Family Theories and Models - Maternal-child Nursing Care

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

Nursing Insight—

Recognizing the relationship between family stressors and poor health outcomes Families may have multiple stressors that increase their vul- nerability to poor health outcomes. Problems such as sub- stance abuse, mental illness, domestic violence, and limited access to medical care due to unemployment, loss of medical insurance, or inadequate insurance coverage can affect families across all strata of society.

Societal Pressures

The family also faces societal pressures. The incidence of violent crimes has decreased in major urban areas, but suicide among children and adolescents continues to represent an important societal issue. The number of families currently affected by AIDS is increasing at a startling rate.

Women and children, a vulnerable population due to bar- riers associated with access to health care, constitute the fastest growing segment of the population to contract HIV. Public education is in a state of crisis as demands increase on teachers who are confronted with diminishing resources.

These and many other issues continue to challenge families. Meanwhile, family structure and roles are undergoing changes that frequently increase the potential for further family problems. Present trends show a diminishing number of nuclear family households. The traditional family structure is being replaced by one that includes a single head of household, most frequently a divorced or abandoned mother. The number of unmarried mothers continues to increase. Statistics refl ect the current trend: the percentage of children living with two married parents decreased from 85% in 1970 to 68% in 2004. A divorced or single woman is usually the head of household in those families, although recently there has been an increase in single male head of household families from 1% to 5% (Child Trends Data Bank, 2006). In other situations, the head of household is homo- sexual or sharing a home with a same-sex partner.

These trends refl ect increasing opportunities for alterna- tive forms of parenthood within contemporary American society. The nontraditional parenting arrangements result from more liberal social mores as well as the technological and medical advances that now offer the possibility of parenthood to single men and women (Greenfi eld, 2005).

Homosexuality and same-sex partnerships/marriages and their effects on the family raise political, social, and reli- gious issues that have increasingly found their way into present-day discussions. Although the far-reaching impact of same-sex relationships on family structure and function has not been adequately studied, areas that frequently must be addressed concern child custody, legal consent, power of attorney, and confi dentiality. The following case study pro- vides an example of some of the issues and questions that may need to be addressed by the family and the patient’s care providers.

— Effective tools for families Covey (2006) discusses effective tools that may enhance family performance. The nurse can communicate these principles to families that may promote healthy family functioning.

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Be proactive: Become an agent of change in the family.

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Begin with the end in mind: Develop a family mission statement.

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Put fi rst things fi rst: Make the family a priority in a turbulent world.

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Think “win–win”: Move from me to we.

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Seek fi rst to understand then be understood: Solve family problems through empathetic communication.

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Synergize: Build family unity through celebrating differences

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Sharpen the saw: Renew family spirit through traditions

case study

The Family with Same-Sex

chapter 3 The Evolving Family 51

from a number of related disciplines (Harmon Hanson et al., 2005), helps to guide assessment and intervention within a holistic framework that views the entire family as client. The following discussion presents several theore- tical models representing a cross section of useful concepts to assist in the nursing assessment and to facilitate a cre- ative application to various family interactions.

FAMILY SYSTEMS THEORY

A systems approach to understanding the family centers on the recognition that changes that occur in one member affect the entire family. The family systems theory, which views persons as “open systems,” has at its central theme:

“The sum of the parts is greater than the whole” (Harmon Hanson et al., 2005). According to this theory, the family shares a unique identity that is far more complex than that of its collective members. The family is dynamic, con- stantly adjusting to information that fi lters in from the surrounding environment and from within the family.

Nursing Insight—

Clinical application of the family systems theory

When working with families, the nurse uses the family systems theory to “view the family as a unit and focus on observing the interaction among family members rather than studying family members individually” (Wright & Leahey, 2005).

The following situation helps to illustrate application of the family systems theory: An addicted member receives help for the addiction and then returns to the family system. The changes in the recovering family member have a signifi cant impact on how the entire family acts and reacts. A new system of communication is established. In the new system, the family members communicate assert- ively and supportively with each other and no longer adhere to the former framework of denial that a problem exists and secret keeping. The nurse working with the family recognizes that teaching and referrals to appropriate community resources are most likely be needed to facilitate the family’s healthy adjustment to the changes.

