Islamic University of Gaza Faculty of nursing Done by:Mhonnead Hamdan Supervised by : Dr. Ashraf Eljedi.

Islamic University of GazaFaculty of nursing

Done by: Mhonnead Hamdan

Supervised by : Dr. Ashraf Eljedi

Families as Resources, Caregivers,and Collaborators

Ever since Florence Nightingale, nurses have involved family

members in the care of patients with heart disease, cancer,

diabetes, and similar disorders. In contrast, the families of patients

with mental illnesses were for many years considered to be part of

die problem, not part of the solution.

However, during the 1990s professional perceptions of families

changed dramatically. Today, families are the largest group of

caregivers for the mentally ill, since two thirds of hospital

patients are returned to live with their families.

Psychiatric nurses work with families at all levels of functioning.

Patients are or have been members of a "family" system. Past and

present family relationships affect a patient's self-concept,

behavior, expectations, values, and beliefs.

. Thus understanding principles of family dynamics and

interventions is critically important (O'Connell, 2006; Huey

et al, 2007). Competence in this area will enhance the nurse's:

*Assessment of the individual's and the family's needs and

resources.

*Identification of problems and strengths displayed by an

individual and a family.

*Selection of interventions to promote positive coping strategies

and adaptive functioning.

*Decision making related to referrals to other appropriate

resources.

Psychiatric nurses are encouraged to partner with families as

resources, caregivers, and collaborators in their clinical

practice.

FAMILY ASSESSMENT

The concept of "family" has evolved from the "two married

heterosexual parents with several children of their own"

household of several decades ago to a variety of extended and

creative nontraditional "family" systems. Nurses encounter many

different configurations of the family unit in their clinical work.

Although the definitions of family have become more fluid in

recent decades, a family is usually defined in terms of kinship:

individuals joined by marriage or its equivalent or by

parenthood. A broader definition describes family members

as those who by birth, adoption, marriage, or declared

commitment share deep, personal connections and are

mutually entitled to receive, and obligated to provide,

support, especially in times of need.

Family Family AssessmentAssessment

1. 1. MembersMembers of the household of the household & relationships to the head& relationships to the head of the of the family. family.

2. 2. Demographic DataDemographic Data: : age, sex, civil status, position in the familyage, sex, civil status, position in the family

3. 3. Place of Residence of each memberPlace of Residence of each member – whether living with the – whether living with the

family or elsewhere family or elsewhere

4. 4. Type of family structureType of family structure: matriarchal, patriarchal, nuclear or extended : matriarchal, patriarchal, nuclear or extended

5. 5. Dominant family membersDominant family members in terms of decision making in in terms of decision making in matters of health carematters of health care

6. 6. General relationshipGeneral relationship – presence of any obvious readily observable – presence of any obvious readily observable conflict between members; characteristic communication patterns among conflict between members; characteristic communication patterns among

membersmembers

B. Socio-Economic & Cultural FactorsB. Socio-Economic & Cultural Factors

1. Income and Expenses1. Income and Expenses Occupation, place of work and income of each working Occupation, place of work and income of each working

membermember Adequacy to meet basic necessities (food, clothing and Adequacy to meet basic necessities (food, clothing and

shelter)shelter) Who makes decisions about the money and how is it Who makes decisions about the money and how is it

spent?spent?

2. Educational attainment of each member2. Educational attainment of each member

3. Ethnic Background and Religious Affiliation3. Ethnic Background and Religious Affiliation

4. Significant Others – role they play in the family’s life4. Significant Others – role they play in the family’s life

5. Relationship of the family to larger community – family’s 5. Relationship of the family to larger community – family’s participation in the community activitiesparticipation in the community activities

C. Environmental FactorsC. Environmental Factors

1. Housing1. Housing Adequacy of living spaceAdequacy of living space Sleeping arrangementSleeping arrangement Adequacy of the furnitureAdequacy of the furniture Presence of insects and rodentsPresence of insects and rodents Presence of accident hazardsPresence of accident hazards Food storage and cooking facilitiesFood storage and cooking facilities Water supply – source, ownership, potabilityWater supply – source, ownership, potability Toilet Facility – type, ownership, sanitary conditionToilet Facility – type, ownership, sanitary condition Garbage/Refuse Disposal – type, sanitary conditionGarbage/Refuse Disposal – type, sanitary condition Drainage System – type, sanitary conditionDrainage System – type, sanitary condition

2. Kind of neighborhood: congested, slum, etc.2. Kind of neighborhood: congested, slum, etc.

3. Social & Health facilities available3. Social & Health facilities available

4. Communication & Transportation Facilities Available4. Communication & Transportation Facilities Available

Health Assessment of each memberHealth Assessment of each member

1. Medical & Nursing history indicating past significant 1. Medical & Nursing history indicating past significant illnesses, illnesses,

beliefs & practices conducive to illness.beliefs & practices conducive to illness.

