FAMILY ASSESSMENT

Family Health Care Nursing: An Introduction

OBJECTIVES:

The Child in Context of the Family

No other factor in a child's life has a greater influence than the family, which is the first and generally, the most important socializing agent in one's life. Successful socialization is the process by which children acquire the beliefs, values, and behaviors deemed significant by society and is, to a large degree, a function of parenting and other familial interactions. The family's organization, structure, and function have significant impacts on children during growth and development. Nurses caring for children must consider the entire family, rather than just the child, as the client. This chapter reviews several family theories relevant to pediatric nursing, discusses the various family structures in today's society, and concludes with a discussion of parenting.

DEFINITION OF THE FAMILY

The family, despite its changing and increasingly diverse nature, remains the basic social unit. Two ways that nurses identify families have been described by Gilliss (1993). The first views the family as context; the second sees the family as a client. When families are treated as the context within which individuals are assessed, the emphasis is on the individual (family as context).

Conversely when the nurse treats the family as a set of interacting parts and emphasizes assessment of the dynamics among these parts rather than the individual parts themselves (family members), the family as a whole, rather than the individual members, becomes the client (family as client). In either case, the nurse must grasp the interacting aspects of the family, to understand the context within which the individual lives and to which she or he reacts, or to work with the family as client (Hitchcock, 1999).

Definitions of the family differ depending on one's discipline and theoretical orientation. The legal definition emphasizes relationships through blood ties, adoption, guardianship, or marriage. The biological definition focuses on perpetuating the species. Sociologists define the family as a group of people living together; psychologists define it as a group with strong emotional ties.

Traditional definitions usually include a legally married woman and man with their children. This narrow definition is reflected in the U.S. Bureau of the Census (2000) definition of family as a group of two or more persons related by birth, marriage, or adoption and residing together. The Census Bureau has used this same definition for years. However, this traditional definition fails to address the diversity of family structures present in U.S. society today. A broader definition of family is two or more persons who are joined by bonds of sharing and emotional closeness, and who identify themselves as members of the family (Friedman, 1998). Another definition that reflects contemporary society is that a family is what the client says it is (Patterson, 1995). Nurses working with families should first ask their clients whom they consider to be in their family and then include those individuals in their health care planning.

THEORETICAL FOUNDATIONS OF FAMILY NURSING

Nursing has consistently had an interest in families and has acknowledged its importance in relation to health. A number of theories of families in nursing and social sciences give insight into understanding its dynamics and processes.

Nursing Theories

Early nursing theories focused on the individual and considered the family only as part of the client's context. However, some theorists have enlarged their perspectives to include the family as the client.

Neuman's System Theory Neuman's (1983) theory is consistent with a family systems approach. Originally, her theory did not discuss the family as such, but it was later expanded to include the family as the recipient of nursing care (Neuman, 1972). The family is described as an appropriate target for both assessment and nursing interventions. The way each member expresses self influences the whole and creates the basic structure of the family. The major goal of the nurse is to help keep the structure stable within its environment.

King's Open Systems Theory King viewed the family as a social system that influences the growth and development of individuals (King, 1981). The family is seen as both context (environment) and client. Her theory of goal attainment is useful for nurses when assisting families to set goals to maintain their health or cope with problems or illness. She believes that nurses are partners with families. The role of nursing is to help members become healthy enough to function in their roles.

Roy's Adaptation Theory In Roy's (1983) theory, the client is an individual, family, group, or community in constant interaction with a changing environment. The family system is continually changing and attempting to adapt. When the family is confronted with unusual stresses and coping patterns are ineffective, problems in family functioning occur. The goal of nursing is to promote adaptation and minimize ineffective responses.

Social Sciences Theories

A number of theories from the social sciences help to explain families; however, there is little consensus about which are the major ones. Therefore, for the purpose of this chapter, three will be examined: structural-functional, developmental, and general systems.

Structural-Functional Theory The structural-functional theory emphasizes the organization or structure of the family and how this structure facilitates its functioning. It characterizes the family as a social system and examines the relationship between the members as they carry out family functions (Friedman, 1998). Basic assumptions of this theory are as follows:

• The family is viewed as part of the social system, with individuals being parts of the family system.

