaluated. The basic nursing process in family health care then, is one of (1) analysis of the total family health situation, (2) nursing determination of the needs, (3) identification of the health and related needs with the family, (4 ) motivation of the family toward development of the health goals, (5) the preparation of an appropriate plan specific to these goals, (6) execution of the plan, and (7) evaluation of its effectiveness.3 It is an epidemiologic approach to family health problems, and teaching this approach has become one of the major challenges to educators of nurses today.
Teaching the Family Health Nursing Process
At Emory University in Atlanta, Georgia, nursing students are taught the systematic approach to comprehensive nursing care in the family. One quarter of the final year of the basic baccalaureate program is devoted to teaching the principles of the scientific approach to family nursing. Classroom and laboratory facilities are used, and families from the Fulton County Health Department's nursing case load are cared for in clinical practice. Each student works with three or four families throughout the quarter.
The instructor selects the families for student experience. The selection is based on the criteria that the family will (1) have health problems that presumably will respond to intensive nursing service, (2) create interest and challenge for the student, and (3) provide opportunity for cooperation with other agencies. Families with overpowering social problems are avoided. Socioeconomic range, culture, complexity of health needs, and long- and short-term problems are factors in selecting learning situations. A family with, or expecting, a new baby and one with a member who has a chronic disease or an older person with health difficulties, is always included Also, a family which illustrates a problem of major concern to the community presents an excellent learning experience. Lastly, families are selected in relation to the individual needs of students for development. All families live within walking distance of the health department.
With a ratio of one instructor to every six to eight students in the laboratory, there is opportunity for the instructor to personally guide each student. In addition, clinical seminars are held to supplement this individual guidance, the classroom learning, and the laboratory experience. The focus of the course is on the learning of the nursing process in family health. In greater detail, what is this process, and how can it be taught?
Assessment of Family Health Needs
The initial phase of the nursing process is the collection of pertinent facts about the family. Facts are assembled to determine the health needs and the characteristics of the family that are significant and related to the family's ability to change its health status. The information collected includes the known state of the health of individual family members, the health history of family members, their attitudes toward health, their usual behavior in handling health problems, environmental factors of the home, and data which would identify the cultural, educational, social, and economic status of the family.
Gaining such information in a nonthreatening manner mandates considerable interviewing skill. A substantial portion of time is spent with students in helping them to further develop skills of communication gained from their experiences in psychiatric nursing and in other courses. Some students find it difficult to relate to more than one family member at a time, as is frequently required in home visiting. Others have problems in establishing a suitable physical environment for an interview -what does one do when the television dominates the scene, or when children incessantly interrupt? One clinical seminar is used exclusively for a discussion of interviewing skills and for exploring problems associated with a home interview. Informal group discussions seem to give excellent support to students confronted with problems of this nature.
Another skill that often needs further cultivation is that of observation; observation of the environment and of verbal and nonverbal behavior. Although the student sees, hears, smells, or feels, she does not always perceive. Home visits with the focus on observation of the home, and process recordings or interpersonal relations notes, are used toward developing communication and observation skills.
In addition to information secured during home visits, data is obtained from the records of community agencies to which the family is known. Communication with other members of the health team, such as the physician, school teacher, or social worker, who may be involved in the family situation, provides further knowledge regarding the family.
Although it is recognized that assessment continues as long as there is nursing contact with the family, for practical purposes analysis of the data follows soon after the primary information regarding the family can be obtained. The student applies her knowledge of the basic health and social sciences and of nursing to the facts she has collected. Considerable nursing judgment is necessary for a student to be able to establish from die heterogeneous mass of facts before her a general meaning of the particular family situation. The specific facts together form a pattern, a pattern unique to this one family, a pattern which has meaning. It is this general meaning, drawn from the specific, from which an assessment of a family health situation is formulated.
