1. Community as the client

2. Approaches to analyzing data about families
Systems theory
Includes structural and functional components of the family as a system
Structural Family Assessment: considers family’s composition; roles and relationships
Functional Family Assessment: nurse collects info re: how well family is fulfilling basic functions in the context of continual change in the system as information and energy are exchanged between the family and the environment

3. Approaches to data analysis continued
Developmental theory
Approaches family from tasks and stages of progression through its life cycle and tasks that need to be accomplished
The stages of family development are used as a guide to categorize and analyze the baseline data
Risk factor assessment
Identify family’s risk factors based on Healthy People 2010 criteria

4. The Family from a Risk Factor Perspective
In the risk factor theory, the family is the most important social support system involved in lowering risks for its members
Risk factors can be estimated for death or diseases by comparing a group that has been exposed to a risk factor with a group that hasn’t been exposed to the risk factor, and comparing rates of death or disease in the two groups

5. Risk & families continued
Probabilities of risk change throughout the life cycle
The stages of family development are used to classify risk factors
Many chronic health problems are related to behavioral excesses that are learned through the family

6. Developmental Assessment
Four steps:
Determine family’s developmental stage
Consider family member’s health problems in context of tasks of their developmental stage
Determine if family members are meeting the tasks at their individual levels of development
Identify nursing interventions that would facilitate family meeting their developmental tasks
In developmental model, family enters stages with birth of first child or according to the age of the oldest child

7. Limitations of the Developmental Assessment Approach
Changing demographics, variations in family structures (not all families fit neatly into stages)
Nurse’s viewpoint has to take structure into account, thus, assessment becomes more complicated
Family conflicts cause difficulty, compounded by individuals’ role disruption from illness
Overall, family developmental tasks are related to meeting their basic family functions

8. Structural Family Assessment
Considers composition of family
Can be very helpful to nurse in many situations
May be a good assessment to start with
Genogram can be helpful for assessing social supports, seeing familial disease patterns, clarifying family dynamics, among other things
May be good to start with because in many ways it is less threatening than the other methods
Genogram is something that is worth learning to do and incorporate into health history; can open the door to a lot of information

9. Functional Family Assessment
Six family functions:
Affective
Healthcare and physical necessities
Economics
Reproduction
Socialization and placement
Family coping
Through interviews with family members, nurse collects info re: family members’ perceptions of how well family is fulfilling basic functions (for specific questions see p. 93 Hunt)
Use characteristics of a “healthy family” as framework for assessment (e.g., use characteristics as baseline or benchmark for comparison)

10. Characteristics of Healthy Families
There is a facilitative process of interaction among family members
The family enhances the development of its individual members
Role relationships are structured effectively
The family actively attempts to cope with problems
The family has a healthy home environment and lifestyle
The family establishes regular links with the broader community
When formulating nursing diagnosis remember that focus is on client & family’s effect on their recovery

11. Characteristics of Healthy Family Interactions
Communication among members is open, direct, and honest, with shared feelings
Family members express self-worth with integrity, responsibility, compassion, and love to, and for, one another
All members know the family rules. Rules are clear and flexible and allow individual members their freedom
The family has regular links with society, which demonstrate trust and friendship
Family members belong to various groups and clubs

12. Nursing Process
The purpose of writing a family nursing diagnosis is to help the family promote health through the life cycle and prevent disease through low-risk-taking behaviors
In planning phase, delineate expected outcomes for family health; Use mutual goal-setting with family
Process of collaborative goal-setting should have positive influence on nurse’s interactions with families
Also facilitates adherence to agreed-upon plan of care
Remember: Assessment is a two-way enterprise; the family is assessing you, as well
The purpose of the plan is to bring about some behavioral change in the family that will promote health or prevent dysfuntion; the family takes an active part in the planning process; the degree o responsibility that the family assumes for perseonal health status is important to the success of behavior change.l

13. Examples of Family Nursing Diagnosis
Theoretical
Model
Stage
Health
Status
Pattern
Problem
Developmental
Family with
Preschoolers
Potential for
physical injury
Health-
Perception-
Management
Medications &
poisonous cleaning
substances within reach of children
adolescents
Potential
alteration in
parenting
Roles-
relationships
pattern
Value systems of
Parents & adolescent members in conflict
Risk Factors
Young couple
Compromised &
ineffective
Coping-
stress-
tolerance pattern
Teenage marriage
Pregnancy before age 16
From: C. Edelman & C. Mandle (2002) Health promotion throughout the lifespan. St. Louis: Mosby.

