Communicating with Families

Definition of family

Wright and Leahey (2009) state, “A family is who they say they are” (p. 70). Identified family members may or may not be blood related. Strong emotional ties and durability of membership characterize family relationships regardless of how uniquely they are defined. Even when family members are alienated, or distanced geographically, they “can never truly relinquish family membership” (Goldenberg & Goldenberg, 2008, p. 3).

Some people identify their family as those with whom they have close relationships and who care for them (Kristjanson & Aoun, 2004). Each family member relates to the other and to crisis affecting the family in unique ways. Communication, even when reactive, is designed to maintain the integrity of the family. Understanding the family as a system is relevant in today’s health care environment, as the family is an essential part of the health care team.

The family represents the primary sociocultural system, in which children learn values and behavior patterns (Novilla, Barnes, De La Cruz, & Williams, 2006). Family health beliefs, past family experience with illness or injury, family loyalties and conflicts are important pieces of information that help explain client and family responses to health disruptions.

Families have a profound influence on sick clients as advisors, caretakers, supporters, and sometimes irritants. Clients who are very young, very old, and those requiring assistance with self-management of chronic illness are particularly dependent on their families.

Learning about the family’s dynamics provides:

Family composition

There is significant diversity in the composition of families, family beliefs and values, how they communicate with each other, ethnic heritage, life experiences, commitment to individual family members, and connections with the community (Schor, 2003). Box 13-1 identifies different types of family composition.

Families today are much more complex than in past generations. Modern definitions of family include “declared commitment” family households without marriage (Levine, 2004). Single-parent families must accomplish the same developmental tasks as two-parent families, but in many cases, they do it without the support of the other partner or sufficient financial resources.

Blended families have a different life experience than those in an intact family because their family structure is more complex. Children may be members of more than one family unit, linked biologically, physically, and emotionally to people who may or may not be part of their daily lives. Their “family” may include two or more sets of grandparents, step- or half-brothers and sisters, and multiple aunts and uncles (Byng-Hall, 2000). The child may spend extended periods in separate households, each with a full set of family expectations that may or may not be similar. Blended families can offer a rich experience for everyone concerned, but they are more complex because of multiple connections. Table 13-1 displays some of the differences between biological and blended families. Issues for blended families include discipline, money, use of time, birth of an infant, death of a stepparent, inclusion at graduation, and marriage and health care decisions.

General systems theory

Kurt von Bertalanffy’s (1968) general systems theory provides a conceptual foundation for family system models (Barker, 1998). A systems perspective examines the interdependence among all parts of the system and how they support the system as a functional whole. Systems’ thinking maintains that the whole is greater than the sum of its parts with each part reciprocally influencing its function. If one part of the system changes or fails, it affects the functioning of the whole. A clock is a useful metaphor. It displays time correctly, but only if all parts work together. If any part of the clock breaks down, the clock no longer tells accurate time.

A system interacts with other systems in the environment. An interactional process occurs when “inputs” are introduced into the system in the form of information, energy, and resources. Within each system, the information is processed internally as the system actively processes and interprets its meaning. The transformation process of raw data into desired outputs is referred to as throughput. The output refers to the result or product that leaves the system. Each system is separated from its environment by boundaries that control the exchange of information, energy, and resources into and out of the system. Evaluation of the output and feedback loops from the environment inform the system of changes needed to achieve effective outputs. Figure 13-1 identifies the relational components of a human system’s interaction with the environment, using von Bertalanffy’s model.

Applied to the human system, individuals take in food, liquids, and oxygen to nourish the body (inputs). Within the body, a transformational process occurs through enzymes and other metabolic processes (throughputs). so that the body can use them. This interactional process results in the human organism’s growth, health, and capacity to interact with the external environment (outputs). Nonusable outputs excreted from the body include urine, feces, sweat, and carbon dioxide. A person’s skin represents an important boundary between the environment and the human system.

Family systems have boundaries that regulate information coming into and leaving the family system. Family systems theory helps explain how families strive for harmony and balance (homeostasis), how the family is able to maintain its continuity despite challenges, (morphostasis), and how the family is able to change and grow over time in response to challenges (morphogenesis). Feedback loops describe the patterns of interaction that facilitate movement toward morphogenesis, or morphostasis. They impact goal setting in behavior systems. The systems principle of equifinality describes how the same outcome or end state can be reached through different pathways. This principle helps explain why some individuals at high risk for poor outcomes do not develop maladaptive behaviors (Cicchetti & Blender, 2006). Hierarchy is the term used to describe the complex layers of smaller systems that exist within a system. Subsystems refer to the smaller parts within the system, and suprasystems help describe the larger economic, social, and political systems in which the family system exists.