Nursing Identification of Health and Related Needs
Nursing judgment is again used in drawing health and related needs of the family from the facts collected during the assessment. Related needs are any needs that are not strictly health needs, but needs that have an effect on the family's ability to maintain health. The needs are categorized, and they vary in number, seriousness, and type from family to family. Once the student has identified the needs from the assessment, she then is required to decide which needs may be met by nursing, which may require referral to another source, e.g., a social worker, and which may be laid aside temporarily, or permanently, for various reasons and not require imperative consideration.
Identification of the Needs with the Family
The identification of the needs with the family is the next step of the nursing process. The student nurse prepares the family for a visit in which they will look at all the identified needs together and plan ways to meet them. She recalls with the family her assessment activity since the beginning of her contact with them. She explains she is now ready to share this information with them. The student usually makes an appointment in advance to visit the home when this is most convenient for the family, since it is an especially important contact. She suggests a time when few interruptions would be expected and when the mother and father or other leading members of the family can be present. The student carefully plans the approach she will use in this visit by studying the data from the assessment. She is helped at this time to develop judgment in exploring defined needs with the family and in deciding whether to explore all or a limited number of the needs in relation to the family's level of readiness. Occasionally, needs are reidentified with families from visit to visit. This approach may be appropriate for families who are under much stress and who could not be expected to face at one time a total picture of their health needs. It is also a proper approach for families with limited ability to comprehend a total situation, as in the case of low parental intelligence.
Students frequently find the identification visit a rather difficult assignment. This is attributed mainly to the lingering of the familiar and comfortable patterns traditional to nursing, in which nurses perform things "for" their patients, without fostering active participation from them. At times this approach may be entirely proper, especially in a hospital situation, when patient incapacitation may at times be great. More often, however, families gain more from nursing support in solving their own problems, rather than in having the nurse attempt to "take over" from them. With guidance and a carefully prepared plan for the visit, most students are able to make this visit satisfactorily. A few are unable to do so on the first attempt, but gain greater competence with another family later in the course.
Motivation of the family toward development of the family's health goals
After identifying the needs with the family, the student begins to analyze her role in the motivation phase. Motivating the family to set goals to meet their health needs takes much nursing skill and considerable understanding of human behavior. The student is helped in learning how to apply the principles of motivation in family health. 4 While planning the approach to motivation, she reviews her interpretation of the family's values, which were learned in the assessment period. Sometimes a student finds it difficult to view the family within its own value system; reading in the social sciences has been helpful in guiding students who have this problem. After attainable goals have been set, possible means of meeting them are explored.
Preparation of a nursing care plan
Once the goals have been determined by the family, various means for realizing them are examined. Some families can be quite independent in making plans; others require more help from the student. Sensitive to this, she plans mutually with the family the means that will serve to meet the health goals set. A broad plan of action is developed. The student identifies with the family the part of the plan in which she can assist them, the part in which some other resource might be of help, and the share for which the family has acknowledged responsibility. The family and the student agree on an interval of time to which the plan will be limited, either an arbitrary time such as two weeks, or even six weeks or longer, or a natural time limitation, such as the arrival of a new baby.
Guided by planning accomplished with the family, the student prepares a broad, master nursing care plan. This master plan is used to give direction to the daily or weekly activity of the family and the student nurse, and to guide the timing of home visits and other contacts with the family. For instance, the student may arrange to be present when the family expects to visit the physician or a clinic. Sometimes an office visit may be more useful than a home visit Frequently a plan may call for collaboration with other members of the health team. From the master outline, a detailed plan for each contact with the family is derived.
This brings up the point of the need to emphasize flexibility in family situations in a student program. In order to teach a systematic approach to family nursing it is easy to give the impression of desiring conformity or rigidity in carrying out expected plans. Adapt ability and nursing sensitivity to ongoing family life is stressed, so that nursing action will be appropriate to the moment and will be effective. At first it may be difficult for students to reach the delicate balance of preparedness and purposeful action and its counterpart in sensing the time to alter the plan to meet the new and higher priority needs of the family. As the students gain in experience, they seem better able to adapt their plans to unexpected developments in a family situation.