14. Steps in the Planning Process
Prioritize problems & potential problems
Determine which items can be handled by the nurse and the family, and items that must be referred to others
Decide on actions and expected outcomes

15. Goals Goals describe a desired outcome Goal statements include:
The expected behaviors of the family
The circumstances under which the behaviors will be demonstrated
Criteria by which to determine when and how the behaviors will be performed
Health promotion goals reflect a desire to function at a higher level of health and to grow beyond maintaining health or preventing disease

16. Implementation With The Family
Family nursing interventions aim to assist family members in carrying out functions that the members cannot perform for themselves
Health promotion: the nurse assists the family in improving their capacity to act on its own behalf
Three Broad Categories of Interventions with Families
Cognitive interventions
Affective interventions
Behavioral interventions

17. Four Types of Interventions are Found in Health Promotion/Disease Prevention
Increasing knowledge and skills
Increasing strengths
Decreasing Exposure
Decreasing susceptibility
Increasing knowledge and skills so that families can improve their capacity to act on health-promotion and disease-prevention behaviors may be the primary strategy
Assist family to make informed choices about healthful lifestyle behaviors
Family health care has shifted in focus over the past several years from an illness or problem and deficiency focus to a strength-based focus
Assisting functional families may simply involve providing information in terms that can be understood and offering them opportunities to ask questions and clarify information
A family’s perceived susceptibility will determine how they change their behavior

18. Evaluation With The Family
Purpose of evaluation is to determine how the family has responded to the planned interventions. Concrete objectives are easier to measure
Family’s baseline data needs to be used as comparative criteria in evaluation
Five measures of family functioning that can be used to determine effectiveness of interventions
Changes in interaction patterns
Effective communication
Ability to express emotion
Responsiveness to needs of members as individuals
Problem-solving ability
If goals are not met, review process

19. Health Promotion/Prevention Strategies as Applied to the Family
Primary Prevention
Completing a family genogram and assessing health risks with the family to contract for family health activities to prevent diseases from developing
Secondary Prevention
Using a behavioral health risk survey and identifying the factors leading to obesity in the family
Tertiary Prevention
Developing a contract with the family to change nutritional patterns to reduce further complications from obesity
EVALUATION: LEADS TO CHANGES/MODIFICATIONS IN PLAN OF CARE; A CIRCULAR PROCESS

20. STRESS
AND COPING

21. Management of Stress and Crisis
“Family health” defined in terms of framework (e.g., developmental, systems, etc.)
Normative events (birth of a child, death of a grandparent, etc.) can be stressors
Non-normative events (e.g. death of a child) cause added stress for families; stress that is different from stress experienced with normative events

22. Theoretical Frameworks for Family Stress and Coping
ABC-X model most common
Systems model challenged Hill’s model

23. ABC-X Model Crisis=X Event=A Family’s definition of event=B
Resources available to family=C
Crisis (X) was proposed to be the
product of A, B, & C

24. Double ABC-X Model
Model extended to encompass the period right after the initial crisis
Introduced the idea of “pile-up” of stress
Adaptation or maladaptation by the family determined by the “pile-up” of stressors, (Aa), the family’s perception of the crisis, (Bb), and new resources and coping strategies, (Cc)

25. Systems Framework of Family Stress and Coping
Families develop a series of processes to manage or transform “inputs” to the system (e.g., time, energy) to outputs (e.g., cohesion, growth, love), known as rules of transformation
With time, families develop these patterns in enough quantity and variety to handle most changes and challenges; called requisite variety of rules of transformation

26. Systems Framework Continued
When families don’t have adequate variety of rules to respond to an event, the event becomes stressful
Family then falls into a pattern of trying to figure out what to do; usual tasks of family are then not addressed
Implicit family rules are reconsidered and redefined

27. Interventions: Helping Families Manage Stress/Crisis
In general, interventions for helping individuals and families should focus on empowerment rather than enabling, or “doing for”
Failure to recognize a family’s competencies and help define an active role for them can lead to dependency and lack of growth
Families need to feel a sense of personal competence to become active participants in problem-solving

28. Characteristics of Empowered Family Seeking Help
Access and control over needed resources
Decision-making and problem-solving abilities
The ability to communicate and to obtain needed resources

29. Outcomes of Empowerment
Positive self-esteem
The ability to set and reach goals
A sense of control over life and change processes
A sense of hope for the future

30. Empowerment Continued
Empowerment assumes a partnership between professional and client
Families are assumed to be competent, or capable of becoming empowered
Families need to identify that their action results in behavior change (evaluation)

31. HEALTH PROMOTION FOR THE COMMUNITY
ASSESSMENT:
HEALTH PROMOTION FOR THE COMMUNITY
WHAT IS COMMUNITY ASSESSMENT?

32. Components of a Community Assessment
Community: an entity made up of people, a place, and social systems
The characteristics of a “healthy community” can be used to assess a community’s health
Community assessment is a problem-solving process similar to the nursing process

33. Community Assessment Community-based vs community-oriented nursing
All three dimensions of community are assessed:
The people
The place
The social systems
Community assessments vary in scope and complexity; nurse’s role depends on nurse’s educational preparation and expertise

34. People
Demographic characteristics: number, composition by age, rate of growth and decline, social class and mobility of people in the community
Other vital statistics: birth rate, overall death rate, death rate by cause and age, and infant mortality rate
Infant mortality rate is considered to be the most important statistical indicator of maternal-infant health in the community
Infant mortality rate is widely used to to predict overall health of a community; also varies with resources etc, socioeconomic etc