Bowen’s systems theory

Murray Bowen (1978) family systems theory conceptualizes the family as an interactive emotional unit. He believed that family members assume reciprocal family roles, develop automatic communication patterns, and react to each other in predictable connected ways, particularly when family anxiety is high. Once anxiety heightens within the system, an emotional process gets activated (Nichols & Schwartz, 2009) and dysfunctional communication patterns can emerge. For example, if one person is overly responsible, another family member is less likely to assume normal responsibility. Until one family member is willing to challenge the dysfunction of an emotional system by refusing to play his or her reactive part, the negative emotional energy fueling a family’s dysfunctional communication pattern persists.

Bowen developed eight interlocking concepts to explain his theoretical construct of the family system (Bowen Center, 2004; Gilbert, 2006). He viewed self-differentiation as the fundamental means of reducing chronic anxiety within the family system and enhancing effective problem solving. Self-differentiation emphasizes thinking rather than feeling in communication.

Family legacies have a powerful influence on family relationships and in shaping parenting practices. Knowledge of family relationships helps explain behaviors that would not be clear without having a family context. Helping families gain clarity about how their family heritage can be used as an asset in health care and/or what areas need work strengthens the potential for effective family-centered care.

Minuchin’s structural model

Family structure models, pioneered by Salvador Minuchin (1974), emphasize the structure (subsystems, hierarchies, and boundaries) of the family unit as the basis for understanding family function. Family structure refers to how the family is constructed legally and emotionally. The concept of hierarchy describes how families organize themselves into various smaller units, referred to as the subsystems that comprise the larger family system.

Subsystems are organized by position, gender, generation, interest, or function to accomplish the goals of the family through related tasks. Common subsystems include spousal, parental, and sibling units. Family members typically belong to several subsystems simultaneously (Goldenberg & Goldenberg, 2008). Their behaviors in each subsystem reflect the nature of the relationship, for example, an adult feeling like a child when visiting parents. Being in multiple subsystems can generate conflict when the expectations of one subsystem interfere with those of another, for example, being a parent while having caregiving responsibility as a daughter for a frail elder and finding time for the spousal subsystem.

Boundaries, defined as invisible limits surrounding the family unit, protect the integrity of the family system. Boundaries draw a line in the sand by identifying what belongs within the family system and what is external to it. They define the level of participation between family members (Nichols & Schwartz, 2009). Clear generational boundaries provide security for family members, for example, setting legitimate limits with children and balancing individual needs with caring for the needs of chronically ill family members.

Boundaries regulate the flow of information into and out of the family. Permeable boundaries welcome interactions with others and allow information to flow freely. Families with clear, permeable boundaries are better able to balance the demands of the illness with other family needs and can communicate more effectively with care providers (Dalton & Kitzmann, 2008). Diffuse boundaries lead to family overinvolvement, whereas rigid boundaries are operative in families with little interaction between members and family secrets. Rigid boundaries restrict flow of information. Interaction with outsiders is discouraged or heavily regulated. Diffuse boundaries are found in enmeshed families.

Exercise 13-1 provides an opportunity to look at the communication process of family from a structural functional perspective. Structural and functional aspects of families determine the nature of interactions between family members. Family interactions offer protective and health-promoting support for members in crisis when they function well, and are an area of concern when they function ineffectively.

The family performs its functions through subsystem alliances and coalitions to maintain the system as a whole (homeostasis). Wright and Leahey (2009) describe two ways of examining family functioning: instrumental and expressive. Both are important descriptors of family functioning.

Assessment of a family’s structure and function for strengths and weaknesses, and comparing current functionality with previous functioning helps focus nursing interventions and supports.

Duvall’s developmental framework

Evelyn Duvall (1958) proposed a family life stage framework for understanding issues that normal families experience based on expected family development through the life span, each with its own set of tasks. Her model describes the life cycle of a family, using the age of the oldest child in the family as the benchmark for determining the family’s developmental stage. Developmental tasks represent the challenges and growth responsibilities each family experiences at different life stages (Table 13-2).

Duvall’s stages of family development are helpful in guiding nurses about possible concerns families may have at different stages of family development. It helps nurses appreciate a family’s current developmental needs that may coincide with their family member’s illness or injury. Nurses can provide information about natural family development as a basis for discussion of the limitations imposed by the health deviation.