• The family, as a social system, performs functions that serve both the individual and society.

• Individuals act in accordance with a set of internalized norms and values that are learned primarily in the family through socialization.

Family structure refers to the ordered set of relationships among the parts, and between the family and other social systems. Family structure or organization is evaluated based on how well it fulfills its functions, and the goals important to its members and society. The structure serves to facilitate the achievement of the functions. To determine family structure, the nurse must identify the individuals that make up the family, their relationships to each other, and the relationships between the family and other social systems.

Five functions of the family have been identified that are important for nurses to understand (Friedman, 1998):

• Affective

• Socialization and social placement

• Reproductive

• Economic

• Health care

The affective function is one of the most vital functions for the formation and continuation of the family unit. This function refers to the family meeting the needs for love and belonging of each member. The family is a home base where the individuals can express their true feelings and thoughts without fear of rejection. The family is the social milieu for the generation and maintenance of affection, where one is first loved and given to, and learns to love and give in return.

Although the affective function is important for all families, those that must focus on providing the basic physical necessities of life have minimal energy remaining to meet the affective needs. Socialization and social placement function refers to teaching children how to function and assume adult social roles. This function involves the acquisition of internal controls needed for self-discipline and values such as what is right and wrong according to society. Socialization occurs predominately in the family, and caregivers are the primary agent (Gelles, 1995). The continuity of both the family and society continues to be ensured through the reproductive function. In the past, marriage and the family were designed to control sexual behavior as well as reproduction. Individuals considered it their responsibility to marry, have many children, and rear those children within the bounds of marriage. The reproductive function is carried out very differently today. Many single people are having children, including adolescents, and many married couples are remaining childless. Reproduction has also been influenced by technological advances such as artificial insemination, in vitro fertilization, and surrogate mothers.

The economic function involves the family's provision of sufficient resources and their effective allocation. An assessment of the family's economic resources provides the nurse with information about their ability to appropriately allocate these resources to meet needs such as food, shelter, clothing, and health care. By gaining an understanding of how a family distributes its resources, the nurse can also obtain a perspective about their value system. One responsibility of the nurse is to assist families in obtaining appropriate community resources to meet their needs.

The health care function includes provision of physical necessities to keep the family healthy, such as food, clothing, and shelter as well as health care (Friedman, 1998). The family keeps its members well by passing on attitudes, values, and behaviors that promote health and by caring for them in times of illness.

The structural-functional approach is very useful for assessing family life because it enables the nurse to examine the family system holistically, in parts, and interactionally with other institutions and the wider society. A limitation of this theoiy is that it tends to present a static view of the family and minimizes the importance of growth and change (Friedman, 1998).

Developmental Theory

The developmental or life-cycle theory is based on the premise that families evolve through predictable developmental stages, and experience growth and development in much the same way as individuals. Stages begin with marriage followed by childbirth and child rearing. Each stage is characterized by specific issues and tasks. Developmental theories explain the changes that occur in human organisms or groups over time. This approach is based on the following assumptions (Duvall, 1977):

• Critical role transitions of individual members, such as birth, retirement, and death of a spouse, are viewed as resulting in a distinct change in the family life patterns.

• Families develop and change over time in predictable ways.

• Families and their members perform certain timespecific tasks that are decided upon by themselves, within their cultural and societal context.

• Family behavior is the sum of the previous experiences of its members as incorporated in the present and in their expectations for the future.

The best known formulation of the developmental stages comes from Duvall (1977; Duvall & Miller, 1985), who identified eight chronological stages through which the family passes. Each stage includes predictable tasks that the family must master prior to proceeding to the next one. Table 3-1 delineates the stages of family development and tasks of each stage. An advantage of the developmental approach is that it provides nurses with information about what to expect of families at different points in their life cycle and, thus, what teaching and counseling services may be needed. This theory also provides criteria for assessing a family's current stage and its ability to accomplish the tasks of this stage. The nurse is then able to support the family in order to progress smoothly from one stage to another.