2. Nutritional Assessment (specially vulnerable or at risk 2. Nutritional Assessment (specially vulnerable or at risk members)members)

– Anthropometric data: weight, height, mid upper Anthropometric data: weight, height, mid upper arm circumferencearm circumference

– Dietary history indicating quality & quantity of Dietary history indicating quality & quantity of food intake per dayfood intake per day

– Eating/Feeding Habits/PracticesEating/Feeding Habits/Practices

3. Current health status indicating presence of illness 3. Current health status indicating presence of illness states states

(diagnosed or undiagnosed by medical practitioner)(diagnosed or undiagnosed by medical practitioner)

Characteristic of functional Characteristic of functional familyfamily

Five Freedoms ExpressedFive Freedoms Expressed—In order to be fully functional, each —In order to be fully functional, each human being needs to express freely the five basic powers that human being needs to express freely the five basic powers that constitute human strength. These are: the power to perceive; to constitute human strength. These are: the power to perceive; to think and interpret; to emote; to choose, want and desire; and to be think and interpret; to emote; to choose, want and desire; and to be creative through the use of imagination.creative through the use of imagination.

Unfolding Process of IntimacyUnfolding Process of Intimacy—The marriage, as the chief —The marriage, as the chief component of the family, needs to be in the process of becoming component of the family, needs to be in the process of becoming intimate. This process goes through the stages of: intimate. This process goes through the stages of: in love; working in love; working out differences; compromise and individualization; out differences; compromise and individualization; and and plateau plateau intimacy.intimacy.

Negotiated DifferencesNegotiated Differences—Negotiating differences is the crucial —Negotiating differences is the crucial task in the process of intimacy foundation. To negotiate differences task in the process of intimacy foundation. To negotiate differences there must be the desire to cooperate. This desire creates the there must be the desire to cooperate. This desire creates the willingness to fight fair.willingness to fight fair.

Laws Are Open and FlexibleLaws Are Open and Flexible—The laws in functional families will —The laws in functional families will allow for mistakes. They can be, and are, negotiable.allow for mistakes. They can be, and are, negotiable.

Clear and Consistent CommunicationClear and Consistent Communication—Clear and consistent —Clear and consistent communication are keys to establishing separateness and intimacy—communication are keys to establishing separateness and intimacy—clear communication demands awareness of self and the other, as clear communication demands awareness of self and the other, as well as mutual respect for each other’s dignity.well as mutual respect for each other’s dignity.

TrustingTrusting—Trust is created by honesty. Accurate expression of —Trust is created by honesty. Accurate expression of emotions, thoughts, and desires is more important than agreement. emotions, thoughts, and desires is more important than agreement. Honesty is self-responsible and avoids shaming.Honesty is self-responsible and avoids shaming.

IndividualityIndividuality—In functional families differences are encouraged. —In functional families differences are encouraged. The uniqueness and unrepeatability of each person is the number one The uniqueness and unrepeatability of each person is the number one priority.priority.

Open and FlexibleOpen and Flexible—In a functional family the roles are open and —In a functional family the roles are open and flexible. One can be spontaneous without fear of shame and flexible. One can be spontaneous without fear of shame and judgment.judgment.

Needs FulfilledNeeds Fulfilled—Happy people are getting their needs met. A —Happy people are getting their needs met. A functional family allows all of its members to get their needs filled.functional family allows all of its members to get their needs filled.

AccountabilityAccountability—Functional families are accountable. They are —Functional families are accountable. They are willing to acknowledge individual problems, as well as family willing to acknowledge individual problems, as well as family problems. They will work to resolve those problems.problems. They will work to resolve those problems.

CultureNurses have a professional responsibility to be aware of and be

sensitive to aspects of family structures that are due to cultural

and ethnic differences. Specifically, culture within a family

determines the following:• The definition of family.

• The beliefs governing family relationships.• The conflict and tensions present in a family and the adaptive

or maladaptive responses to them.• The norms of a family.

• How outside events are perceived and interpreted.• When, how, and what type of family interventions are most

effective.

Family History Family history information usually induces a11 family

members across three generations. It is convenient to use a

family genogram as the organizing structure for collecting this

information. A three-generation family genogram is a

structured method of gathering information and graphically

depicting the factual and emotional relationship data in the

initial interview and during subsequent family meetings

(McGuinness et al, 2005).

