This work belongs to Paul1986 it is provided purely as a guide to
other student nurses. It should in no way be copied or passed off as belonging to a 3rd party.
It is protected under the UK and international law of copyright.
This work belongs to Paul1986 it is provided purely as a guide to
other student nurses. It should in no way be copied or passed off as belonging to a 3rd party.
It is protected under the UK and international law of copyright.
Since the time of Florence Nightingale, nurses have had
family at the forefront of their minds whilst caring for an individual (Wilson
2004). The holistic approach of the
nursing model should convey to nurses the importance of the family on the
health and the illness of individuals (Friedemann 2002). The term ‘family’ is a complicated one and
its different definitions will be discussed within this essay; as it can evoke
different meanings not only out-with individual countries but also within a
country (Friedemann 2003). The two
traditional familial structures are decreasing, whereas a variety of other
familial structures, including same-sex couples, are not only increasing but
not being seen as ‘abnormal’ (Hanson, 2005).
No matter the structure or location, it will be shown all families
provide the same support and function.
With the understanding of the term, ‘family’ this essay will then look
at the concept and aims of family nursing.
Nursing traditionally takes it roots from medicine, where the
individualistic approach is accepted.
Nursing however, argues Wright and Leahey (1990) should embrace holism
and consider the individual as a member of a family; this along with other
approaches to family nursing will be discussed. The situation within the modern Scottish healthcare setting
merits the implementation of a family nursing approach. This will ensure that the family is assessed
on not only its ill-health and its care but more importantly, the health and
prevention of ill-health of the family as a whole (Scottish Executive,
2003a). To guide practice, an possible
appropriate family nursing model will be discussed, along with its benefits and
drawbacks associated with its implementation into the Scottish situation. The reasons for the gap in theory of family
nursing will be discussed. Finally,
conclusions will be drawn in relation to the appropriateness of a family
nursing approach in Scotland. To ensure a thorough understanding of family nursing, we
firstly need to conceptualise the term, ‘family’. The family is the basic unit of society and in every country and
culture of the world there is a readily interpretable concept of ‘family’
(Smith 2003). According to Hanson
(2005) there is no absolute definition of ‘family’ as it may mean something
entirely different between individuals and groups from similar and diverse
cultural backgrounds. Bradshaw’s (1988)
definition of a family was: “A group of persons usually
related by marriage, birth or adoption giving a mutual obligation of
influencing, social and moral values, transmitting physical characteristics and
contributing to the emotional and psychological make up of its individual
members.” This compares to Hanson (2005) who defines family as: “…two or more individuals
who depend on one another for emotional, physical, and economical support. The members of the family are self-defined.” These two definitions highlight the
change in attitude, in less than two decades, to what constitutes a
family. Robb (1998a) highlights that
there are two main family structures – the nuclear and extended; with nuclear
being married parents and children whilst an extended family being parents,
their children and their children’s families.
Typically, extended families exist in agricultural societies, where
labour is needed and resources shared amongst the family. Post-industrialisation, Scotland’s families
were typically nuclear in nature.
However, the nuclear family has been a minority for over thirty years,
and is in decline in modern Scotland: with just under a quarter of families
fitting the description. Factors causing the decrease in the
‘traditional’ family structure include Scotland’s population decline, decreased
social pressure to marry, rise in number of women entering education and
professional occupations, fewer births and the blurring of gender roles
(General Register Office for Scotland 2001).
Hanson (2005) states that there can be legal, biological, sociological
and psychological families and expands the concept of family into a wide range
of structures. These include the
traditional and the “post-modern”:
single-parent, reconstituted and same-gender families (Hanson 2005 p.7). Nevertheless, regardless of its structure, a family performs essential functions,
including: nurturing the young, financial survival and support, protection from
danger or harm, instilling cultural and religious beliefs, and provision of
care in health as well as illness. With the introduction of the Civil
Partnerships Act 2005 this year, where there is legal recognition for
same-sex couples equal to married couples this shows that traditional family
structures are changing but more importantly, are being recognised (The Daily
Telegraph 2005). Highlighting that
family structures and functions are constantly changing and adapting to
external environmental and societal trends.
In many societies, the family is part of the larger
system of society, and supported by social welfare and law enforcement
agencies, religious institutions, schools and health services in carrying out
its functions. However, whatever the changes, the
concept of family survives as an important social unit in almost all societies
(Baggaley 1997). These definitions of ‘family’ allow us to approach family nursing;
which according to Wright and Lehay (1990) can be considered in four ways which
corresponds with Hanson’s (2005 p.7) definition of family nursing. These approaches in family nursing view
family as: a context, a client, a system and a component of society (Wright
& Lehay 1990). Nursing used to
focus on the individual rather than the family, who are seen as a stressor and
a resource to the individual; this is nursing the family as a concept. In approaching the family as a client, the
nurse assesses the needs of all members of the family, with no-one having any
precedence over another. The third
approach focuses on the family as a whole, but assesses the interactions
between family members and if one of those members is ill or incapacitated how
this affects the family functioning.