There are several limitations of the developmental theory. It has a middle class bias and it assumes homogeneity (two caregivers, nuclear family) and that young adults marry in their early twenties before they develop a career. Additionally, this theory views the family from a traditional perspective. It does not take into consideration the diversity of family forms found in today's society, such as divorced, remarried, single-parent, and gay or lesbian families. The focus of the developmental approach is primarily child rearing; however, today this activity occupies less than half of a woman's adult life span. Thus, child rearing is no longer the central focus of the life cycle.

Family Systems Theory

The family systems approach is based on the general systems theory developed by von Bertanlanffy (1968), which describes principles that govern all living systems. One of the central propositions of the general systems theory is that the system is not the total sum of its parts but is characterized by wholeness and unity. Family theorists have applied these principles to explain how families interact with their members and with society. The family is defined as a system characterized by continual interaction between its members and with the environment. The interrelationships in a family system are closely tied together so that a change in one member results in a change in the other members. Therefore, one cannot understand the family as a whole by only knowing each of its members. The interrelationships of the members with each other and with the larger society must be analyzed.

FAMILY ASSESSMENT

Family assessment is the process of collecting data about the family structure, and the relationships and interactions among individual members. It is a continuously evolving process of data collection. Data about the family are systematically collected using predetermined guidelines or questions, and then classified and analyzed according to their meaning. Nursing diagnoses can then be generated, with goals and interventions for care created in collaboration with the child and caregivers.

Assessment Instruments

Two of the most commonly used instruments for developing a family database are the genogram and the ecomap. Neither requires the purchase of a standardized assessment instrument; yet, both have the advantage of providing a means for interacting with children and their family members in a nonthreatening way to obtain data about potentially complex and difficult issues (Kodadek, 2000).

A genogram is a format for drawing a family tree that records information about family members and their relationships over a period of time, usually three generations. It is a method of mapping the structure of the family and to record the health history of all members (morbidity, mortality, and onset of illnesses), thus revealing information about genetic and familial diseases. The genogram displays the family visually and graphically in a way that provides a quick overview of family complexities. It is also an efficient and nonjudgmental way to convey information about a family to other health care providers. Figure 3-1 is an example of a genogram/family tree.

An ecomap - is a visual representation of a family in relation to the community. It demonstrates the nature and quality of family relationships and what kinds of resources or energies are going in and out of the family. Figure 3-2 shows a family ecomap. This assessment instrument is useful in identifying the strengths of family networks and what resources they have available during stressful times or crises.

An in-depth family assessment requires a significant amount of time, and every family does not need a comprehensive assessment. However, when a nurse identifies a family at risk for dysfunction, such an assessment may be required. Referral to other health care professionals and community organizations is appropriate in these situations. Assessment information can be obtained through interviewing and questioning, observing interactions between members, and utilizing a family assessment instrument. Ideally, all family members are included in the interview, and it takes place in the child's home. At a minimum, the child and primary caregivers are assessed.

Several family assessment instruments are available. Criteria for the selection of an instrument are listed in Box 3-1. Many assessment instruments have been developed by family theorists, mostly nonnurses, and are used by the health care team to obtain information about family systems. Nurses have created some instruments, two of which will be presented: the Calgary Family Assessment Model (Wright & Leahey, 1994) and the Friedman Family Assessment Model (Friedman, 1998).

FAMILY STRUCTURE

The structure of the family refers to how it is organized— i.e., the manner in which members relate to one another, and the form it takes, such as nuclear or blended. During the past 40 years, U.S. society has undergone vast economic and social changes that have transformed the structure of the family, and the roles and responsibilities of women and men. Some of these societal changes are the increase in rates of divorce and remarriage, an increase in the number of mothers employed outside the home, the incidence of more adults waiting until they are older to marry or choosing to remain single, lower birth rates, and a longer life expectancy.

Today, society is composed of a greater multiplicity of values, lifestyles, and family forms than ever before. The two-parent nuclear family consisting of a mother and father bonded by marriage with one or more children no longer reflects contemporary lifestyles. Knowledge of a child's family structure helps the nurse to determine the communication patterns and decision-making authority within the family unit (Grossman, 1996). Such information is vital when the nurse is deciding who will be involved in making decisions related to heath care.