A sample genogram is presented in Figure 10-3. Drawing a

family genogram in full view of the family on large easel paper

or. a blackboard broadens the family's focus and facilitates an

understanding of the family constellation.

The genogram is usually designed around the patient, and all relatives are included. First-degree relatives include

parents, siblings, and children of the patient. Second-degree relatives include grandparents, uncles, aunts, nephews, nieces,

and-grandchildren. All family members by marriage, partnership, or adoption and

stepfamily members also are included. The health status of each is noted, as are the current household,

configurations. Relationships between members also are recorded.

The genogram provides an invaluable family map for discovering both individual and family insights and for

generating discussions. It can continue to be updated by the family over time.

Family APGARFamily APGAR FAPGAR (Family APGAR) FAPGAR (Family APGAR) A – AdaptationA – Adaptation P – Partnership P – Partnership G – GrowthG – Growth A – Affection A – Affection R – Resolve R – Resolve

FAPGAR… FAPGAR… :: Adaptation: –Adaptation: – Use of intra and extra familial resources for problem solving Use of intra and extra familial resources for problem solving

when family faces crisis.when family faces crisis. Partnership: Partnership: – Sharing of decision making and nurturing responsibilities by – Sharing of decision making and nurturing responsibilities by

family members.family members. Growth:Growth: – Physical & emotional maturation achieved through mutual support – Physical & emotional maturation achieved through mutual support

and guidance.and guidance. Affection:Affection: – The caring relationship among family members. – The caring relationship among family members. Resolve: Resolve: – The commitment to devote time to other members of the family – The commitment to devote time to other members of the family

for nurturing. Also includes decision to share wealth & space for nurturing. Also includes decision to share wealth & space

Functions measured by the Family APGAR include how

the following are shared within the family:• Resources, or the degree to which a member is satisfied with

the assistance received when family resources are needed.• Decisions, or the member's satisfaction with mutuality in family

communication and problem solving.• Nurturing, or the member's satisfaction with the freedom

available within the family to change roles and attain physical

and emotional growth or maturation.• Emotional experiences, or the member's satisfaction with the

intimacy and emotional interaction that exist in the family.• Time, space, and money, or the member's satisfaction with the

time commitment that has been made to the family by its

members.

Working with familiesWorking with families

Partnering with patients' families is an essential part of nursing

care. Nurses have always made intuitive observations about

family dynamics. Although many nurses have gained

additional knowledge and received training in formal family

therapy techniques, all nurses use techniques, such as

psychoeducational programs developed from a competence

paradigm, in order to more effectively work with families in

everyday nursing practice.

Competence paradigmCompetence paradigm

The competence paradigm provides a significant shift m The competence paradigm provides a significant shift m how family interventions are considered (Marsh, 2000; how family interventions are considered (Marsh, 2000; Greenberg et al, 2006). Older conceptual models tended Greenberg et al, 2006). Older conceptual models tended to focus on family pathological states and dysfunction. to focus on family pathological states and dysfunction. The competence model focuses on family strengths, The competence model focuses on family strengths, resources, and competencies and values empowerment resources, and competencies and values empowerment instead of dependency. It stresses the importance of instead of dependency. It stresses the importance of treating people as collaborators who are the masters of treating people as collaborators who are the masters of their own fate and capable of making healthy changes their own fate and capable of making healthy changes (Table 10-1).(Table 10-1).

The competence paradigm emphasizes the following points:• Focus is on growth-producing behaviors rather than on

treatment of problems or prevention of negative outcomes.• Promotion and strengthening of individual and family functioning

occur by way of fostering prosocial, self-sustaining, self-efficacious, and other adaptive behaviors.

• Definition of the relationship between the help seeker and help giver is based on a cooperative partnership that assumes joint

responsibility.• Assistance is provided that is respectful of the family's culture and congruent with the family's appraisal of problems and needs.

• The family's use of natural support networks is promoted.In this framework it is expected that families will play a major

role in deciding what is important to them, what options they will choose to achieve their goals, and whether they will accept

help that is offered to them.

Benefits of family involvementBenefits of family involvement

There are many benefits to involving families in the care of their There are many benefits to involving families in the care of their

loved ones with mental illness. Research confirms that family loved ones with mental illness. Research confirms that family

input in treatment decisions improves patient outcomes, with input in treatment decisions improves patient outcomes, with

maximum benefits occurring when the families are supported and maximum benefits occurring when the families are supported and

educated for these partnership roles (Heru, 2006).educated for these partnership roles (Heru, 2006).

Family psychoeducation consists of educational, supportive, Family psychoeducation consists of educational, supportive,

cognitive, and behavioral strategies of at least 9 months‘ cognitive, and behavioral strategies of at least 9 months‘

duration.duration.