Duvall (1958) identified nine family characteristics indicative of successful family development:

Developmental family theory helps nurses appreciate the family’s current developmental needs that may coincide with their family member’s illness or injury. This knowledge helps nurses craft a developmentally appropriate level of involvement for each family system (Leon, 2008). Families benefit from information about normal developmental patterns and typical limitations imposed by a health deviation. For example, hair loss for the adolescent having chemotherapy can be devastating because of the heightened attention to appearance during this developmental stage. Anticipatory guidance about natural developmental milestones and associated behaviors is helpful.

Mccubbin’s resiliency model of family coping

McCubbin’s Resiliency Model of Family Stress, Adjustment, and Adaptation is considered the most extensively studied model of family coping with traumatic and chronic illness (McCubbin, McCubbin, Thompson, et al, 1993; Clark, 1999). In this model, A (an event) interacts with B (resources) and with C (family’s perception of the event) to produce X (the crisis). An expansion of this model adds the concepts of “pileup of demands, family system resources, and postcrisis behavior” (McCubbin, McCubbin, & Thompson et al., 1998, p. 49). With any serious illness, most people experience a roller coaster emotional response that parallels the course of the illness—optimism and hope when things are going well, disappointment and anger when they are not.

Protective factors related to stress adaptation include good problem-solving skills and flexibility to try different constructive actions. Successful coping built on family capabilities, strengths, and resources leads to positive adaptation. Unsuccessful coping strategies result in maladaptive behaviors (Greeff & Human, 2004). Exercise 13-2 provides an opportunity to look at the differences between positive and negative family interactions.

Pile-up demands (McCubbin et al., 1998) from the environment such as job loss, unexpected expenses, overcrowded housing conditions, and limited caregiving skills can place children and vulnerable adults at risk for significant stress. Family violence, substance abuse, neglect, and dysfunction are on the rise as families become more and more stressed while trying to cope with the demands of chronically ill clients. Nurses must be able to recognize families who are providing unsafe environments for individual family members or who have reached dangerous stress levels themselves.

Family-centered care

Family-centered care allows health care providers to have a more uniform understanding of the client and family’s knowledge, preferences, and values in health care as the basis for shared decision making. This information allows them to provide consistent information to all those involved in the client’s care, and to identify any barriers that might arise with the care plan.

The health events of one family member affect the whole family. Trotter and Martin (2007) note, “Families share genetic susceptibilities, environments, and behaviors, all of which interact to cause different levels of health and disease” (p. 561). Families bear a bulk of the care and/or support of client self-management of chronic health conditions. They are instrumental in helping clients appreciate the need for diagnosis and treatment, and in encouraging the patient to seek treatment. Family members are involved in a client’s health care decisions ranging from treatment options to critical decisions about end of life care. Families play a pivotal advocacy role in treatment by monitoring and insisting on quality care actions for an individual family member.

The challenges for the nurse in family-centered care are:

Assessment

For immediate health care purposes, family is defined as the significant people in the client’s environment who are capable and willing to provide family-type support. This definition of family includes members who may not be related by blood, marriage, or adoption (Medalie & Cole-Kelly, 2002). Regardless of how it occurs, any health disruption becomes a family event. Even when the family is not directly involved in the client’s care, they will have feelings about it—individually or collectively—that support or sabotage the effectiveness of treatment and the client’s quality of life (Bell, 2000). Box 13-2 lists sample indicators that could warrant family assessment and nursing intervention.

Assessment tools

Wright and Leahey’s (2009) 15-minute interview, consisting of the genogram, ecomap, therapeutic questions, and commendations provide a comprehensive look at family relationships. Assessment tools such as the genogram, ecomap, and family time lines are used to track family patterns. The structured format of these tools focuses on getting relational data quickly and can sensitize clinicians to systemic family issues that affect patterns of health and illness (Gerson, McGoldrick, & Petry, 2008).

Orienting the family

The nurse-family relationship in client care depends on a reciprocal relationship between the nurses and family in which both are equal partners and sources of information. Nurses should begin offering information to the family as soon as the client is admitted to the hospital or service agency. Orientation to the unit, location of the cafeteria and restrooms, parking options, nearby lodging, and access to the hospitalist or physician are important data points.

The initial encounter sets the tone for the relationship. How nurses interact with each family member may be as important as what they choose to say. Begin with formal introductions and explain the purpose of gathering assessment data. Even this early in the relationship, you should listen carefully for family expectations and general anxiety that may be revealed more through behavior than through words.