Nuclear Family

The nuclear family is defined as a husband, wife, and their children—biological, adopted, or both (Friedman, 1998) (Figure 3-4). No other individuals, relatives or nonrelatives, live in the household. The nuclear family form became common after World War II, and, until recently, it was considered the most common family form. However, with the increase in divorce rates, nonmarital childbearing, and cohabitation outside of marriage, family forms other than the nuclear family have proliferated. Currently, in the United States in 2001, families in the traditional pattern of a working father, homemaker mother, and one or more children are in the minority. The nuclear family has been credited with providing stability for children. However, concern has been raised about the limited number of adult role models in this type of family structure. Additionally, in the nuclear family, the two adults have many expectations placed on them, such as working to meet the financial needs, rearing the children, meeting the emotional needs of all members, and maintaining a home. In situations where both parents are employed, managing all of these responsibilities often results in significant stress in the family.

Figure 3-4 Family structure is different for every family; thus the nurse needs to understand this structure to determine communication patterns and decision-making authority.

Extended Family

The extended family consists of those members of the nuclear family and other blood-related persons such as grandparents, aunts, uncles, and cousins (Figure 3-5). This family structure was prominent in the 1800s in the United States because the family was the main unit of economic production. Several generations of a family lived together, worked together, and shared resources and responsibilities. Children were reared by not only their parents but also by grandparents, aunts, and uncles and had a choice of adult role models after which to pattern their behavior and personalities. With the advent of the Industrial Revolution, families were forced to move and seek employment in urban areas, and the nuclear family became more common. Extended family situations are still seen. Situations include elderly parents moving in with adult children or an adult child and/or their spouse and children moving back into the home of their older parents for financial reasons.

Figure 3-5 Members of an extended family benefit from the sharing of responsibilities and resources.

Blended (or Step) Family

A blended or stepfamily occurs when a divorced, widowed, or never-married single parent forms a household with a new partner; both partners or only one may have children. The formation of a stepfamily can present many stresses for the parent, stepparent, and children. In the new stepfamily, there has been no time to blend family styles and traditions, or to negotiate parenting. Additionally, there has not been time to establish or nurture the marriage. A remarried parent must deal with many strong emotions, and feeling a special loyalty to one's own biological children may create conflicts with the new spouse. The remarried couple may be unable to form a new spousal relationship because to do so would appear to be a betrayal of the intimacy between parent and child. This issue frequently conflicts with the needs of the new spouse, who may feel like an outsider in an established household. Stepfamilies in which both adults have children from a previous marriage living with them have the greatest incidence of redivorce (Witrak, 1997). Divorces occur more frequently and rapidly in remarriages than in first marriages, with onefourth of remarriages being disrupted within 5 years (Hetherington & Stanley-Hagan, 1999).

Stepparents and biological parents often believe that the growth of the new family will be instantaneous. The time required to create the stepfamily is usually longer than the adults expect. The stepparent should make clear to the children that she or he does not consider herself or himself to be a replacement for a dead or absent parent. Instead, the stepparent is another adult who can meet some of the child's needs for closeness and love. Parental relationships need time to build. With older children, they may never fully materialize (Visher & Visher, 1995).

The transition to a stepfamily is also stressful for the children. Having suffered the loss of one of their parents and typically the loss of familiar surroundings, children may encounter a new series of losses, and suffer loyalty conflicts and loss of control. The adults have chosen to make major changes in their lives; the children have had those changes imposed on them. Feelings of sibling rivalry are more intense in the stepfamily as the children feel jealousy, insecurity, and a fear that a new sibling is more loved.

Enhancing understanding of a child's condition can reduce fear and pain, as well as encourage active participation in care decisions (Rushforth, 1999). This understanding is especially enhanced when effective communication occurs among nursing staff, children, and their care-givers and families. In fact, the ability to communicate effectively is recognized as a basic and central component in delivering care to children and their caregivers (Riesch, 1997; Stuart & Sundeen, 1995). Therefore, it is essential that nurses practice and integrate effective communication skills into every facet of interaction. Effective communication expressed in an authentic, nonjudgmental, em pathetic manner improves not only the quality of care but also determines the success of relationships established in delivering care. Since one cannot not communicate, learning effective communication skills is essential to delivering effective care and can be compared to learning aseptic skills; once one understands the principles behind effective communication, one can integrate these principles into practice.

