Traditional Nursing Care - Maternal-child Nursing Care

Taking a look at the traditional role of nursing in the care of families and children helps identify the signifi cance of both positive and unfavorable changes that have occurred during the past century and framed current standards of care.

HISTORICAL PERSPECTIVE

Physicians, the general public, and the nursing profession historically viewed health as the absence of disease and the presence of optimal functioning. Illness was seen as patho- logical and something of which the health care provider worked to rid, heal, or cure the patient. This curative approach commonly was referred to as the medical model.

It often entailed a paternalistic, one-way channel of communication between the powerfully dominant and more knowledgeable health care provider and the submissive and uneducated patient or family. The power base for all decisions rested with the medical or, infrequently, the

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chapter 1 Traditional and Community Nursing Care for Women, Families, and Children 5

nurse provider who together often took an objective, detached biomedical approach (Gordon & Nelson, 2005).

Over the previous quarter century, a number of infl u- ences have affected how family and child health and nursing care are now defi ned in the 21st century (Fig. 1-1). The infusion of multiple cultures and beliefs about health care systems, along with exponential growth in scientifi c and technological capabilities, have been major forces in shap- ing the structure and delivery of nursing care. In addition, increased consumer access to health-related information via the Internet, mass media, and other sources that may or may not be accurate, the unprecedented rise in health care costs, and increasing imposition of cumbersome regu- lations have also contributed to change.

Now Can You— Discuss elements of contemporary nursing and health care for families and children?

1. Identify a major force that accounts for the present-day shift toward family-centered decision making in health matters?

2. Describe a nursing approach that fosters empowered caring for the patient?

3. Name four factors that have shaped contemporary family and child health and nursing care?

The growth of ethnopluralism (diverse cultures) daily impacts health care systems and providers. Often each culture comes with its own beliefs, values, and practices about health and illness. The United States Department of Com- merce, Bureau of the Census, projects that within the next 10 to 12 years, only one-half of the U.S. population will be of Euro-Caucasian descent, although the medical model formed and that continues to be supported is based on this group (U.S. Census Bureau, 2008). The population of other ethnici- ties and cultures will double and triple in that time, rapidly making up the other half of the U.S. population and bringing to the forefront their beliefs, values, and health practices.

During the past century the values, beliefs, and practices of the predominantly Euro-Caucasian male health care provider system drove health care decisions, interac- tions, and treatments based on the belief that these were unquestioningly in everyone’s best interest and by far superior to all others: a belief referred to as ethnocentrism (Leininger & McFarland, 2002).

In a culture changing as rapidly as is that of the United States today, ethnocentrism can critically compromise effective health care. One of the predominant problems with a health care system founded on ethnocentrism, paternalism, and the medical model is the system’s closed- mindedness and prejudice toward other solutions and viewpoints of health. It is this viewpoint that often alien- ates people in need of health care and deters them from seeking or accepting help.

HEALTH–WELLNESS CONTINUUM

For decades, the goal of nursing has been to move the patient toward well-being and away from disease and pathology. The aim of the nurse–patient relationship was to facilitate the attainment of that goal. The relationship process had a beginning (illness), middle (treatment), and end (wellness). This prominent emphasis on treating illness defi ned the scope of the nurse’s practice, or the nursing process: assess for signs of illness, diagnose alterations in health, determine interventions to restore health, conceptualize a targeted health outcome moving away from illness, and evaluate the treatment plan for nurse-determined modifi cations (Fig. 1-2).

In nursing there has recently been a shift in this health–

wellness continuum and process. The emphasis is changing from a linear beginning-to-end, illness-to-wellness process. No longer is the predominant nursing perspective to return the patient from illness (beginning) to a prior disease-free state (end) but toward a shared experience of transcending or controlling the health threat and changing it into one of purposeful meaning (LeVasseur, 2002). The nurse–patient relationship now is a circular or spiral process formed to motivate the patient or family toward promotion, maintenance, and restoration of health; health potential; prevention of illness; and self-care (Fig. 1-3).

Ethnocultural Considerations—

Perceptions of desired health and health outcomes

Based on personal beliefs, values, and practices, an ever- increasing culturally diverse population has many differing defi nitions of health and the outcomes desired during health- seeking encounters.