Gathering assessment data

Inquiring about the relationship the family member has with the identified client is an initial step nurses can take in establishing a relationship with the family. For example, you can initially say, “I would like to understand more about the effect of your husband’s heart attack on the family.” This simple statement frames the information needed. It also serves as a reminder that each family member plays a role in the health care scenario and has associated support needs that the nurse needs to consider (Vandall-Walker, Jensen, & Oberle, 2007). Box 13-3 illustrates a framework for a family assessment with a client entering cardiac rehabilitation.

Family participation in the data assessment process enhances the therapeutic relationship and completeness of the data. It is important to inquire about the family’s cultural identity, rituals, values, level of family involvement, decision making, and traditional behaviors as it relates to the health care of the client (Leon & Knapp, 2008).

Knowledge of a family’s past medical experiences, particularly whether they were positive or negative, the family’s medical beliefs, major family events a family is struggling with concurrently, plus family expectations for treatment and care are essential pieces of family assessment data. Suggested questions include:

Interventive questioning

Wright and Leahey (2009) identify therapeutic questioning as a nursing intervention that nurses can use with their client families to identify family strengths; help family members sort out their personal fears, concerns, and challenges in health care situations; and provide a vehicle for exploring alternative options. Interventive questioning can be either linear or circular.

Circular questions focus on family interrelationships and the impact a serious health alteration has on individual family members and the equilibrium of the family system. Examples of therapeutic questions are found in Box 13-4. The nurse uses information the family provides as the basis for additional questions.

The following case example demonstrates its use when the nurse asks a family, “What has been your biggest challenge in caring for your mother at home?”

In this example, each family member’s concern is related but different. The therapeutic circular question opens a discussion about each person’s anxiety. As family members hear the concerns of other family members, and as they hear themselves respond, their perspective broadens. The resulting conversation forms the basis for developing strategies that are mutually acceptable to all family members.

Selekman (1997) identifies four elements to consider when designing therapeutic interventions within a family context:

Meaningful involvement in the client’s care not only differs from family to family, it differs among individual family members (Sydnor-Greenberg, Dokken, & Ahmann, 2000). Individual family members have different perspectives. Hearing each family member’s perspective helps the family and nurse develop a unified understanding of significant treatment goals and implications for family involvement.

Although treatment plans should be tailored around personal client goals, acknowledging family needs, values, and priorities enhances compliance, especially if they are different. Shared decision making and development of realistic achievable goals makes it easier for everyone concerned to accomplish them with a sense of ownership and self-efficacy about the process. Taking little achievable steps is preferred to attempting giant steps that misjudge what the family can realistically do.

Exercise 13-7 provides practice with developing a family nursing care plan.

Implementation

Nurses can only offer interventions; it is up to the family to accept them (Wright & Leahey, 2009). Suggested nursing actions to promote positive change in family functioning include

Proximity to the client

The need to remain near the client is a priority for many family members of clients in the ICU (Perrin, 2009; Verhaeghe et al., 2005). Although the family may appear to hover too closely, it is usually an attempt to rally around the client in critical trouble (Leon, 2008). Viewed in this way, nurses can be more empathetic. As the family develops more confidence in the genuine interest and competence of staff, the hovering tends to lessen. Liberal visitation policies can result in “increased family involvement with patient care, increased family communication with nurses, and greatly decreased number of complaints from families” (Van Horn & Kautz, 2007, p. 102).

Families can be a primary support to clients, but they usually need encouragement and concrete suggestions for maximum effect and satisfaction. Family members feel helpless to reverse the course of the client’s condition and appreciate opportunities to help their loved one. Suggesting actions that family members can take at the bedside include doing range-of-motion exercises, holding the client’s hand, positioning pillows, providing mouth care or ice chips. Talking with the client, even if the person is unresponsive, can be meaningful.

Helping families balance the need to be present with the client’s needs to conserve energy and have some alone time to rest or regroup is important. Family members also need time apart from their loved one for the same reasons. Tactfully explaining the need of critically ill clients to have family presence without feeling pressure to interact can be supportive. Encouraging families to take respites is equally important.

At the same time, nurses need to be sensitive to and respect a family member’s apprehension or emotional state about their critically ill family member. Individual family members may need the nurse’s support in talking about difficult feelings.

Nurses can role model communication with clients, using simple caring words and touch. Families are quick to discern the difference between nurses who are able to connect with a critically ill client in this way, as evidenced in a family member’s comment that “some seem to have a way with him and they talk to him like he is awake” (Eggenberger & Nelms, 2007, p. 1623).