Boundaries

Another concept inherent in family systems theory concerns boundaries. Each system contains a boundary that affects how the outside world is allowed to interact with the family members. Stated another way, boundaries identify the family’s control of how the family system interacts with the outside world. A family whose children obtain food and shelter by begging from the neighbors demonstrates a problem with boundaries that are too permeable. Permeability refers to the degree that information and interchange are allowed to fl ow between systems. An ideal system is one that is semipermeable. In a semipermeable system, the boundaries are secure enough to keep the family intact, but still allow for free interchange with the outside world. In this situation, the family system readily interacts with outside systems. A healthy family has a semipermeable boundary that allows and encourages interaction with outside agencies such as work, school, church, and family, and friends.

A closed boundary serves to keep family secrets inside and therapeutic interventions outside. Closed boundaries often occur in families with issues of addiction or abuse.

Families of alcoholics soon learn not to disclose information about their problems to outsiders. Conversely, a family that is so lacking in structure that it allows an unin- terrupted free fl ow of information/intervention to and from outsiders can be said to have an open boundary or no boundary at all. For example, an open boundary exists with a family whose children are so neglected that they rely on friends or neighbors to feed them.

Nursing Insight—

Recognizing the childbearing family’s boundary permeability

The extent to which the suprasystem (the broad system that surrounds the family unit, such as the cultural community) infl uences the childbearing family’s participation in activities such as childbirth education, prenatal care, and infant care is dependent upon the family’s boundary permeability.

Subsystems

Family systems are further divided into subsystems. A family of four may constitute the “main” system. The mother and father represent a subsystem that has a permanent or temporary relationship that is a part of, yet separate from, the main family system. Children often form alliances with other siblings or with one parent. A subsystem can develop when a sibling marries or cohabits with another individual who is temporarily or permanently accepted into the family. Subsystems are necessary parts of family functioning, especially in health crisis situations when families must make decisions for sick or disabled members, or when new dependent members join the family. For example, the birth of a baby introduces a new member who becomes part of the family system, but is also a subsystem with the mother or father or other family caregiver(s).

Ethnocultural Considerations—

Boundaries and receptivity to information

Families that have recently immigrated to this country may be receptive to health information only from extended family members or from persons within their cultural community.

Balance and Homeostasis

The family system continually strives to return to balance or achieve homeostasis after a crisis. When a family member is sick or injured, or when an emergency arises that requires a reorganization of the family (i.e., an evacuation during a storm), the family quickly attempts to return to former routines and rules as a way of reestablishing homeostasis. At certain times the family is unable to return to former normalcy and instead must adjust or form adaptive behaviors. For example, the family may learn to work with a wheelchair and other adaptive devices when a member suffers a stroke or spinal cord injury. Over time, adap- tations become the norm for the family.

Maladaptive behaviors are an alternate adaptation that involves the use of unhealthy or abnormal behaviors to adapt to a family crisis. Enabling and codependency are common maladaptive behaviors that are often adopted by an addictive family (Townsend, 2005). Enabling involves making excuses or obtaining substances for the addictive

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

family member. Codependency is a maladaptive behavior in which the nonaddicted family member joins the addicted member in the use of alcohol or other substances as a way of interacting or communicating.

FAMILY DEVELOPMENTAL STAGES AND THEORY

Developmental theory (Friedman et al., 2003; Harmon Hanson et al., 2005) has at its core the idea that every life moves through developmental stages with tasks that need to be accomplished before moving on to the next stage.

Duvall identifi es eight family stages: beginning, childbearing, preschool children, school-age, teenagers, launching, middle-aged, and retirement (Friedman et al., 2003). Each stage is accompanied by specifi c tasks that are performed to assist with the physical and emotional development of the family members in that particular stage.

