FAMILY NURSING
Family Assessment: Characteristics of
Healthy Families
Objectives:
1. Five family health practice guidelines.
2. Three conceptual frameworks that can be used to assess a family.
3. The 12 major assessment categories for families.
4. List the five basic principles the community health nurse should follow when assessing family health.
5. Parenting.
Working with Families in Community Health Settings
Family visits need not be limited to homes. Family members may be visited in school or at work during a lunch break, in a day care or senior center, in a group home, or in a myriad of after-work or after-school and recreational settings. The nurse must be creative to accommodate various family schedules and routines. In general, if a visit is all right with the family, school, or employer, it should be all right with the nurse. Families appreciate the individualized effort and respond more positively wheurses are willing to work with family member schedules.
When making visits in public places such as worksites or schools, be mindful of confidentiality and respect the family’s wishes. A client may agree to your visit during lunch break in the department store on a Tuesday, which is the boss’s day off, or after the lunch crowd in a fast-food restaurant disperses and the client can take a break. Seek out a place for the visit where other employees or customers cannot overhear your conversation with the client. Sometimes, visiting clients during the day helps to enhance family assessment. In families with a child in day care or an older adult in an adult day care program, your assessment of the individual’s ability to manage, participate, and interact can give insight into problems the family is referring to when you make a home visit.
Visiting children during the school day often gives insight into health problems the parents may be concerned about. Such a visit offers the community health nurse an excellent opportunity to consult with the principal, teachers, school nurse (see Chapter 28), counselor, and school psychologist. The community health nurse may suggest a team meeting of school professionals and the parents, coordinate the meeting, and act as liaison and client advocate during the meeting.
Working With Families Where They Live
Depending on the setting for community health nursing practice, the nurse encounters most clients in their homes and in their neighborhoods. Some see families in transition, who are living on the street, in a homeless shelter, or with other relatives. Regardless of the family’s location, the client is the family; the family is the unit of service in family nursing (Friedman, Bowden, & Jones, 2003).
Selection of Family Assessment and Measurement Tools
Because there are approximately 1000 family-focused instruments that have been developed and used in assessing family-related variables (Touliatos, Perlmutter, & Straus, 2001), it is imperative that the assessment and measurement tools that nurses select render information pertinent to the purpose of working with the family. At times a simple tool that can be administered and completed in a few minutes can provide insight into planning and intervention, such as a tool that addresses the discipline of children or attitudes about spanking. Other times, more comprehensive family assessment tools are necessary, such as use of the Family Systems Stressor-Strength Inventory (FS3I) (Hanson, 2001; Kaakinen, Hanson, & Birenbaum, 2004). For example, the FS3I can be used to explore ways of helping a family adapt to having an elderly grandmother move in with her son’s family.
No matter which tool the nurse is using, families should always be informed of how the information provided from the tool will be used by the health care provider. In order to select the most appropriate tool, nurses need to understand the distinction between assessment and measurement and between qualitative and quantitative assessment strategies. Assessment is a continuously evolving process of data collection whereby the nurse draws on the past and the present in order to plan and predict for the future (Hanson, 2001). Measurement is the process of assigning numbers or symbols to variables upon which we perform statistical operations (Vogt, 1999). Measurement involves a formal instrument that gives numerical values or quantifies the traits being measured. Such instruments generally give a quantitative result when a particular attribute is examined. Measurement is often considered a narrower aspect of assessment that focuses on more specific concepts or traits. The following suggestions will help the nurse select the most appropriate short assessment instrument:
• The tools should be written in uncomplicated language at a sixth grade level.
• These tools should be able to be completed in 10–15 minutes.
• The tool should be relatively easy to score and should provide valid data on which to base decisions.
• The tools should be sensitive to gender, race, social class, and ethnic background.
• Genograms and ecomaps are two short easy tools to use that supply valuable family data.
Note: Do not confuse a genogram with a pedigree.
A pedigree is specific to genetics assessments, whereas a genogram has broader uses for nurses.
GENOGRAMS AND ECOMAPS
The genogram and ecomap are essential components of family assessment. The genogram provides a quick snapshot of the family members from an intergenerational perspective, such as how they are related, health or genetic trends, and potential sources of support for the family. The ecomap provides information about systems outside of the family that are sources of support or stressors to the family. Sometimes these tools reveal valuable sources of support that are not currently being used or accessed by the family. Both tools should be used concurrently with all family assessment models, as they are easy to conduct and provide a wealth of information in a visual format that can be placed in the chart for use by multiple health care providers.