35. Place Where the community is located and its boundaries
Type of community (e.g., rural or urban)
Location of health services
Climate: flora, fauna & topography

36. Social Systems Economic Educational Religious Political Legal
Human services
Recreation
Communication
systems

37. Power Systems
How decisions are made and how change occurs for planning

38. Methods of Community Assessment
Windshield Survey
A motorized equivalent of a simple head-to-toe assessment
Observer drives through neighborhood and uses observation skills to conduct a general assessment of the neighborhood
E.g., common characteristics about the way people live, where they live, type of housing, etc

39. Informant interviews
“Key informants” or members of the general public
Interviews are usually unstructured and used to collect general information
Participant-observation
Observe formal and informal community activities to determine significant events and occurrences
Formal: government, city council, etc.
Informal: gatherings at coffee shop, school, etc.
Can help with determining values, norms and concerns of a community

40. Records, documents and other previously collected information
Secondary data
Records, documents and other previously collected information
Includes databases from schools, departments of health, county data, private foundations and state universities
Constructed surveys
Usually time-consuming and expensive
Survey random sample of a target population asking specific questions
Data is analyzed for patterns and trends
Another important source of secondary data is census data
Often (usually) need funding for surveys

41. Epidemiologic Model Core component of public health Multidisciplinary:
Clinical medicine
Quantitative methods
Public health policy and goals

42. Epidemiology:
“The study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to control of health problems”
Correlation between cigarettes and lung cancer was the product of an epidemiological study

43. Descriptive Epidemiology:
Study of the distribution of disease and other health-related states in terms of:
personal characteristics (person)
geographical distribution (place)
temporal patterns (time)
MEASURES OF MORBIDITY AND MORTALITY:
Rates: the basic measure in epidemiologic studies; a rate is a measure of the frequency of a health event in a defined population during a specified period
Risk: the probability that an event will occur within a specified period
Measures of morbidity:prevalence and incidence rates are the most commonly used measures of levels of disease in a population
Mortality rates: overall and group-specific mortality rates are used, including cause-specific rate, case-fatality rate, infant mortality rate, are comon examples
Incident rates and Prevalence rates: Incidence rate is the number of new cases developing in a population at risk during a specified time; Prevalence rate is the measure of an existing disease in a population at a given time.

44. Analytic epidemiology:
Studies the origins and causal factors of disease and other health-related states and events
Cohort studies: subjects are classified on factors of interest and are followed over a period to observe some health outcome (ex-Framingham studies) Cohort study designs allow for calculation of incidence rates, and therefore, estimates of risk of disease. Cohort studies may be prospective or retrospective.
Case-control studies: subject selection based on outcome status. Given the way subjects are selected for a case-control study, neither incidence nor prevalence can be calculated directly.
Cross-sectional studies: subjects are simultaneously classified on exposure and outcome status.
Ecological studies: the ecological study is a bridge between descriptive epidemiology and analytical epidemiology. In ecological studies, only aggregate data such as population rates are used. There are multiple flaws, including uncertaintly about temporal sequence.
Experimental studies: randomized controlled clinical trials; best but most expensive and often not practical in clinical situations

45. Recently, lifestyle and multiple chronic conditions were accounted for by a multiple cause-multiple effect model:
Cause Effect
This model closely embraces the concepts of holism and wellness.
Cardiovascular disease is an example.

46. The Epidemiologic Triangle
Represents complex relationships among:
causal agents
susceptible persons
environmental factors
Quantitative methods used in analytic epidemiology have become very sophisticated and complex
Epidemiologic triangle (agent-host-environment) indicates the relations among causal agents, susceptible persons, and environmental factors. The Web of Causality (pictured in book) a related concept, more adequately illustrates the complex interrelationships of numerous factors interacting to increase or decrease the risk of disease.

47. Stages of Health and Prevention
Susceptibility Primary
prevention
Asymptomatic Secondary
disease prevention
Clinical Tertiary
manifestations prevention
The disease process is seen as a continuum from prepathogenesis (susceptibility) through asymptomatic stages, to clinical manifestations and eventual resolution. Levels of prevention are related to these stages of health and disease.
Primary prevention involves interventions to reduce the incidence of disease by promoting health and preventing disease processes from developing.
Secondary prevention includes programs designed to detect disease in the early stages, before signs and symptoms are clinically evident, to allow early diagnosis and treatment (or to identify high-risk individuals)
Tertiary prevention provides interventions directed toward persons with clinically apparent disease, with the aim of curing, ameliorating the course of disease, reducing disability, or rehabilitating

48. Epidemiology and Community-Oriented Nursing
The practice of community-oriented nursing is enhanced by understanding and application of epidemiologic concepts and methods
Used as one method of assessing the health needs of a community (community assessment)
Knowledge gained from epidemiologic studies enables community and public health practitioners to target programs and allocate resources more effectively and to develop effective intervention strategies