Execution of the plan
Putting the plan into effect is a satisfying part of the nursing process for both family and student It is sometimes difficult to impress students with the need to defer action until the initial planning phase is completed. Traditionally nurses feel effective in a manually "busy" role, and the analytic approach to family problems requiring a period of assessment, and planning, can be stressful from this point of view. Occasionally, families need immediate nursing service in acute situations. Obviously prompt nursing action is the only kind appropriate for meeting emergency needs, but other family health needs beyond those of the crisis are handled through the total assessment and plarming process.
Evaluation of family action or change
Ongoing evaluation of the family situation, visit by visit, is necessary in ascertaining the family's ability to follow through with the plan. The student also needs to note whether the situation is remaining stable with respect to the assessment, in order to determine whether plans already developed can be predicted to be as effective as those accomplished to date. But this intuitive approach to evaluating the family's progress with the plan is not enough. How can the student nurse judge progress? A measure, specific to each goal, is planned as an indicator of progress. Sometimes more than one measure is used in judging. Nursing ingenuity is challenged in devising indicators to suitably measure expected change. A suitable time span for evaluation is also planned specific to each goal.
At the conclusion of the planned period of nursing interaction, the student involves the family in the evaluation. Continuing family-nurse interaction may be required, based on the evaluation and a reassessment of the family situation. Or the family may have gained independence and can manage their own affairs satisfactorily. Sometimes a trial period without nursing care may be indicated.
The Teaching Methods
In addition to classroom instruction on theory related to family nursing, and practice in the laboratory, the teaching of the nursing process is heavily dependent on two other teaching methods. One of these is small group discussions. One afternoon a week is devoted to the sharing of problems, and of ways in which problems are met. Students give much support to one another in these sessions, and responsibility for these discussions is rotated in the group. Each student is asked to share with the group material from one of the families assigned to her to stimulate discussion. Focus for the discussion shifts each week following the progression of the nursing process. The first week, the group concentrates on the matter of the assessment; the next, on the identification of health needs, and so on
The second method is regular individual student-teacher conferences. Some conferences are planned with a specific objective in mind. An example of such is a conference based on a process recording which the student will have prepared from a previous home visit. In addition, the instructor accompanies the student on selected home visits (the number according to need); and conferences based on the content of the visit follow. Instructors do not visit with the student on the first home visits, deferring this until the student has had opportunity to establish a relationship with the family. Some conferences are held spontaneously.
The nursing process is useful in all areas of nursing. One of the reactions consistently heard from students is their expression of interest in using the nursing process in areas other than family health nursing. This reinforces the thesis that the family nursing process is fundamental to the giving of comprehensive nursing care in any situation, and that the principles learned in this course may be applied successfully to other clinical settings. Comprehensive nursing, in any situation, can be taught through a systematic approach to the nursing process in the family, a process which is logical and organized.
- 1. Freeman, Ruth B.: Public Health Nursing Practice, 3d ed., Philadelphia, W. B. Saunders Co., 1963.
- 2. Community Service Society of New York City: "Public Health Nursing Practice in a Family Health Service," Nursing Outlook, 7:518-520, September, 1959.
- 3. Freeman, Ruth B. Public Health Nursing Practice, 3d ed., Philadelphia, W. B. Saunders Company, 1963, pp. 36-43.
- 4. Freeman, Ruth B. Public Health Nursing Practice, 3d ed., Philadelphia, W. B. Saunders Company, 1963, pp. 194-198.
- 5. Von Bergen, Ruth, " Intensive Family Health Work," Nursing Outlook, 11:202-203, March, 1963.
- 6. Wiedenbach, Ernestine: "The Helping Art of Nursing," American Journal of Nursing, 63:54-57, November, 1963.