Genogram
The genogram is a format for drawing a family tree that records information about family members and their relationships over at least three generations (McGoldrick, Gerson, & Schellenberger, 1999). Basically the genogram is a diagram, a skeleton, or a constellation that depicts the structure of intergenerational relationships. Genograms are used in both genealogy and genetics and are now being used in family therapy and in health care settings. They offer a rich source of information for planning intervention strategies because they display the family visually and graphically in a way that provides a quick overview of family complexities.
The genogram does not have to be completed at one sitting. As the same or a different nurse continues to work with the family, data can be added to the genogram over time in a continuing process.
Ecomap
An ecomap provides information about systems outside the family that are sources of support or that are stressors to the family (Hartman & Laird, 1983; McGoldrick, Gerson, & Shellenburger, 1999; Ross, 2001; Friedman, Bowden, & Jones, 2003; Hanson, 2001). The ecomap is a visual representation of the family unit in relation to the community; it shows the nature of the relationships between family members and between family members and the world around them. The ecomap is thus an overview of the family in its situation, picturing both the important nurturant and stress-producing connections between the family and the world (Hanson, 2001).
The blank ecomap form consists of a large circle with smaller circles around it (Figure 8–3). To complete the ecomap, the genogram of the family is placed in the center of the large circle. This circle marks the boundary between the household and its external environment. The smaller outer circles represent significant people, agencies, or institutions in the family’s context. Lines are drawn between the circles and the family members to depict the nature and quality of the relationships and to show what kinds of resources are going in and coming out of the family. Straight lines show strong or close relationships; the more pronounced the line, the stronger the relationship. Straight lines with slashes denote stressful relationships and broken lines show tenuous or distant relationships. Arrows show the direction of the flow of energy and resources between individuals and between the family and the environment.
NURSING AND CLINICAL REASONING
It is imperative in any discussion of nursing that critical thinking be recognized as an essential underlying element. Critical thinking is the “cognitive engine” driving the process of professional nursing judgment (Facione & Facione, 1996). Paul (1993) stated that critical thinking is the “intellectually disciplined process of actively and skillfully conceptualizing, applying, synthesizing, or evaluating information gathered from, or generated by, observation, experience, reflection, or communication, as a guide to belief or action” (p. 110). Nurses are able to direct the intellectual process in a way that is disciplined and effective in the recognition of and subsequent solving of client problems. Each “comprehension” of the family client needs, and nursing interventions, must be adjusted to the unique family story.
Each step of working with families, whether applied to the individual within the family as context or to the family as client, requires a thoughtful deliberate clinical reasoning process. Nurses decide what data to collect and how, when, and where that data is collected. The nurse determines the relevance of each new piece of information and how it fits into the emerging family story. Before moving forward, nurses decide whether sufficient information has been obtained on problem and strength identification or whether gaps exist that require additional data gathering. Each situation evolves as it is analyzed, and each item of new information must be judged in terms of accuracy, clarity, and relevance.
The nurse must always be aware that the “common” interpretation of the data may not be the “correct” interpretation in a given situation, and the commonly expected signs and symptoms or cues may not appear in every case or in the same configuration. The ability to be open to the unexpected, to be alert to the unusual or different response, is critical to the identification of the keystone problem confronting the family client. As each new nurse-client interaction begins, creative thinking allows access to any or all the possibilities. Nurses are able to see that which is not obvious or clearly drawn and to understand how this family story is similar or different from others. In the context of nursing, the creative nurse thinker must be open to the universe of possibilities in any given situation, be able to recognize the new and the unusual, decipher unique and complex situations, and be inventive and imaginative in designing approaches to problem solving.
Development of Family Nursing Process
Yura and Walsh (1988) initially defined the nursing process using four steps: (1) assessment, (2) planning, (3) implementation, and (4) evaluation. Nurses used to write problem lists for a client in the order of priority of client needs; the medical model heavily influenced these problem lists. A list of common patient problems led to the groundbreaking work of the classifications of nursing diagnosis in 1973 (Gebbie & Lavin, 1975). At that time, nursing diagnoses were focused on the individual client. The second generation of the nursing process occurred from 1970 to 1990, during which time several processes developed. The linear four-step process evolved into an information-processing and decision-making five-step process, which included assessment, diagnosis, planning, implementation, and evaluation. The family nursing process described by Ross (2001) entailed family assessment, analysis, planning, implementation, evaluation, and reassessment steps.