When working with families, the nurse should identify what stage(s) the family is in and assess how well the needs for that particular stage are being met. Learning, attachment, and grieving represent specifi c tasks that are affected by the developmental stage. Teaching needs and nursing interventions are structured and implemented according to the developmental stages of the family and its members. Although the stages follow one another in a linear progression, some families may simultaneously be in more than one stage or they may revert to previous stages (Wilkinson & Van Leuven, 2007).

Beginning Families

Beginning families are those that have just been formed through marriage or that self-identify as family, as in the case of common-law unions. The beginning family identifi es shared goals that may include career paths, home- building, and planning for children. Creating shared time together in order to build the relationship constitutes a central developmental task for all families and this special together time traditionally is initiated during the honey- moon period. Combined households and property are common features of all families. One of the limitations of Duvall’s theory concerns its application with the childless family. If the family has no children, many of the developmental stages are not applicable until the couple reaches middle age and beyond. If the family does have a child, the family developmental stage parallels the age of the child.

When more than one child is present, the family is usually in more than one developmental stage.

Childbearing Stage

The childbearing developmental stage begins with con- ception. Early tasks during this stage include seeking prenatal care and planning for space for the child. If there are other children already in the home, the family begins to prepare and socialize the other children into a sibling role. Ideally, the family involves the children in decision making related to preparation for the expected baby. For example, siblings can help to choose paint colors for the baby’s room or offer advice regarding toys or clothes to select for the baby. When the baby is born, the family must adapt its routines to include the various tasks associated with feeding and caring for the baby.

Family teaching needs may include dealing with sleep

pattern disturbances related to feeding and changing diapers through the night. Along with strategies for successfully coping with these adjustments, the nurse can offer support and reassurance. The nurse assesses the family’s readiness and openness to learn and receive help (an open boundary) and, according to specifi c needs, may provide additional information concerning nutri- tion, the importance of well-baby visits, car seats, immunization schedules and infant crib monitors.

Optimizing Outcomes— Applying developmental theory when caring for the childbearing family

An understanding of the normal phases of the life cycle helps the nurse to provide anticipatory guidance for the childbearing family. Strategies to bolster the young child’s sense of security when a newborn is brought home may divert a potential family crisis.

Preschool Stage

The preschool developmental stage includes toddlerhood and attending kindergarten. During this stage, the child has learned to walk and actively explore her world, which encompasses siblings and other family members and friends. At this time, families need information about the prevention of injuries and interventions for accidents that usually result from the child’s increased motor abilities coupled with less-developed judgment and coordination.

The nurse should be alert for signs of abuse or neglect during this stage. Points of contact that allow the nurse to assess developmental progress occur during well-child checks, immunization appointments and offi ce or hospital visits for the child or other family members.

School-Age and Adolescent/Teenage Stages

The school-age and adolescent/teenage developmental stages provide the optimal opportunity for teaching about drugs, sex, and health promotion. Personal values are shaped and clarifi ed and ethical development occurs during this time. Surveys have shown that nurses are included among the top ten trusted people sought by school-aged children to discuss issues important to them.

Launching, Middle Age, and Retirement Stages The launching, middle-age, and retirement developmental stages bring the family full-circle back to the early issues of self and couple-building with less emphasis on children (if successfully launched) and more involvement in community and hobby-related interests. The young adult who is not successfully launched from the childhood home presents a complication of incomplete launching. This situation may represent a temporary arrangement necessary for continuing education or it may provide a conve- nient and economical “non-action” by the son or daughter until ties with others have been established. The nurse’s role in this situation is to assess whether the living arrangement creates a problem (e.g., anger, frustration, and delay in meeting goals) for either the parents or the child. Interventions may include strategies to improve communication between the parents and the child and/or community referrals for assistance with goal setting and vocational training.

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chapter 3 The Evolving Family 53

STRUCTURAL–FUNCTIONAL THEORY

Structural–functional theory focuses on the functioning of the family and the roles assumed by each family member to promote family function. Necessary roles include provider, housekeeper, child caregiver, socializer, sexual partner, therapist, recreational organizer, and kinship member. Although a family member often assumes more than one role, some roles may be exclusive to only one identifi ed member. This arrangement takes on added signifi cance concerning the family’s ability to move forward when a member is unable to fulfi ll his or her exclusive role (Friedman et al., 2003; Harmon Hanson et al., 2005; Wright & Leahey, 2005). According to structural–functional theory, if any of the roles are not managed by one or more members of the family, problems such as disorganization, defi cits in hygiene, isola- tion, and other negative situations will emerge that may require a nurse’s intervention to help the family return to balance (Harmon Hanson et al., 2005).