THE COMMUNICATION

Communication is defined as the exchange of meanings between and among individuals through a shared system of symbols. The sender, message, channel, receiver, and feedback are major components of the communication process. The sender generates a message in response to a need to relate to others, to create meaning, or to understand various situations. The message is a verbal or nonverbal stimulus produced by a sender and responded to by a receiver. The channel is the medium through which a message is transmitted. It may be visual, auditory, or kinesthetic. Visual channels include sight, observation, and perception. Auditory channels include the spoken word and cues. Kinesthetic channels include sensations experienced, as in touch. The receiver is the person intercepting the sender's message. Feedback provides the sender with information from the receiver about the message. The sender can then adjust the message so that it is understood more effectively by the receiver the next time it is sent (Estes, 2002).

Communication is both talking and listening. Nurses must be able to not only use words to explain information to caregivers and children, but also to listen to what caregivers and children say. The ability to prepare and present ideas, feelings, and thoughts accurately (by talking) and to respond to messages accurately (by listening) reduces distortion and results in effective communication.

BARRIERS TO COMMUNICATION

Barriers to communication include physical factors and psychological factors. Physical or environmental factors include the physical space or distance between the receiver and sender, the temperature or ventilation in the environment, and distracting noises such as the radio or television. They can also include health status, especially if the child (or family) is disoriented or has a hearing or visual handicap. Since effective communication will not occur when children and families do not understand the medical terminology used, explanations should include common words and simple terms. Finally, hearing or speech difficulties, including accents and speech impediments, may become barriers for some (Estes, 2002; Marquis & Huston, 1992).

Psychosocial barriers include one's personal judgments, past experience, emotions, developmental level, or social values. Preconceived ideas and allowing feelings to influence behavior, opinions, or beliefs may also be problematic. Expressions of personal opinions need to be carefully shared with children and their caregivers since nurses represent authority figures. Finally, facial expressions that convey disapproval may become a psychosocial barrier if the child or family suspects disapproval (Estes, 2002; Marquis & Huston, 1992).

MODES OF COMMUNICATION

Communication can be examined and described according to whether it is formal/informal or verbal/nonverbal. Formal communication refers to communication that occurs in an organized way, with a particular agenda, as when teaching a child's care to the caregiver upon discharge. Formal communication needs to be clear and understandable. Informal communication occurs when individuals talk using no particular agenda or protocol. Often, informal communication occurs sporadically when caring for children and their caregivers in day-to-day interactions.

VERBAL COMMUNICATION

Verbal communication refers to messages that are communicated through words and language (Estes, 2002). Verbal communication is most effective if it is brief, clear, effectively toned, paced appropriately, relevant, and well timed. The receiver will be confused if more words than necessary are used or if the speaker does not speak slowly and clearly. Important points should be repeated and medical jargon avoided, especially when talking to children and their caregivers and families. Messages also need appropriate pacing; they should not be too slow or fast, and there should be few pauses and periods of silence. Only important and relevant information should be conveyed, and the tone should be pleasant. Messages should also be sent at the appropriate time. For example, teaching will not be effective if delivered when children are in pain or have visitors, or when caregivers are preoccupied with personal thoughts. When interacting with families, it is also essential to convey interest and warmth; to avoid distractions, yes/no questions, and personal bias; and not to monopolize the conversation. Paraverbal cues, also part of verbal communication, include the tone and pitch of the voice; volume, inflection, and speed; and grunts or other vocalizations not considered language (Luckman, 1999). These cues add meaning to the words spoken, and can and often do influence the listener more than the actual words themselves (Estes, 2002). Confusion results when verbal messages are inaccurate or unreliable.

NONVERBAL COMMUNICATION

Nonverbal communication conveys feelings, attitudes, and intentions (Luckman, 1999). It enables one to decode verbal communication and transcend the literal content of the message. Nonverbal communication is especially apparent when emotions cause observable body changes, and comes through more powerfully and effectively when there is incongruence between the verbal and the nonverbal message. In fact, most communication is nonverbal, and most verbal communication contradicts nonverbal messages. Nonverbal communication is important because the listener will believe the nonverbal message rather than the verbal message if they contradict each other. Therefore, it is critical to always consider nonverbal communication in any interaction since it contributes to what others "hear."