Gordon (1982, 1994) described a six-step process: assessment, analysis, outcome projection, planning, implementation, and evaluation. Carnevali and Thomas (1993) included diagnostic reasoning, nursing prognosis, and testing concepts along with the traditional five-step nursing process model.
The classic work of Benner (1988) and Benner, Tanner, and Chesla (1996) demonstrated that novice and expert nurses use different critical thinking processes. They found that expert nurses make clinical judgments and decisions based on pattern recognition of client problems and therefore arrive at decisions more rapidly thaovice nurses. They suggested that expert nurses use a more abstract thinking process that simultaneously considers multiple aspects of a client issue; they termed this thinking process “nursing intuition.” However, they only described this process via individual nursing exemplars and qualitative research. They did not diagram how nurses begin to think in this fashion.
The Home Visit
Working in the community and being able to visit families in their homes is a privilege. In this unique setting you are permitted into the most intimate of spaces we, as human beings, have. Our homes are our creations, our private spaces; they hold our personal treasures, our memories. To let a stranger into our home takes a certain amount of trust. To enter a client family’s home also takes trust on the part of the nurse. Once the door is shut behind you, you are in the client’s world. The rules have changed; they are the experts, you are the guest. You must respond to the family with this “switch” in mind. A home visit is conducted to visit clients where they live in order to assist them in their efforts to achieve as high a level of wellness as possible. Later sections in this chapter discuss the components of a family health intervention that are included in a home visit and how the community health nurse can best use the phases of the nursing process to enhance family health.
Nursing Skills Used During Home Visits
There are many skills, in addition to expert nursing skills, that are needed when assessing, planning, implementing, and evaluating service in the home to families at a variety of levels of functioning (Tapia, 1997). Expert interviewing skills and effective communication techniques are essential for effective family intervention (see Chapter 11). Special skills required when making home visits are described in the following paragraphs.
Acute Observation Skills
The environment is new to you, and observation of environment and client are equally important. In addition to focusing on the family members’ concerns and the purpose of the visit, you need to be observant about neighborhood, travel safety, home environmental conditions, number of household members, client demeanor and body language, and other nonverbal cues. Travel iew neighborhoods and attempts to locate a family can cause distress to even the most experienced nurse. Often clients are difficult to locate because the house or apartment number is missing. The residence may be situated behind another house or it may be a basement apartment without a number. Many anomalies in the layout of a building or a neighborhood may make it difficult for the nurse to locate a client. Addresses on referrals may have numbers transposed such as 123 Hickory instead of 132 Hickory. Perhaps there is a North Hickory–miles away from South Hickory – or there are different streets called Hickory, such as Boulevard, Drive, Street, Road, Court, Lane, and Way. In some communities, house numbers such as 1321/2 or street numbers such as 131/2 Avenue or 121/4 Street may be used. There is always the chance that the address is fictitious–given by clients who, for whatever reason, prefer to remain as anonymous as possible.
Assessment of Home Environmental Conditions
Conditions in the neighborhood and home environments reveal important assessment information that can guide planning and intervention with families. While traveling to and arriving at the family home, you have been gathering information about resources and barriers encountered by the family. This information is used during planning with the family. It is important to remember that neighborhood conditions and even the physical appearance of the apartment or house may belie the family’s values, resources, and goals. They have little control over the neighborhood or, frequently, the building they live in, especially if they are renting. For instance, the family may be a young couple with a baby who can afford $475 in rent; the only apartment available to them for that amount is in a deteriorating low-income neighborhood with dilapidated buildings occupied by renters and owned by absentee landlords. These landlords do not live in the neighborhood and may own several buildings, mainly for profit. Properties are handled by managers who may not know the landlord and are employed through the owner’s management company. Yet when you enter the apartment, you may see a well-furnished, neat, clean home that is opened to you, with pride by the family. In another situation, you may plan to visit an older couple who live in their own home in an upscale suburban neighborhood. On approaching the house, however, you may see an overgrown yard and a house ieed of painting and repairs. Inside the home, you barely manage to squeeze through a pathway made in the living room, which is piled ceiling-high with boxes, newspapers, and furniture. This continues throughout the house and even into a back bedroom, where half the bed is covered with papers, books, and a few cats. An older woman is in the bed. The husband moves very slowly, and after showing you in, he leaves the bedroom and heads toward the back yard.