Providing information

Families with clients in the ICU have a fundamental need for information, particularly if the patient is unresponsive—“Not knowing is the worst part.” This cannot be stressed enough. Providing updated information as a clinical situation changes is critical. Even if there is no change in the client’s condition, most families will need to have information repeated because of anxiety that may limit processing of complex or emotionally difficult information (Van Horn & Kautz, 2007). They need to know exactly what is being done for their loved one in simple understandable terms, and to have their questions answered honestly (Miracle, 2006). This information is particularly critical when family members must act as decision makers for clients who cannot make them on their own (Perrin, 2009).

How health care providers deliver information is important. Even if the patient’s condition or prognosis leaves little room for optimism, the family needs to feel some hope and that the staff genuinely cares about what is happening with the client and family (Perrin, 2009; Verhaeghe, Defloor, Van Zuuren, et al., 2005).

Daily contact with the nurse assigned to the client in the ICU is a critical nursing action (Miracle, 2006) that the family needs. Identifying one family member to act as the primary contact helps ensure continuity between staff and family. A short daily phone call when family members cannot be present keeps the family connection and reduces family stress (Leon, 2008). Families need ongoing information on the client’s progress, modifications in care requirements, and any changes in expected outcomes, with opportunities to ask questions and clarify information. Nurses in the ICU often serve as mediators between client, family, and other health providers to ensure that data streams remain open, coordinated, and relevant.

Meeting family informational needs

Sharing information is a mutual process. Nurses need to welcome and respect family input and engage the family in mutual decision making (Levine, 2004). Helping client families anticipate what will happen as a chronic disease progresses and how the day-to-day needs will change helps eliminate the stress of the unknown. Nurses can offer suggestions about how to respond to these changes, and offer support to the family caregiver as they emerge. Helping family members access services, support groups, and natural support networks at each stage of their loved one’s illness empowers family members because they feel they are helping in a tangible way.

Supporting the caregiver

Providing emotional support is crucial to helping families cope. Remaining aware of one’s own values and staying calm and thoughtful can be very helpful to a family in crisis. Remember that your words can either strengthen or weaken a family’s confidence in their ability to care for an ill family member.

Focus initially on issues that are manageable within the context of home caregiving. This provides a sense of mastery and satisfaction. The nurse can encourage the family to develop new ways of coping or can list alternatives and allow the family to choose coping styles that might be useful to them. Focus on what goes well, and ask the family to share with you their ideas about how to best care for the client.

Many families will need information about additional home care services, community resources and options needed to meet the practical, and financial and emotional demands of caring for a chronically ill family member.

Encouraging families to use natural helping systems increases the network of emotional and economic support available to the family in time of crisis. Examples include contact with other relatives, neighbors, friends, and churches. Spiritual beliefs and support from extended family and friends enhance family resilience in times of trauma and loss (Greeff & Human, 2004).

Validating and normalizing emotions

Families can experience many conflicting emotions when placed in the position of providing protracted care for a loved one. Compassion, protectiveness, and caring can be intermingled with feelings of helplessness and being trapped. Major role reversals can stimulate anger and resentment for both client and family caregiver.

Sibling or family position or geographic proximity may put pressure on certain family members to provide a greater share of the care. Criticism or advice from less involved family members can be disconcerting and conflicts about care decisions can create rifts in family relationships. Some caregivers find themselves mourning for their loved one, even though the person is still alive, wishing it could all end and feeling guilty about having such thoughts.

These emotions are normal responses to abnormal circumstances. Listening to the family caregiver’s feelings and struggles without judgment can be the most healing intervention you can provide. Nurses can normalize negative feelings by offering insights about common feelings associated with chronic illness. Family members may need guidance and permission to get respite and recharge their commitment by attending to their own needs. Support groups can provide families with emotional and practical support, and a critical expressive outlet.

Psychosocial issues for parents with chronically ill children can cover many relationship issues, for example, how to respond and discipline children with chronic illness. Siblings sometimes get shortchanged emotionally, if not physically, when the focus necessarily is on the child with a serious illness or disability (Drench, Noonan, Sharby, & Ventura, 2007). Well siblings may experience feelings of resentment, worry that they might contract a similar illness, or have unrealistic expectations of their part in the treatment process. Siblings need clear information about the sick child’s diagnosis and care plan. They need to be treated as children with needs of their own and should not be expected to assume adult caretaker responsibility for younger siblings while parents focus on the ill child (Fleitas, 2000). Exercise 13-9 provides practice with using intervention skills with families.

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