Nonverbal communication also includes spatial relationships (the distance between participants); appearance (clothing, grooming, hair style); eye contact; body posture (slouching, standing erect with the head leaning to receiver); gestures (which sometimes add emphasis to words); facial expressions (which need to agree with the message); timing (hesitation may imply untruthfulness or diminish the effect of the message); and, with children especially, touch (Luckman, 1999) (Figure 13-1). In fact, touch maybe one of the most important communicative behaviors nurses use since it conveys warmth, understanding, affection, willingness to become involved, nurturance, and caring (Fredriksson, 1999). Touch, however, may have special meanings to children and their families depending on their gender or ethnic background. Therefore, nurses always need to be sensitive to the message transmitted when touching, since, for some, touch may mean concern and empathy, whereas, for others, it may mean dominance, interpreted as the nurse overstepping her bounds, or a desire for intimacy, resulting in uncomfortableness.

Figure 1 3-2 When interacting with parents, nurses need to be sure the environment is conducive to effective communication.

Empathetic nurses are able to appreciate and understand children and caregivers as unique individuals, and allow them to feel cared about and accepted. For this to happen, the nurse's empathy needs to be integrated with verbal and nonverbal behavior. Empathy, however, is not to be confused with sympathy. The empathetic nurse maintains a sense of objectivity, and is supportive, understanding, and able to plan and implement helpful behaviors by teaching and giving examples that facilitate the ability of the child and the caregivers to function in difficult and sad situations. The sympathetic nurse, on the other hand, offers condolence and pity, and is not able to develop or carry out behaviors that engage the child or parent in activities that help them to maintain their relationship and ability to function in difficult situations. For example, Shawn, an 11-year-old boy with an inoperable brain tumor, is being cared for at home by his parents. The nurse sympathizer feels sorry for Shawn and is often near tears when she looks at him and tries to talk to his parents. She assumes all of Shawn's care. The nurse empathizer would teach the parents how to participate in Shawn's care, make suggestions on how to conserve Shawn's energy, and outline diversional activities that all might enjoy together given Shawn's condition. The nurse empathizer would direct energy toward finding ways to enable the parents to have quality time and experiences with Shawn and might even "share tears with" parents as they talk about what to expect in the end. The nurse empathizer is able to establish an accurate understanding of the child and the caregivers from their perspective, build rapport, and relate to the child and caregivers in such a way as to allow them to express their feelings and concerns.

Listening

Listening consists of providing verbal and nonverbal cues that communicate interest (Luckman, 1999). It is an activity that requires attention and effort as one not only listens to the words of the child and the caregivers, but one also listens to how words are used and decides whether or not what is said is what is meant. Accurate listening does not happen without effort. It requires actively attending to what is verbalized, observed, and created by the entire communication context (Fredriksson, 1999). It is important not to allow one's mind to wonder, daydream, prejudge what is being said, or think about what will be said as a response; one must listen attentively and wait for others to finish what they are saying. Attentive listening goes beyond hearing and includes what is not said or what is conveyed through gestures. Active listening also includes maintaining eye contact, taking an open and relaxed posture, and facing the child or caregivers (Luckman, 1999). See Box 13-1 for more information on effective listening.

When working with children and caregivers, the nurse should encourage and allow each to give input, discuss concerns, express feelings, and acknowledge problems. Respecting other's feelings and views, and appreciating each other's understandings and fears even though they are different than one's own are also important. While listening to children, the nurse must consider their developmental level, cognition, and emotional behavior. Children who are social and verbal may seem to be more in control and able to understand, and think more logically and rationally than children who engage in shy, clinging, and dependent behaviors. Nurses should use developmentally appropriate language and behavior with children and attend to their behavioral cues for clues as to their concerns and fears (Figure 13-3). For example, a child may continue talking and asking questions in order to avoid beginning a treatment.

BOX 13-1 Four Bs of effective listening

· Be attentive; eliminate distractions.