There are many environmental clues in each of these situations that help the nurse begin an assessment that will lead to a plan to assist each family. Most neighborhoods and homes do not present such extremes. However, if you are unprepared for the extremes, they may overwhelm you, and you may become so distracted that you cannot focus wholly on the family and incorporate these important observations into the plans.
Assessment of Household Members’ Demeanor, Body Language, and Other Nonverbal Cues
After you have knocked on the door or rung the doorbell and are in the home (see What Do You Think?), or even while greeting the people in the doorway, you are gathering data. Being human, you may form opinions or make judgments about the family from the initial meeting. Know that they are doing the same thing. Be aware of all household members; acknowledge and greet them. If some are absent, inquire about them. Make this a habit on all visits. Each member of the family is important and has opinions and health care needs, even if you only see parts of the family on each visit. Be observant of family body language and demeanor. These nonverbal cues provide information that must not be overlooked. Observations such as, “You seem anxious today,” or “Did I come at a bad time? You seem distracted” are openings that allow family members to express what is on their minds. If you are not open to body language while making a visit, you may overlook important cues and continue with your agenda, without realizing that the family is distracted by another, more pressing issue.
On a related note, it is important for the nurse to be aware of her or his own body language or demeanor. If you fidget with your car keys during the entire visit, noisily chew gum, give minimal eye contact while continuously looking at your paperwork, appear rushed, or refuse to sit on any of the family’s furniture, your behavior will tell the family a great deal about you, including how you feel about being in their home. PLANNING TO MEET THE
HEALTH NEEDS OF FAMILIES DURING HOME VISITS
The greatest barrier to a successful family health visit is a lack of planning and preparation. A visit is not successful just because the nurse enters a home or other setting where clients are present. A successful family health visit takes much planning and preparation and requires accurate documentation and follow-up. In addition, safety measures must be followed, not only while traveling in the neighborhood, but also in the home.
Components of the Family Health Visit
The structure of family health visits can be divided into four components that follow the nursing process (Display 24–1). Previsit preparation steps (assessment and planning) are necessary to ensure that the actual family health visit (implementation) is complete. The documentation and planning for the next visit (evaluation) concludes the responsibilities for one visit and prepares the nurse for the next actioeeded.
Previsit Preparation
Community health nurses design a plan for the initial family health visit based on a referral coming into the agency. A referral is a request for service from another agency or person. This request is formalized by the use of a form or information that the originating agency has transferred to the receiving agency. Referrals may be formal coming from complementary agencies, or they may be informal, resulting from verbal or telephone referrals from friends or relatives who believe that someone is ieed. Referrals are the source of new cases for agencies, and they need timely responses. Referrals could be from labor and delivery units, requesting service for low-birth-weight babies and teen mothers, aged 17 years and younger. They could be from social service agencies requesting a home assessment for a child being returned to parents after previous removal from the home. A referral could come via a telephone call from a woman in a city
Some agencies issue a nursing bag to their nurses. This bag, traditionally black leather with two handles, now may be made of canvas with an agency or program logo on it. Such a bag serves to carry the materials a nurse may need on a home visit and can identify where the person carrying it comes from. Not all agencies provide a nursing bag, so many nurses become creative and devise their own carry-all for supplies. Canvas “conference” totes, briefcases, or small molded plastic carriers may be used. The supplies community health nurses need are minimal and depend on the type of visit; some nurses have several totes for different kinds of visits. If the focus is educational, such as a Denver Developmental Screening Test (DDST) or a newborn assessment, each tote should have the appropriate materials in it. Basic supplies for any visit include disposable gloves, paper towels, and soap packets or a waterless hand cleanser. Nurses engaged in home health nursing are prepared with more supplies for each visit, because the focus is on treatment in most of the visits (see Chapter 37).
Once the nurse is prepared, contact with the family is needed. For a home visit, ideally the referral contains a correct telephone number for the family, a relative, or a neighbor. If the referral or chart does not contain this information, the nurse makes an unannounced visit. During this visit, it is important to get a telephone number of the client family, or of a relative or neighbor if there is currently no telephone in the residence. When calling for the first time, the nurse must introduce herself or himself, explain the reason for the call and why this family was selected for a visit, tell what the visit consists of, and determine a time when a visit would be convenient for the family and the nurse.
