Contemporary Nursing Care

8 unit one Foundations in Maternal, Family, and Child Care

Nursing’s domain in the earlier times consisted of being a provider of care and a teacher. As a provider of care, the nurse would change elements of the patient’s environ- ment through hygienic measures, nourishment, and com- fort to enable the best opportunity for recovery. As a teacher, the nurse would prepare the patient for proce- dures, surgery, and the uncertainties of hospitalization.

Even in the 1860s, nurses saw their patient responsi- bilities not only for the individual for whom they minis- tered but also for the living conditions of the individual’s family. The most frequent cause of illness and death dur- ing these years was infectious diseases. The nursing emphasis on sanitation, nutrition, and family education played a key role in the decline in deaths well into the 1950s when antibiotic drugs and scientifi c treatments became widely available.

Until the late 20th century, nurses continued to be seen as passive, deferential, and compliant advocates to pater- nalistic physicians. Nurses still practiced from the male dominated, ethnocentric, patriarchal medical model of the professional nurse. In 1963, the nursing process began to change that.

The nursing process was developed as a framework of systematic problem solving and actions to be used by nurses in identifying, preventing, or treating the individ- ual health needs of patients. The nursing process was problem oriented, goal directed, and involved critical thinking and decision making. Clear differentiations were made between nursing and medical diagnoses, interven- tions, and outcomes. Ten years later, the North American Nursing Diagnosis Association (NANDA) developed a list of standardized nursing diagnoses used by the nurse through individualized patient care plans to express to other caregivers the fi ndings of the nurse’s assessment, diagnosis, and plans of action (Johnson et al., 2006). An example of the use of the NANDA-I Diagnosis to formu- late a nursing care plan for a child with culturally different verbal communication is presented in Box 1-1.

Now Can You— Follow the evolution of today’s nursing professional roles?

1. Explain the central focus of the nurse as a provider of care and teacher before the 1950s?

2. Describe how the introduction of the nursing process as a systematic framework changed the nurse’s professional role?

chapter 1 Traditional and Community Nursing Care for Women, Families, and Children 9

in a crucially compressed time. The nurse in these settings may be responsible for direction of unlicensed assistive personnel who may not have the highly devel- oped expertise needed to recognize subtle physiological changes in a patient’s condition before discharge. Follow- up procedures that once were performed and monitored by nurses in the acute care setting now must be taught to the patient and family as they prepare for a rapid return to their home.

Collaboration in Caring—

Preparing the family for community-based care

The nurse can prepare the patient and family for care outside of the acute setting by:

• Discussing the feasibility of using specialized equipment in the home

• Encouraging the patient and family to investigate health insurance coverage for home care

Box 1-1 Use of NANDA-I Diagnosis to Formulate a Nursing Care Plan

C a r e P l a n f o r t h e P a t i e n t w i t h C u l t u r a l l y D i f f e r e n t V e r b a l C o m m u n i c a t i o n

Patient and Family Data: Extended three-generational family comes to the health care provider with a complaint of weakness and loss of appetite in a 3-year-old family member. The family has arrived from a Middle Eastern country within the previous 2 weeks; they do not speak English and converse among themselves loudly and with much gesturing.

NANDA Nursing Diagnosis: Impaired Verbal Communication related to patient-care provider cultural and language difference

Measurable Short-term Goal: The family will have an opportunity through appropriate interpretation resources to share and interpret information regarding the well-being of the child.

Measurable Long-term Goal: The family will express concerns, needs, wants, ideas, questions and understanding about immediate and long-term home care of the child.

NOC Outcome: NIC Interventions:

Communication (0902): Reception, interpretation, and expression of spoken, written, and nonverbal messages

Active Listening (4920) Culture Brokerage (7330)

Nursing Interventions:

1. Assess contributing cultural and language factors that may impede simple communication.

RATIONALE: A shared understanding of culture and language is necessary for communication to take place.

2. Evaluate extent and level of impairment.

RATIONALE: Misunderstandings of intent and content are heightened with increased levels of communication disparity.

3. Establish a therapeutic relationship by listening carefully.

RATIONALE: Communication is enhanced when intent of trust and understanding is established.

4. Assist the family and patient to establish means of communication via an interpreter.

RATIONALE: Law mandates that interpretation services be made available for accurate and precise basic understanding of medical terminology and care provided.

5. Validate the meaning of nonverbal and verbal communication.

RATIONALE: Words and gestures can easily be misinterpreted, and affect the delivery and reception of important concepts.