· Be clear about the message; clarify if necessary.

· Be empathetic; convey concern and caring.

· Be open minded; avoid prejudices

Figure 1 3-3 Adolescents often need reassurance when they are to undergo treatments or procedures. Used with permission of Baystate Medical Center Children's Hospital

Providing Feedback

Providing feedback can include nodding of the head, reflecting back to the client what was said, asking questions to clarify, seeking validation from the client to ensure one is talking about the same thing, and focusing on a single idea and exploring it further. Focusing means to direct the conversation based on a statement made by the client. For instance, during a conversation with a child regarding her broken leg, the child mentions that another child on the playground has been pushing her around. The nurse may want to direct the conversation and delve more deeply into the fear the child may be experiencing due to the playground incident, other violent interactions the child may have had in the past, and what may occur during interactions in the future.

Conflict Management

There are three ways to approach conflict resolution: win-win, lose-win, and win-lose. The win-win approach occurs when both parties are committed to solving the conflict. They work together toward a resolution, searching for a variety of ways to resolve the problem so that they are able to finally arrive at a solution acceptable to all parties. The lose-win situation occurs when one person allows a resolution at their own expense; the win-lose approach occurs when one person resolves the conflict by having their needs and wants satisfied, but forces others to agree with their solution. It is important for the nurse to strive for the win-win approach. This allows the child and caregivers to feel in control, and there is more likelihood of adherence to whatever decisions are made.

Professional Boundaries

The nurse should create and maintain professional boundaries in relationships with children and their caregivers. Therapeutic relationships should be caring and empathetic, but should avoid emotional overinvolvement and overprotec-tiveness. It is always helpful to explain to children and families the type of care that will be provided, when the care will be provided, and how both parents and children can assist in the care. Identifying needs and establishing expectations will enhance and facilitate interactions. The nurse should never interfere with the relationship between the child and the caregivers. Rather, the nurse best serves the child by assisting the caregivers in caring for and nurturing the child, and by recognizing the need of the caregivers to feel accepted by the professionals and to be recognized as important to the child's well-being. Finally, nurses should avoid personal behaviors that signal overinvolvement such as socializing with the child or their family, sharing personal information such as home addresses or telephone numbers, and giving or accepting gifts. See Box 13-2 for more information about how to avoid becoming overinvolved.

Additional Skills Useful in Communicating

Several additional skills have been found especially useful when communicating with children and their caregivers. These include observation, silence, being aware of the environment, humor, play, writing, drawing, and using third parties.

Observation

Observational skills enable the nurse to validate and interpret what children and caregivers do not say. Nonverbal behavior provides meaningful information about what the child and caregivers are communicating to each other and to the nurse. How words are delivered is as important as what words are used. Congruence between the meaning of the words and all other behaviors validates the message. Observing the eyes (position, movement, gaze, and expression), mouth, furrowing of the brow and nasolabial area, general emotional mood, bodily movements, and posture is important. Cues also need to be interpreted from within the child's cultural perspective to avoid erroneous interpretations. For example, in some cultures, eye contact and directness are signs of paying attention. However, in other cultures, looking someone directly in the eye is considered rude. The nurse should also observe the ways children and caregivers respond to each other's request for attention, and behave and interact in disciplinary or nurturing situations. These observations can help the nurse assess the effectiveness of the communication patterns between children and caregivers and allow development of health-related strategies that are respectful of the relationship

BOX 13-2 To avoid overinvolvement

o Do not have contact with children and families after discharge.

o Do not purchase gifts for children and families.

o Do not share personal information with children and families.

Silence may be another method used to communicate. Silence should be interpreted in relation to the environment where communication occurs and the normal behavior of those interacting. A child who is shy and hesitant with strangers may be silent when the nurse approaches for care. A caregiver who is silent after being told of a child's terminal diagnosis is likely to be experiencing shock and disbelief and to be trying to come to grips with the reality of what was just heard. Children may be silent out of separation anxiety and fear, as in the case of a 4-year-old child who is hospitalized and must spend time in a strange environment without caregivers nearby. Silence also may demonstrate comfort, respect, and concern as when a nurse sits with parents after upsetting news is heard or when the child is falling asleep after an upsetting procedure.