Provider Role

The provider role is the money-earner or the resource gatherer. One or more family members pay the bills and distribute resources to other family members for clothing, food, and recreation. If the provider is sick or hospitalized, the family identifi es an alternate provider to temporarily meet that need or identify other resources such as savings, insurance, or public assistance in order to pay bills.

Housekeeper

During recent years, the housekeeper role has evolved from the traditional stay-at-home mother as increasing numbers of women are engaged in full-time employ- ment outside of the home. Housekeeping involves not only the physical cleaning and maintenance of the family environment but also the organization of family duties to maintain a stable, healthy living situation for the family.

Child-Caregiver

The child-caregiver role is assumed by the person (usually the mother) who is designated as the primary care provider for the children. This role is performed by a designated member such as the mother, father, grandmother or uncle, depending on the family structure. Someone (i.e., childcare facility, babysitter) is responsible to ensure that the children are supervised and cared for even when the primary child-caregiver is away from home.

Socializer and Recreational Organizer

The socializer and recreational organizer roles may not be as consciously directed as the previous roles, but they encom- pass how the family interacts with others. Initially, the parents or guardians may arrange interactions for the children through family and friend gatherings, trips, and activities.

Eventually, most members begin to organize their own social events through personal friendship choices and pre- ferred activities outside the home. Socialization is taught by the family and may be a role that is shared equally among family members unless a problem occurs. Family trips, holi- days, and birthdays are important events that teach family patterns that children will later use to help them develop their own family’s social and recreational roles.

Sexual Partner

The sexual partner role should exist between the parental units. Variations exist in different family structures. In every structure, children should have education and role modeling on how to interact in socially and sexually appropriate ways. Healthy family interactions constitute the fi rst defense against abuse and violence.

Therapist

The therapist role is assumed when one family member expresses concern for another’s health or emotional well- being. For example, concern about the husband’s blood pressure prompts the wife to make a doctor’s appointment for him. The therapist role can also involve active listen- ing and other expressions of caring as family members help one other through a loss or a crisis.

Kinship

The family member who organizes family reunions, corre- sponds with friends, sends birthday and holiday greetings, and reminds children to write thank you notes assumes the kinship role. The wife most often assumes this role and is charged with the responsibility of remembering important dates for her spouse’s family as well as for her own.

Optimizing Outcomes— Applying the structural functional theory

Structural–functional theories view the family as a social system and focus on outcomes, not process. Nurses can use structural functional theory to assess how well the family functions internally among family members and externally with outside systems.

COMMUNICATION THEORY

Communication theory asserts that emotional problems result from the way people interact with each other in the context of the family (Harmon Hanson et al., 2005). Healthy families have clear rules such as “we don’t interrupt each other when speaking” or “we don’t yell at each other.” Com- munication is clear and congruent and nonverbal cues match what is being said. Unhealthy families give mixed or double-binding messages, which are statements accompanied by nonverbal expressions that are inconsistent and incongruent with the verbal message. Healthy families communicate love and support clearly and often. Verbal communication is matched by nonverbal communication (such as hugs, voice tone, and eye-contact) that supports the intended message. Families check with each other to make sure the intended meaning is understood. For example, a parent explains; “I am setting a curfew because I care about you and want you to be safe. Does that make sense to you?”

The parent then encourages discussion to ensure clarity and understanding of the purpose of curfew.

Nursing Insight—

Family communication patterns Patterns of family communication reveal much about family functioning. In addition to providing information about “who is saying what and to whom,” they also convey information about the structure and functions of family relationships in

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Dalam dokumen Maternal-child Nursing Care - Repository Poltekkes Kaltim (Halaman 102-113)