Documentation Focus:

1. Assessment of pertinent patient physical, psychological, and cultural concerns 2. Description and meaning of nonverbal cues as related by interpreter

3. Type of interpreter services utilized 4. Teaching and explanations communicated

5. Level of outcome (NOC) completion/accomplishment

6. Discharge needs, referrals and stated family/patient understanding

NIC ⫽ Nursing Interventions Classifi cation; NOC ⫽ Nursing Outcomes Classifi cation.

Adapted from Doenges, M.E., Moorhouse, M.F., Murr, A.C., & Murr, A.G. (2006). Nursing care plans: Guidelines for individualizing client care across the life span.

Philadelphia: F.A. Davis.

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10 unit one Foundations in Maternal, Family, and Child Care

• Suggesting the parents of a young patient contact school offi cials before a child returns after an illness

• Evaluating the family’s transportation needs for follow- up care

• Discerning when an interaction in the acute care setting is conducive to teaching and learning

Since the early 1990s, there has been a dramatic increase in home- and community-based nursing care.

Home- and community-based nursing care is provided in settings such as adult and child day care centers; public and private schools; churches and religious body parishes;

penal systems; health and disease related camps; foster homes and homeless shelters; physicians’ offi ces, public health clinics, and nurse managed care centers (Fig. 1-5).

Nurses in these settings often experience different degrees of professional independence and accountability, yet still need to possess expert skills as providers of clinical inter- ventions, health history interviewers, culturally compe- tent teachers, coordinators of extended care services, managers of allied health colleagues, supporters of family functionality, and advocates for family-centered care.

Now Can You— Recognize the changes created by family- centered care for professional nursing in acute care settings?

1. List at least four characteristics of acute care hospitalization that have changed since the introduction of family- centered care?

2. Identify at least fi ve community-based care settings in which the nurse may practice family-centered care?

3. Compare and contrast the role of the professional nurse in acute and specialized care hospitals and alternative care settings?

FAMILY-CENTERED CARE

Acute care providers have made strides toward keeping family members informed of hospital procedures and pro- cesses affecting their loved ones, and the patient outcomes expected. Acute care settings still, however, are major sources of family disruption during times of stress and illness. Plac- ing family relationships, their coping mechanisms, values,

priorities, and perceptions at the center of a patient’s health care needs is the essence of family-centered care (FCC).

Family-centered care requires sensitivity to the beliefs, values, and customs of each family member and those of their supporting culture or community. The role of the family-centered nurse is to facilitate and assist the family in making informed choices toward the outcome the patient and family desire. Family-centered care necessi- tates that the nurse relinquish an authoritarian role that tells the family what is best for them while the nurse does things to and for them. The nurse becomes a human just like all other members of the family, each with their spe- cial abilities to support the patient. The center of power shifts from the one with the most clinical knowledge to the whole of the group’s knowledge.

This is a large shift for the nurse educated under tradi- tional Euro-Caucasian theories of nursing care. The global nature of health care as a multiethnic (ethnopluralitic), multicultural composite of health-seeking people requires an ever-growing sensitivity on the part of the nurse. Conside- ration of the family’s cultural infl uences allows the nurse to take a more in-depth approach to health assessment and outcome-directed interventions. For example, the proximity and quality of the family’s support systems; religious and spiritual beliefs; customs and traditions, especially as they relate to health, illness, and healing; micro-living environ- ment of the home; and macro-living environment of the neighborhood all must be incorporated into the plan of care.

Other elements to be considered include fi nancial resources, including willingness to ask for and accept additional resources; signifi cant historical events, especially crises, losses, and new beginnings; and the members’ communica- tion patterns and verbal abilities, coping strategies, and problem-solving techniques.

One format used for assessing the health of a family is the community health map (Falk-Rafael, 2004). With this tool, the nurse assesses the family structure, function, and support networks. The map provides a diagram of signifi - cant data and helps the nurse focus on the family as it interacts with the social systems within and around them (Fig. 1-6). Actively including the family members in the development of the community health map provides the nurse insights into the family’s health experience and fos- ters the nurse–family alliance. The nurse should remem- ber that the focus is on family health, past successes, and current strengths, not on family problems.

Learning, recognizing, and comprehending that these cultural factors are what shape a family’s perception of their health and health-related events is known in nursing as cultural sensitivity. The nurse does not need to seek congruency between these factors, values, traditions, and beliefs and his or her own. The nurse does, however, need to recognize that how the patient and family comprehend and respond to a particular health event is shaped by these factors, values, and beliefs.

In order to use cultural competence as a nursing assessment tool, the nurse must be open and receptive to gaining awareness and respect of these cultural infl uences.