Nursing families as a component of society strives to view families as a
part of larger society and how they interact with other institutions of society
(Wright and Lehay 1990). When a family member is ill, various cultural groups support the ill
member differently to others. This is
apparent in less developed and ‘non-westernised’ cultures of the world where the
family shoulders the burden of care of their relation. In Thailand for example, the family provides
most care to their sick relative with very little if no government provision to
assist in caring for their family member (Farvis 2002). Compare this to the situation in Scotland,
where almost all ill people are attended to either in hospital or in the
community by health and social care professionals with very few families
providing all care. Contemporary
Scotland however is changing to involve the family in the care of their
relative both when in primary and secondary care (Scottish Executive
2003a). Since the mid-twentieth century and inception of the National Health
Service (NHS), the focus of caring for the ill was transferred from the care of
families in the home to the hospital by trained members of staff (St John &
Rolls 1996). This led to families
becoming excluded from the care of their relation literally from ‘cradle to
grave’; with the medicalisation of birth and the increasing number of people
spending their final days in hospital (Hanson 2005). This situation continues to the present day although this
approach is gradually being relegated by new initiatives to provide enhanced
primary care services and reducing the number of unnecessary hospital
admissions (Scottish Executive 2003a).
This allows familial input once again by participating in the home-care
of their loved one (St John and Rolls 1996).
Although an individual is identified as the patient, the actions of
the family members affects the whole family, therefore Wilson (2004) argues
that the family is the real patient. An
ill family member affects the structure and organisation of the family unit
which must modify, be it temporarily, to accommodate these changes caused by
the illness. Families may suffer both
financially as well as emotionally because of a sick loved-one, no matter the
rigidity of the support networks within and out-with the family. Conversely not all families are close to all
its members, with friction and tension between individual family members
causing difficulties to the familial unit as a whole (Nolan et al. 2003). Families, however, are an asset to holistic
nursing care and can provide a wealth of information that can be utilised to
enhance their family member’s quality of life.
Families should be considered as an ally and be acknowledged as an
important resource to the nurse. Nurses
should recognise that families need the consideration and acknowledgement of
their feelings and emotions felt for their ill relative. Also, nurses should understand the changed
circumstances of both the client and family while facilitating the maintenance
of relationships through time (Farvis 2002). In practice, however, the reality
of approaching nursing from a family angle is somewhat different in theory; as
the concept of family nursing in Scottish nurse education is still in its
infancy (Scottish Executive 2003b). With family nursing still in its developmental stages with the
Scottish healthcare situation the use of an appropriate model or framework for
implementation of family nursing will be necessary. There has been a tradition in North America for family nursing
and the basis of models and frameworks such as those described by Wright and
Leahey (1990) and Friedemann (1995) have shaped the practice of family nursing
there (Scottish Executive 2003a). Once such model could be the Calgary
Family Assessment Model (CFAM) developed by Wright and Leahey and may be
appropriate to implement family nursing in Scotland today. The CFAM is based on various theories:
systems theory, communications theory, cybernetics and change theory (Neabel et
al. 2000). Systems theory defines the
individual as a system and as a sub-system of the family unit, which in-turn is
part of a larger system. A disturbance
in one family member will affect the family as a whole and how they respond to
the change. By observing both verbal
and non-verbal interactions, this model uses communications theory; which seeks
to assess the inter-professional and intra-professional attributes of family
members. Cybernetics strives to
understand the control of situations that affect the family. It is mainly used to examine the ‘feedback
loops’ within a family, where an action of one member is influenced by the behaviour
of others. Interventions that transform
the family system so drastically are known as change theory. This may occur at the emotional or
behavioural level and in family nursing is assisted by the nurse in cooperation
with the family (McCormack 1997). The CFAM consists of three main categories that the nurses can
assess: structural, developmental and functional (McCormack 1997). Included, amongst others, in examining the
structural component is the composition of the family; gender of the individuals;
connections internal and external to the family; and position of individuals
within the family. The development
category aims to understand the changes associated with the growth of a family. This may be any event which alters the
nature of family life which may be expected or otherwise. This category is associated with the life
cycle, which may include birth, raising of children, children leaving
household, retirement and death. The
third area focuses on the functional aspects of family; which looks at how
individuals behave in relation to one another within the context of the family
(Kaakinen & Hanson 2005).