Barriers to family involvementBarriers to family involvementThe barriers to educating families for involvement in their loved

one's treatment include the following:• Professional bias against families based on exposure to family

systems theories that suggest families cause or perpetuate the illness.

• Family attitudes that equate all family interventions with past, unwelcome experiences with family therapy

• Professional fears that an alliance with the family will endanger confidentiality and threaten the therapeutic alliance with the

patient• Administrative restraints in a managed-cost environment, where

services to families (as non patients) receive the lowest priority. These barriers are gradually disappearing, but only when the

considerations of treatment and prevention are drawn around the family unit (as opposed to simply the individual) will they

disappear completely (Rose et al, 2004).

Families as a population at riskFamilies as a population at risk

The impact of mental illness is a shattering, traumatic event in the The impact of mental illness is a shattering, traumatic event in the life of a family, and, as such, family members are ideal candidates for life of a family, and, as such, family members are ideal candidates for secondary prevention strategies (Burland, 1998). They are affected by secondary prevention strategies (Burland, 1998). They are affected by the resource needs of their ill loved one, including housing and the resource needs of their ill loved one, including housing and employment. They also face potential stigmatization and diminished employment. They also face potential stigmatization and diminished social contact themselves, risk for violent victimization, and concern social contact themselves, risk for violent victimization, and concern about access to and the quality of health care their relatives receive about access to and the quality of health care their relatives receive (Copeland, 2007).(Copeland, 2007).

Parents, siblings, spouses, and children may respond in different Parents, siblings, spouses, and children may respond in different ways, but all experience some level of ways, but all experience some level of griefgrief. In addition, all families . In addition, all families experience the experience the stigma of mental illnessstigma of mental illness on behalf of their loved' one on behalf of their loved' one and sometimes by association.and sometimes by association.

• Aging parents who expected to have an empty nest find

themselves in their fifties, sixties, and seventies sharing the

nest with adult children who have a mental illness. Not only must

their dreams for their children be revised, but also these parents

must learn to live with loved ones whose moods arid behaviors are

often baffling and sometimes dangerous.

• Children of mentally ill parents are a population at risk (Mason

and Subedi, 2006; Mason et al, 2007). Living with a mentally ill

parent does not necessarily mean that the child will develop the

disorder, but it can make growing up more difficult. Although the

mechanisms for transmitting psychiatric illness across generations

are controversial, many studies support the fact that parental illness

affects children.

For example, it has been noted that coping with a mentally

ill parent may be more difficult than coping with parental loss.

These children also feel psychologically vulnerable and fear

becoming ill themselves. The major research findings on this topic

are as follows:

• Children of mentally ill parents are at greater risk for

psychiatric and developmental disorders than are children of well

parents.

• The risk to children is greater if the mother rather than the

father is the ill parent.

• In studies of depressed versus non depressed groups,

differences in the mother-child interaction are evident as early as 3

months postpartum.

• Many children with emotionally disturbed parents do not

Well siblings are another vulnerable group who can experience problems in living (Lively et al, 2004)..When the

emotional and financial resources are devoted disproport- ionately to the son or daughter with the illness, less is available for

the siblings. They may be resentful but unable to express their resentment because of survivor's guilt. Some siblings detach from the family. Others remain involved, often at the expense of career

and marriage options.

Siblings and offspring are likely to have problems as adults because

they had less parental attention than they needed as children and

adolescents. It is ironic that professional caregivers who are very

knowledgeable about the effects of childhood trauma in general

terms are often unaware of the specific difficulties faced by children

growing up in families preoccupied by mental illness.

Building bridgesBuilding bridges

I the late 1980s NAMI's Curriculum and Training Network I the late 1980s NAMI's Curriculum and Training Network offered a program to train two persons from each state affiliate offered a program to train two persons from each state affiliate as family education specialists." Later, a 12-week curriculum as family education specialists." Later, a 12-week curriculum known as the NAMI Family-to-Family Education Program known as the NAMI Family-to-Family Education Program was written. This peer-taught program has been presented free was written. This peer-taught program has been presented free of charge to more than 60,000 families across the United of charge to more than 60,000 families across the United States. It is no coincidence that many family members trained States. It is no coincidence that many family members trained to teach the course have a nursing background. To make this to teach the course have a nursing background. To make this unique referral resource better known to-mental health unique referral resource better known to-mental health professionals, a "Clinician's Guide to the NAMI Family-to-professionals, a "Clinician's Guide to the NAMI Family-to-Family Education Program" was written (Weiden, 1999).Family Education Program" was written (Weiden, 1999).