Nursing interventions that are based on a solid knowledge of these values and practices have been demonstrated to achieve much higher levels of successful outcomes for families and patients (Locsin, 2002). Listening to the cultural voices and experiences of family and patients Figure 1-5 The nurse is instrumental in providing

family-centered care in the community setting.

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chapter 1 Traditional and Community Nursing Care for Women, Families, and Children 11

affi rms their value and is critically important to unifying the nurse–patient relationship as it motivates the patient toward positive health-promoting activities.

Across Care Settings:

Ensuring cultural sensitivity and reliable information

In all care settings, nurses should use the services of professionals who can interpret word meanings correctly.

Relying on family members often results in literal translation of words and omission of information—problems that create confusion and misunderstanding. In settings where

professional interpreters are not available, the use of services like AT&T, Roget’s International Thesaurus, or handheld personal information devices can be useful alternatives.

Delivering nursing care that is sensitive to and under- stands cultural differences, whether in knowledge, values, beliefs, or role expectations, should help the nurse evolve into a culturally competent professional who makes assess- ments and plans interventions from a holistic framework.

Framing one’s nursing assessment, intervention, outcome expectation, and evaluation with a holistic perspective gives the nurse a better assurance that no signifi cant physi- ological, psychological, cultural, spiritual, or social com- ponent is excluded.

Ethnocultural Considerations—

Cultural prescriptions and proscriptions for women and children

Cultural prescriptions are folk beliefs, practices, and values of a group that tell women and children what they should do—what their respective roles should be.

Cultural proscriptions are folk beliefs, practices, and val- ues of a group that tell women and children what they should not do—what is “not” incorporated in their res pective roles.

When assessing cultural prescriptions and proscriptions, it is

helpful to consider elements such as clothing, exercise, sexual participation, disciplinary efforts, dietary habits, family roles and relationships, verbal and nonverbal communication, cleanliness, illness remedies, and displays of emotion.

In some cultures, women and children do not have the permission, the decision-making power, or the means to access the American health care system. Legal barriers, language differences that restrict access to medical care and lack of diversity in the health care workforce are some of the obstacles that may prevent immigrant minorities from accessing care. In addition to the barrier(s) that cul- ture may place on accessibility of modern health care for women and children, in many situations, health care pro- viders are not available in the areas where culturally bound groups reside. The real or perceived lack of acces- sibility, affordability, and availability of health care ser- vices to growing numbers of individuals leaves the provi- sion of health care delivery to the family, especially in multicultural societies. In these situations, nurses must help family members identify needs, strengths, resources, coping mechanisms, and desired outcomes. The functions of the nurse and family are intertwined and require col- laborative planning, delegation, coordination, and provi- sion of care (Goldberg, Hayes, & Huntley, 2004).

COMBINING MODERN TECHNOLOGY WITH THE CARING TOUCH

In settings where modern health care may not be accessible, affordable, and available or is culturally restricted, comple- mentary and alternative health care/medicine (CAM) methods often are used. The focus of these low tech- high-touch noninvasive, nonintrusive, nontraditional inter- ventions is the support of the family and child’s whole mind, body, energy, environment, and spiritual healing. The nurse approaches this healing methodology from a holistic philos- ophy of caring, aimed toward a goal of patient-centered autonomy and a patient-defi ned sense of well-being.

Structural Family Assessment

• Number males/females

• Marriage status

• Number/order children

• Family members loss/death

• Significant contacts and strength of relationship (work, church, medical, school, friends, extended family, clubs/organizational participation)

• Ethnicity

• Religion

• Socio-economic status/environment

• Culture

• Health problems

• Living difficulties

Developmental Family Assessment

• Parent's family of origin

• Emotional reactions to changes

• Spiritual beliefs

• Recent life changes

• Degree of family stability

• Recent or expected shifts in family structure/relationships

• Affectional bonds

• Feelings about family roles

• Childcare-work-relaxation balance

• Alone time balance

• Hopes for future

• View of extended family

• Previous health crises

• Method of coping with crises

Functional Family Assessment

• Socio-economic systems in place

• Physical problems and strengths of patient

• Family strengths and weaknesses in shared caregiving

• Who identifies and problem solves what issues

• Parental discipline habits

• Perceptions of health, control over health, strengths and weaknesses

• Health priorities (individual and shared)

• Health values (individual and shared)

• Cultural values (individual and shared)

• Spiritual values (individual and shared)

• Goals for a fulfilling life

• Permeability of family boundaries — who is allowed into inner circle and for what function

• Willingness to accept help

• Communication styles, patterns

• Use of power, by whom, when

• Emotional closeness Figure 1-6 Community health map.