Instrumental functioning refers to the routine activities of daily
living such as eating and sleeping whilst expressive functioning refers to the
communication processes in particular verbal and non-verbal communication
(Wright and Leahey 1990)). This model might be appropriate for integration into nursing
programmes in Scotland as, while comprehensive, it elicits enough understanding
to utilise this model (St John and Rolls 1996). Another strength is that it uses a multiple theoretical approach
which ensures a through assessment and the data collected are reliable
(Kaakinen & Hanson 2005). For the
Scottish situation this means that health boards can plan the future of their
service provision, with families as the context. As with most nursing models there are drawbacks, and the CFAM is
no exception. The main disadvantage is
the volume of paperwork associated with assessing a family; this may result in
the model being incorrectly used possibly meaning the provision of unsuitable
care and support to the family (McCormack 2005). With the workload of the Scottish healthcare professional, this
may leave little time to thoroughly assess and
analyse the data. Although this model
is suited for use by novice nurses, it still contains a huge breadth and depth
of the theory; understanding family nursing totally may not be a reality for
the majority of practitioners using it and until more Scottish pre-registration
courses adopt family nursing into their curricula, the theory of family nursing
may not be totally understood (Kaakinen & Hanson 2005). This models primary focus is in the
community setting, which may be appropriate in the Scottish situation, with the
provision of greatly enhanced primary care services but may limit its use
especially to nurses who start their career in the acute sector (Hanson 2005). As a result of the increasing focus of family nursing, the Scottish
Executive in 2001 created a pilot of family health nurses; who were practising
in remote parts of Scotland where nurses were educated in family nursing
theory. This pilot was exploring the
viability of a community nurse devoid of specialism such as a district nurse or
health visitor and who are not restricted by a professional title. Traditional nurse education in Scotland has
led to some difficulties with regards to the recruitment and retention of
nurses in remote areas. This leads to a
poor service provision in remote communities, as these practitioners may be the
only easily contactable source of health advice and care. The aims of this pilot project were: to
create a generalist role as the first point of contact that had a broad
knowledge of community issues; to ensure that this was a model based on health
rather than illness; and focus on caring for families rather than
individuals. The project has shown that
a family health nurse can provide the care needed for rural and remote
communities (Scottish Executive 2003a).
However, the introduction of a Scottish-wide generalist community role
must be thoroughly deliberated to ensure that the role fits the needs of urban
communities (Scottish Executive 2003b).
Scotland is being pro-active in ensuring that the health of its
communities is not threatened and by using a family nursing model and approach
may result in a greater understanding and subsequent reduction in ill health. Although the Scottish family nurse pilot shows nurses focussing
their efforts in the family, nurses have always acknowledged the importance of
families whilst caring for an individual.
Florence Nightingale advocated the family being involved in a person’s
care. According to Wilson (2004) she
said: “Besides nursing the
patient, she [the nurse] shows them [the family] in their own home how they can
help in this nursing…” However, St John and Rolls (1996) argue that nursing still firmly
concentrates on the individual rather than recognising the importance of the
family whilst caring for an individual.
Segaric and Hall (2005) argue that there has only a limited advance in
providing family nursing care within practice. This may be as a consequence of
increasing reliance of nurse education on the medical model, rather than the
holistic nursing model which takes into account the person as well as factors
affecting that person (Friedemann 2002).
Other reasons may include that nurses trained prior to the
implementation of formal family nursing literature within pre-registration
programmes possibly results in a large part of the workforce focussing on the
individualist approach (St John & Rolls 1996). Furthermore, there is a lack of reliable and understandable
models, frameworks and strategies of family nursing (Forchuk & Dorsay
1994). Only by understanding how nurses
nurse in relation to their practice with both the patient and family will
family nursing become clear and its true meanings known (Segaric & Hall
2005). Nurses have always acknowledged the importance of families in the
care and well-being of individuals.
However, formal teaching of the theories of family nursing is not
apparent in current pre-registration nursing programmes. The concept of ‘family was discussed and how
cultural and geographical boundaries affect the definition of family. It was shown that all people belong to a
family as it is the basic unit of society.
Modern Scotland has seen a decline in the traditional nuclear family for
the various reasons discussed. Also
considered were the aims and approaches to family nursing and how nurses have
the responsibility under the nursing model to ensure they acknowledge the
advantages and disadvantages of families.
The situation within Scotland was discussed and a possible model of
family nursing was examined for implementing family nursing within
Scotland. The Calgary Family Assessment Model provides a range of theoretical
approaches that allow the thorough assessment of the needs of families with a
nursing context. The benefits and
drawbacks were discussed in relation to the Scottish situation and also how
appropriate the family nursing approach would be in modern Scotland with
reference to the Scottish Executive’s pilot study of family health nurses.
last updated 05/06/07
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Family Nursing