Paternalism Health = absence of disease, presence of optimal functioning Cure of illness = goal Illness = pathology to be rid of

Power centered in health care provider Patient submissive, passive recipient of treatment Nursing and medical orders followed unquestioningly Monastic culture recognition Euro-Caucasian nursing model

Consumerism Health = lifestyle Improving lifestyle

= goal Health defined by mass media Power diminished in health care provider, increased in health seeker and payer Patient aggressive partner in treatment Nursing and medical orders questioned by health payer Multi-cultural awareness Patient advocacy nursing model

Holism

Health = culturally and personally defined Purposeful meaning to life experiences

= goal

Decision making power patient/family driven Patient/family defines desired outcome Nursing and medicine motivators in shared health experience Cultural sensitivity essential

Transformative relational nursing model

Figure 1-1 Evolution of family and child health nursing model.

Health

Alteration/problem Signs of illness

Diagnosis Restorative interventions/goals

Expected outcomes Prioritization

Modifications

Evaluation Assessment

Planning

Figure 1-2 Traditional nursing process.

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

Through health promotion, the nurse helps the woman, child, or family understand health risk factors and adopt lifestyle changes that foster health maintenance, prevent health threats through early detection and recognition, and explore options for health restoration.

Across Care Settings:

Health protection for families

With increasing international travel comes also the transport of illness vectors previously unknown in certain locales.

Providing information about ways to protect children and families from these new sources of illness and injury through the use of individual instruction, educational videos, and use of the mass media can help the family maintain confi dence in their ability to protect themselves from new threats.

This form of nursing entails a shared connectedness between patient and nurse. The goal is to experience the illness or health threat in the same way the patient per- ceives it. The nurse moves with the patient beyond the illness through the patient’s own inner healing process to a patient-defi ned state of coping, harmony, wholeness (holism), and unity with the illness and healing outcome;

and hope, purpose, meaning (spirituality), and health potential beyond the illness toward healing. The power base for this healing and future health decisions rests within the patient and his belief in his health potential.

The approach of the nurse provider is to form a caring relationship through listening, understanding, experiencing, presencing, facilitating, valuing, and using nursing aesthetics. Nursing aesthetics, or the art of nursing, is the low-tech, high-touch artistry of caring that strengthens the patient’s confi dence in her or his ability to manage the healing process, make change, or master the threatening health event (Stichler & Weiss, 2001). It is the way the nurse and patient help each other fi nd meaning in the experience. It is a transformative, spiral process with a beginning (a threat), middle (relational building of trust and connection), and future (experiencing new possibilities for health change and outcomes) (Rhea, 2000).

Now Can You— Discuss aspects of health promotion and nursing aesthetics?

1. Describe present-day trends in nursing focus related to the health–wellness continuum?

2. Identify the elements of a health promotion nursing process?

3. Defi ne “nursing aesthetics” and the role it plays in realizing health potential?

Some nursing interventions that fall under this art of aesthetics include imagery, music therapy, and touch (Ward, 2002). Guiding the family or child’s imagination (guided imagery) to visualize repeatedly a positive outcome has been demonstrated to enhance healthy outcomes.

Music therapy helps bond the mind–body–spirit components of health and is especially successful with children.

Touch and speech patterns of the nurse have descriptively been shown to soothe, calm, and encourage patients toward the health outcome of their choosing. One only needs to watch a caregiver stroke, rock, and sing to a sick child to know that this form of the nursing art works.

Across Care Settings:

Teaching simple strategies for stress relief

Most have heard of the benefi cial effects of slow, deep, deliberate abdominal breathing patterns on the stress, anxiety, and pain associated with labor and birth. Nurses can teach these simple techniques to patients who anticipate stress, anxiety, or pain in any care setting.

Ethnocultural Considerations—

Use of imagery, chanting, and after-life encounters

One often thinks of imagery as a collection of nurse-initiated instructions given to the patient. To the woman undergoing treatment for cancer, the nurse may suggest: “Imagine all of the cancer cells fl owing up through your body, gathering all of the bad cells with them, and fi nally bursting into an explosion of color and sparkles like an explosion of fi reworks from your body. Out into the atmosphere they go, fl oating higher and higher as they disintegrate into outer space.” But, have nurses considered the healing power connected with objects used by some non-European Caucasian cultures? For example, the healing feather used by Native Americans, or the “see- ing” of spirits practiced in Asian cultures, the casting of spells performed in the Caribbean Island culture, and the prayer beads used in Middle Eastern cultures. The healing effects of music and speech patterns have been well documented. But do health professionals consider of equal value the healing value of chanting by the Native American, or the wails of sor- row of the Central and Eastern European culture? One’s awareness of various cultural practices is important. Even more important to their healing powers is the nurse’s sensitivity and incorporation of them into a shared perspective of healing with the patient and family.