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12 unit one Foundations in Maternal, Family, and Child Care

In 1998 an Advanced Practice Nurse (APN) established a

“Nurses’ Tool Box” of CAM nursing interventions found to be effective in establishing patient and family autonomy;

relieving various illness symptoms, controlling pain, improv- ing immune function, decreasing anxiety and depression, improving circulation, excreting toxins, and enhancing healing (Ward, 2002). CAM interventions range from guided imagery, aromatherapy, imagining, creating art and writing;

prayer, chanting, meditation, and channeling; therapeutic touch, stroking, and cuddling; acupressure, tai chi, mag- netic forces and massage; music, singing, tonal vibrations, and various water therapies; to storytelling, joking and humor (Helms, 2006) (Fig. 1-7).

It is estimated that Americans spent more than 27 billion dollars on CAM in 2005. This statistic refl ects the level of consumer interest and demand for low-tech medical and nursing interventions, and self-directed healing (Lucey, 2006). The nurse must be aware that not all CAM interven- tions are noninvasive, nonintrusive, or free from side effects and negative consequences. CAM also involves the use of nutritional and herbal supplements, diet adjustments and fasting, chiropractic and body manipulation, and the use of drugs that have not been fully tested for safety and effi cacy.

Today, much confusion about CAM remains in both the consumer and health provider sectors (Box 1-2).

Collaboration in Caring—

Supporting the family that uses CAM

The nurse can provide support to the patient or family that uses CAM by:

• Investigating what they think caused a health event and how they have been able to avoid it in the past

• Encouraging them to seek all approaches of healing that are evidence-based, including both traditional and alternative medicine

• Respecting the participation of a family-chosen folk healer

• Acknowledging the patient’s/family’s religious and spiritual beliefs

• Refl ecting on and understanding personal beliefs and recognizing when they may be in confl ict with those of the patient

• Avoiding judgment

The family-centered nurse has a responsibility to advocate for the patient and family who choose to use CAM; to assess for and educate about the implications, contraindications, and benefi ts of CAM to the family and patient; and to promote health practices that have been proven safe and effective in restoring well-being, whether via conventional treatments or CAM. The nurse must recognize that health can be achieved through various means, both high-tech and high-touch, and that individ- ual well-being is most optimally accomplished when care is directed by concerns expressed, interventions chosen, and outcomes defi ned by the patient. It is easy to under- stand why the nurse–patient relationship and a focus on the patient as a whole being (mind, body, energy, envi- ronment, and spirit) are key to the success of CAM healing.

Also key to a healthy outcome when using CAM ther- apy, as with all nursing interventions, is the responsibility to encourage evidence-based decision making. This method of evidence-based practice is built on the prem- ise that interventions need to be questioned, examined, and confi rmed or refuted in their ability to support healthy outcomes. The nurse using evidence-based prac- tice searches computer databases and current literature for reports that evaluate the safety, quality, and credibility of particular interventions. These searches produce reports from rigorous research studies, textbook and journal readings, stated expert opinions, and best practices result- ing from quality improvement activities. It is the nurse’s responsibility to use the best evidence available and make decisions accordingly, especially when working with prac- tices such as CAM that are viewed by many as mythical, magical, and nontraditional.

Another source of evidence-based guidelines available to the nurse is the standards of care/practice developed by nursing professional organizations such as the American Nurses Association (ANA); Society of Pediatric Nurses (SPN); National Association of Neonatal Nurses (NANN);

National Association of Pediatric Nurse Associates and Prac- titioners (NAPNAP) and Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) (ANA, 2008;

AWHONN, 2008). These published guidelines promote consistency and quality in nursing care and outcomes.

Because of the time it takes to search and retrieve evidence- based knowledge, these guidelines provide the nurse a reli- able source of high-quality interventions on which to base practice.

Box 1-2 Confusion about CAM Through the Ages A HISTORY OF MEDICINE

(Author unknown)

2000 B.C. “Here, eat this root.”

1000 A.D. “That root is heathen. Say this prayer.”

1850 A.D. “That prayer is superstitious. Drink this potion.”

1940 A.D. “That potion is snake oil. Swallow this pill.”

1985 A.D. “That pill is ineffective. Take this antibiotic.”

2000 A.D. “That antibiotic doesn’t work anymore. Here, eat this root.”

Source: Helms, J.E. (2006). Complementary and alternative therapies: A new frontier for nursing education? Journal of Nursing Education, 45(3), 117.

Figure 1-7 Storytelling, joking, and humor are therapeutic complementary and alternative medicine interventions.

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