Some people become defensive or suspicious of the nurse’s intentions. For example, a new young mother may think, “What did they see me doing wrong with my baby in the hospital?” In this kind of situation, it is very important that the nurse explain that
• The visit is a service provided by the agency to all young mothers.
• The visit is paid for by taxes (or donations) or by the client’s health maintenance organization (if applicable), so there is no direct charge to the family.
• Young mothers often have lots of questions about their new babies. Having a nurse come to the home provides an opportunity for the mother to ask questions. It is an opportunity for the nurse to show the mother things about her baby that she may not know.
The nurse needs to ask explicit directions to where the family is staying. The referral may have a different address, and the family may forget to mention that they are staying with an aunt until the nurse requests the directions.
Making the Visit
On locating and meeting the family, the following guidelines for initial contact should be used (Allender, 1998):
• Introduce yourself and explain the value to the family of the nursing services provided by the agency.
• Spend the first few minutes of the visit establishing cordiality and getting acquainted (a mutual discovery or “feeling out” time).
• Use acute observational skills.
• Be sensitive to verbal and nonverbal cues.
• Be adaptable and flexible (you may be planning a prenatal visit, but the woman delivered her baby the day after you made the appointment and there is a newborn now).
• Use your “sixth sense” as a guide regarding family responses, questions they ask, and your personal safety (trust your feelings).
• Be aware of your own personality; balance talking and listening, and be aware of your nonverbal behaviors.
• Be aware that most clients are not acutely ill and have higher levels of wellness than are usually seen in acute care settings.
• Become acquainted with all family members and household members if you are making a home visit.
• Encourage each person to speak for himself or herself.
• Be accepting and listen carefully.
• Help the family focus on issues and move toward desired goals.
• After the body of the visit is over, review the important points, emphasizing family strengths.
• Plan with the family for the next visit.
The length and primary focus of the visit vary depending on its purpose. As a general guide, if the visit is shorter than 20 minutes, it probably should be folded into another visit (unless you are offering a piece of very important information, providing supplies, or have come by family request). On the other hand, if the visit exceeds 1 hour, it should be conducted over two visits. Families have routines that are important to them, and taking a large portion of time out of their day may lead to resentment, putting future visits in jeopardy. Similarly, if nothing of value (according to the family) occurs on a visit, family members may not continue to make themselves available for future visits. This becomes a balancing act for the family and the nurse, and it is an area in which using your sixth sense and picking up on nonverbal cues is helpful (Zerwekh, 1997). In addition, home visits are an expensive way to provide community health nursing services, which are population based. The outcome of better health for family members must be demonstrated in order to support the value of such costly services (see Bridging Financial Gaps).
Concluding and Documenting the Visit
After planning for the next visit, saying goodbye to the family members terminates the home visit. This is a good time to put away the paperwork, materials, and supplies from this visit and retrieve items needed for the next visit on your schedule. It is always safer to open your car trunk in front of this home and get out what is needed for the next family’s visit than to open your trunk in front of the next family’s home. You do not want to give community members information about what is stored in your car’s trunk while it is unattended and you are in the family’s home. Most typically, the documentation of each home visit is completed as soon as the nurse returns to the agency. Some agencies provide their nurses with laptop computers with electronic charting forms, and charting is encouraged at the end of the visit before leaving for the next one. Sometimes, time is allowed for the nurse to chart at home after the last visit of the day. For the most part, you will be expected to complete the charting by hand, using agency forms, as soon as is practically possible. Most agencies expect all charting to be completed by the end of each work day or no later than the end of the work week.
Agencies use a variety of forms that assist the nurse to document fully and succinctly. On some forms, the nurse uses code numbers, letters, or checkmarks on developmental or disease-specific care plans that are devised in a checklist format. For example, a packet of four pages may be used to document a postpartum visit and newborn assessment— two narrative forms to chart the exceptions for mother and baby, and postpartum and newborn assessment forms on which head-to-toe assessment information is documented.
These forms have a place to document parent or client teaching according to expected parameters and a place for listing other professionals involved with the family. Similar developmentally focused forms may be used in the agency for high-risk infants, high-risk children, adolescents, and older adults. Other packets of forms may focus on chronic illnesses, such as chronic obstructive pulmonary disease, hypertension, diabetes, alcoholism, acquired immunodeficiency syndrome (AIDS), or cancer, that are common in the agency client base.