While the family or child relates stories of a lived experience, maintaining en-face eye contact, symbolically enfolding them through proximity, and staying focused solely on them acknowledges their worthiness. Imagina-

Prevention Self-care

Nurse Patient

Health Threat

Potential Meaningfulness

Relationship Promotion

Maintenance Restoration

Figure 1-3 Health promotion nursing process.

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chapter 1 Traditional and Community Nursing Care for Women, Families, and Children 7

tively being in the patient’s experience, refl ectively sharing that experience through the use of body language, and avoiding demonstrations of disappointment and frustra- tion gives the nurse a shared point of reference from which to help the family and child create meaning out of a threatening health experience (Fig. 1-4).

CHANGING DEMANDS AND DEMOGRAPHICS This nursing approach of engaging transpersonal care has evolved from the simple nursing basics of providing treatment-driven, high-technology-centered care. It is an opportunity for the family–child nurse to utilize the nursing process in a new way. The nurse assesses the patient and family’s confi dence to address and manage the health threat, diagnoses the health alteration from the patient’s viewpoint, conceptualizes the outcome as the patient and family envision it, and supports the patient in his or her chosen changes directed at restoring health or transcending the threat. Finally, the nurse evaluates the on going maintenance of health as it is lived by the patient and family.

Over the last half century, public trust in health care providers has continually declined. Some surveys have noted that the public trusts health care providers only slightly more than they do the Internal Revenue Service and the tobacco industry (Ford & Fottler, 2000). Accord- ing to data from the National Coalition on Health Care (2006), much of this is likely due to health care providers’

minimal awareness of consumer preferences and desire for personal control. Starting in the 1960s, health care seekers became increasingly critical of health care providers.

Family–child nursing responded to this call for consumer advocacy (consumerism) by supporting the consumer demand for a shift in the thrust of decision-making power. Other strategies included advocating for the provi- sion of health care in facilities outside of the standard hospital setting (accessibility) and by providing family- centered approaches to care that emphasized health promotion and education. During the next half-century, other societal changes occurred that continued to alter health care delivery.

Across Care Settings:

Family-centered care

The need for family members to feel signifi cant and competent to care for their loved ones is universal, and should not be affected by the setting in which care is provided. Being friendly, encouraging family participation, and modeling of care are techniques that accomplish this goal in any setting.

Family structures (who the members are), functions (the roles members play), and defi nition of the family (a group of people sharing interpersonal bonds, tasks, and activities) have changed during the last half-century. Dyad families can comprise two cohabitating companions or spouses; traditional nuclear families of husband, wife, and children;

extended multigenerational families; communal families of shared religious or social beliefs and values; blended families from separate prior marriages; families of same-sex unions;

foster families; and adoptive families (see Chapter 3).

Social and technological advances of the past half- century have changed family structure, function, and defi - nition. With the increasing acceptance and technolo gically available birth control options made available to families since the 1970s, family size has also changed. The sexual revolution of the 1960s resulted in an increase in the number of single-parent families. The feminist movement of the 1970s sent ever-growing numbers of mothers outside the home into a second work environment. As the workforce increased, industries fl ourished, cities grew, and families became more mobile in search of better lives for themselves, often leaving behind the extended multigenerational family they had learned to depend upon.

In the family’s search for a better life, family health consciousness increased, as did usage of health care services and costs. The changes had implications for the way nursing delivered care and families sought it. Smaller families, single-parent families, families dispersed in search of better lives, and dual-income families meant fewer support persons present during family illnesses and crises. As a result, the role of the nurse inevitably changed from a focus on carrying out medical orders to a fuller scope of providing family support services.

Now Can You— Discuss aspects of cultural practices for healing and comfort, transpersonal care, and components of the family unit?

1. Explain why nurses should develop awareness and understanding of cultural practices intended to foster comfort and promote healing?

2. Discuss a nursing approach that incorporates engaging transpersonal care?

3. Differentiate among family, family structures, and family functions?

PROFESSIONAL NURSING ROLES

Since the time of Florence Nightingale, nurses have played a role that involved clinical interventions, patient and family education, empathetic support, development of therapeutic relationships, and unique opportunities to make a difference in the lives of families during illness.

Relationship

Low tech Listening

Experiencing Presencing Facilitating Valuing

Imaging

Touching

Reflective sharing High tech

Caring

Figure 1-4 Nursing aesthetics that strengthen confi dence in mastering a health threat.

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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 environment through hygienic measures, nourishment, and comfort 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 during 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 paternalistic 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 individual 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, interventions, 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?

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