COMFORT* Communication (narrative) Orientation and opportunity Mindful presence Family Openings Relating Team * Wittenberg-Lyles, E., Goldsmith, J., Ferrell, B., & Ragan, S. (2012). Communication and palliative nursing. New York: Oxford.

Objectives Describe a typology of family caregivers from a communication perspective Identify two communication skills that could be used with family caregivers

Common Family Problems Nurses Face Family doesn’t understand what is being told to them The family doesn’t know the patient’s wishes The family refuses help

Foundations: Family as System Family system – Bounded, interrelated, identifiable communication Interdependent – Influence one another Environment – Interaction, adaption/resistance Boundaries – Define system, communication between/with other systems

Nurse as a member of the family Recognize predictable interactions Family communication efforts become focused on the nurse – Nurse is mediator between family and physician Nurse communication can shape or protect family identities

Family Communication Climates Over time, families establish a communication climate (McLeod and Chaffee, 1972) Two fundamental communication orientations contribute to this environment – Conformity – Conversation (Ritchie and Fitzpatrick, 1990; 1991; 1994)

Conversation Orientation Degree to which all family: – Are encouraged to participate freely – Are encouraged to participate frequently – Are encouraged to participate without time limits – Are encouraged to participate without topic limits

Conformity Orientation Degree to which all family – Stresses homogeneity of attitudes – Stresses homogeneity of beliefs – Stresses homogeneity of values – Stresses fixed family roles

Caregiver Type: Manager High family conformity/High family conversation Caregiver dominates care planning Caregiver as self-appointed Family Spokesperson Caregiver controls decision-making Context of illness exaggerates: – Limited communication within/by family – Lack of diversity in perspectives about illness – Obligation to conform in family

Things to look for* Direct blocked communication – Hang up phone – Refuse to answer – Agree not to talk about illness Indirect blocked communication – Not responsive – Appear uncomfortable – Self-censored speech *Kenen, R., Ardern-Jones, A., & Eeles, 2004

Caregiver Type: Carrier Low family conversation/High family conformity Limited patient-caregiver discussions Caregiver coping takes place outside of family Illness perceived as private Context of illness creates: – Dynamic of caregiver as a proxy for patient authority – Family conflict due to low conversation – Self imposed pressure to over-perform caregiving

Understand family coping style Could you give an example of a difficulty your family has faced when you were growing up? What helped your family get through this? What was tried that did not help?

Caregiver Type: Partner High family conversation/Low family conformity This caregiver partners with family and healthcare team Ability to engage all quality of life dimensions Family-prompted internal family meetings Context of illness creates: – Open discussions about solutions and increased quality of life – An opportunity for this caregiver to be part of the care process – A place for family members to realize their caregiving strength

Assess family stressors What else is going on in your family’s life? What has helped you in dealing with these stressors? What has not been helpful?

Caregiver Type: Loner Low family conversation/Low family conformity A focus on one dimension of quality of life Experiences caregiving as one acute crisis after the next Can feel like a constant outsider to team and family Context of illness creates: – Further isolation for patient, caregiver, and family – Unrelenting caregiver burden – Conflicts for healthcare team and system

Assessing family relationships Tell me about your family. Who is close to whom?

Nurse-Caregiver Communication Managers – Initiate participation of other family members Carriers – provide accolades and reassurance – Offer and emphasize respite care Partners – Engage in dialogue about decision-making Loners – Focus on one-on-one interactions

Nurse Communication with Families Adapt communication to family structure Family meetings should address family uncertainty Surrogate decision-maker support