Focus of Family Health Visits
The focus of family health visits depends on the mission and resources of the agency providing the service and the needs of the families being served. Some agencies provide education, recreational activities such as summer camps, and support groups for families of people with specific health problems such as Alzheimer’s disease, asthma, diabetes, or neurologic disorders. Other agencies provide services directed toward those with special social or economic needs, such as immigrant families, people living in poverty, or the homeless. Home visits may be a part of the services when family members are unable to come to an agency or the service being provided is best conducted and received in the comfort and privacy of a family’s home. In general, family health visits are designed to be educational, to provide anticipatory guidance, and to focus on health promotion or prevention.
PARENTING
Parenting is a dynamic process that evolves over time as parents acquire experience and mature as individuals. The social goal of parenting is to guide and nurture children so that they become productive members of society. The personal goal of parenting is far more individualized, but, in general, it reflects a desire to raise a child, see aspects of oneself continue to exist such as perpetuating the family line, upholding family traditions, or in some cases, the fulfilling of personal dreams through the child’s accomplishments. Individuals approach the topic oi parenting from a unique, experiential base: each has been parented. In the parenting role, women and men create models incorporating those elements that they believe comprise “good” parenting. Whether this personal model is congruent with or antithetical to the parenting they received while growing up, it is nevertheless founded upon personal experiences, acquired knowledge, and beliefs about parents and children.
Social changes have influenced the timing of childbearing, so that large numbers of young people are delaying the start of families to meet other social expectations. The need to complete one’s education, initiate a career track, establish financial security, and build a committed relationship are fast becoming benchmarks to be achieved before one takes on the responsibility of raising a child. Parental roles are shaped by socially ascribed expectations for enacting the role; by family traditions, values, and cultural beliefs, which shape one’s personal perceptions; and by legal and ethical role sanctions and expectations. Principle among these expectations is the responsibility for preparing the child to become a productive member of society. Children learn from their parents how to behave in a manner consistent with their role in the family and appropriate to their culture (Gross, 1996).
While family traditions dictate much of the child-rearing strategies used by parents, they do engage in a process of adapting their actions to fit their personal model of parenting. Such a reflective adaptation of child-rearing strategies may be stimulated when the traditional strategies are not effective, when the parent is confronted with new situations, or when the traditional strategy is incongruent with the parent’s “good parent” model.
Parenting by Developmental Stage
Parenting is an evolving process that changes as parents and children grow and mature. Parents must actively adapt their parenting strategies to meet the needs of the growing child. The work of parenting is sustained by the attachment that develops between parents and their children—the strongest of all human relationships. Parents and children develop deep, personal attachments that enable them to care for and about each other, even when families experience great stress or the family system structure changes through divorce, death, or the addition of new family members. Such caring is essential for human survival. Indeed, small children cannot grow and thrive without care activities, including technical tasks like diapering and feeding, as well as those emotive, cognitive responses that support the growth of a centered well-integrated person.
In order to parent, individuals fulfill certain tasks. These parenting tasks are designed to both support the child’s development as well as maintain family functioning. As dren and their parents grow and develop as individuals, these parenting tasks change to reflect family development. See Table 3-2 for a listing of developmental-related parenting tasks. The growth and development chapters (7-12) in this text contain more detailed information on parenting by developmental stage.
Parenting Styles
Each child is unique in her or his own temperament and basic personality. Birth order, gender, and personality traits are a few of the characteristics a child brings to a family. The way caregivers respond to these attributes and interact with the child are related to the individual’s style of parenting. Four styles have been identified: (1) authoritarian or autocratic, (2) authoritative or democratic, (3) indulgent or permissive, and (4) indifferent or uninvolved (Macoby & Martin, 1983).
Authoritarian caregivers value obedience over independence and favor punitive measures, harsh disapproval, and withdraw of love when children question authority or disobey. They are likely to be less emotionally expressive and to use power to assert their will on their children. Deference and respect for authority are expected. They establish strict and rigid rules, which they don’t discuss with their child. Children whose caregivers are authoritarian tend to be dependent, passive, and less intellectually curious. They usually lack social competence and spontaneity, and have low self-esteem.
Authoritative, or democratic caregivers are warm buf firm. They provide opportunities for their children to develop a sense of autonomy and allow active involvement in decisions that affect them. They are consistent and clear about the expectations they have for their children and are firm when they are disobedient. They guide children’s behavior by sharing reasons for their decisions, rules, and standards.
Indulgent or permissive caregivers are interested and involved in their children’s lives but place few demands “on them and rarely attempt to control their behavior. With the indulgent style, there is an absence of restraints and maximum freedom for the child. Caregivers provide little input or direction, and seldom punish their children because they are encouraged to develop their own standards of behavior (most ol their behavior is considered acceptable by the caregivers). Although children are allowed freedom to set their own limits, most do not feel comfortable with this lack of direction. Additionally, the caregivers’ permissiveness doesn’t usually foster the development of internal control in these children, who tend to be disrespectful, defiant of authority, and irresponsible.
Indifferent or uninvolved caregivers attempt to minimize the amount of time and energy they must invest in their children’s lives. They tend to be very self-centered and structure their home life primarily around their oweeds and interests. They are rejecting of and unresponsive to their child’s needs. The child receives little guidance, and discipline is inconsistent. Children from indifferent homes are often more impulsive, demonstrate disregard for other’s rights, and are more likely to be involved in delinquent behavior (Macoby & Martin, 1983).
Parental Role in Socialization of Children
Socialization is a process of learning the rules and expected behaviors of a society. Expectations for a child’s behavior depend not only on the society and culture, but also on the child’s developmental stage, and physical and cognitive capabilities, and on the values and beliefs of the family and home. One goal of parenting is to socialize children, which includes teaching which behaviors are expected and appropriate, and fostering the development of self-control. Initially, during infancy and early childhood, caregivers provide external controls. Gradually and eventually, children guided by caregivers take responsibility for that control and integrate the adults’ values, attitudes, and expectations into their behavior.
Thus, caregivers nurture their children so that they will achieve self-control, competence, and self-direction in order to be a productive individual in society. It could be said that this is also the goal of discipline, which comes from the root word disciplinare—to teach or instruct (American Academy of Pediatrics [AAP] Committee on Psychosocial Aspects of Child and Family Health, 1998). Discipline should be approached in the broadest sense of helping the child learn rules, regulations, and goals of living in a world with others— and not just as setting limits and punishing (Murphy, 2000). The AAP (1998) suggests that effective discipline should include three components: (1) a positive, supportive, nurturing caregiver—child relationship, (2) positive reinforcement techniques to increase desirable behaviors, and (3) removal of reinforcement or use of punishment to reduce or eliminate undesirable behaviors.
Nursing practice requires the ability to use nursing knowledge and reason through details to make skilled judgments while not losing sight of the whole client picture and desired outcomes of care.
• Nurses decide what data to collect and how, when, and where that data is collected.
• Each family has a story about how the potential or actual health issue influences the individual members, the family functioning, and how they manage the problem.
• Nurses determine through which lens the family health problem will be best addressed: from a family-as-context perspective, family-as-client perspective, or family-as-community perspective.
• Nurses work with families to determine realistic outcomes based on the ability of each family to adapt successfully to the health issue, given the strengths of the family, the pattern of family response in similar situations, and the trajectory of the family health care problem.
• Nurses build on their expertise by reflecting on client stories and their practice with each family.
Self-reflection and self-evaluation are critical thinking strategies that advance nursing practice from the novice to expert designation.
• Selection of appropriate and sensitive assessment tools is important, as the information collected serves as the foundation for the development of client specific plans.
References
1. Stanhope, M., & Lancaster, J. (2000). Community and Public Health Nursing (5th Edition) St. Louis: Mosby.
2.
Stanhope, M., & Lancaster, J. (2006). Foundations of Nursing in the Community: Community-Oriented Practice (2nd Edition) St. Louis: Mosby-Elsevier.
Recommended Optional Materials/References
3. Hitchcock, J.E., Schubert, P.E, & Thomas S.A. (1999) Community Health Nursing: Caring in Action / Delmar.
4.
American Psychological Association. (1994) Publication Manual of the American Psychological Association (4th ed.). Washington, DC: Author.
See required Websites:
http://www.health.gov/healthypeople/.
www.health.state.mn.us/divs/chs/phn/definitions.pdf
Course Website – Log in @ http://www.tdmu.edu.ua/ukr/general/index.php