Environment

The environment can affect communication events among the nurse, the child, and the caregivers even more than the spoken words. The way in which nurses exist in the environment and use space to make people more or less comfortable as they seek care is important. Nurses who are effective in nurse-client communication develop and demonstrate a respect for the client's sense of physical and personal space. For example, when sensitive issues or feelings of anxiety need to be discussed and the environment is in a four-bed unit where roommates can overhear the conversation, sharing fears and anxieties and asking questions may be difficult. A quiet, private environment should be provided before discussion begins. Nursing behaviors such as knocking before entering a child's room, calling the child and caregivers by name, addressing each directly, and asking permission to examine demonstrate respect and engender a sense of ownership over physical and personal space. Clients in care-giving settings such as hospitals and clinics will experience less stress, irritability, and fatigue when they remain in relative control of their physical and personal space. Environments that facilitate therapeutic communication reduce psychological distress so that children can attend to their health care situation. When children are relaxed or not experiencing fear, they are able to cope with people and the environment, and more willingly converse. However, children may vary in their communication levels based on their personality, temperament, experiences, and developmental abilities. The nurse should use concern, care, and knowledge of child development, and be willing to use a variety of communication approaches with the same child during different interactions or with different children in similar interactions.

Humor

Humor is healing and can bridge communicative gaps even when the direct communication is feared and/or offensive (Andrews & Boyle, 1999); it is recognized as an effective method of helping children and adolescents to cope with illness, pain, and hospitalization (May, 1999). For example, nurses who are able to laugh at themselves may be forgiven, and nurses who can make others laugh can't be all bad (or frightening). The nurse should use tasteful humor in dealing with pediatric patients and their caregivers to promote therapeutic interactions.

Play

Play, a natural childhood behavior, should be encouraged in health care environments and employed as a method of communicating (May, 1999). Using puppets, dolls, or stuffed animals, drawing pictures with crayons and paints, or employing a storytelling approach to give information engages the child. Because play is familiar and a daily form of natural behavior, children do not associate it with stress, anxiety, or fear. Play helps the child to relax and shed inhibitions, however temporarily, brought about by health care environments. The nurse who engages in play is likely to be legitimized as someone who can be trusted in communication. For more information about children's play, see Chapter 16.

Writing and Drawing

An especially effective method of communicating with older, school-aged children and adolescents, writing can include keeping a journal or diary, or writing a letter that is not delivered. Other examples include encouraging the child or adolescent to write down thoughts or feelings that are not easy to express verbally to keep track in written form of experiences related to a health care situation, or to write a story or essay about an experience (May, 1999). Sometimes just being able to articulate thoughts and feelings in writing can serve as a springboard for later discussions or concerns.

Drawing can be helpful for younger children since it provides clues to a child's emotional state and feelings (May, 1999). Evaluating the drawings or having a child tell a story about the drawing allows the nurse a window into the child's inner self. One needs to be cautious, however, since the evaluation of drawings should take place in conjunction with the evaluation of other information such as observation of behavior and communication with the child directly. Examination of drawings should include the evaluation of the gender of figures, the order in which the figures are drawn and the position of each in relation to other figures in the drawing, the exclusion of certain individuals, the accentuation or absence of particular body parts, the placement and size of the drawing on the page, whether or not the drawing is made with bold or light strokes, and the colors used (Sorensen, 1993).

Third-Party Communication

The nurse can promote dialogue with children by using indirect methods such as employing a third party. Here, the nurse directs her attention to the child through a trusted friend (e.g., a stuffed toy). By doing this, the nurse is taking an interest in the child's normal activity, is employing a stress-reducing communication method to create a therapeutic environment, and is helping the child to focus on the content of the message rather than on anxieties and fears. See Box 13-3.

Another third-party approach used with older children and adolescents is to attribute feelings or thoughts to other children. This method can be a safe form of interaction that uses the thoughts and feeling of the group rather than of the child or adolescent directly. Using group feelings helps a child or adolescent to feel comfortable talking to an adult because someone else is talking; the adult is told what the third person thinks without the child or adolescent being held responsible for the statement since the statement is made by the third person. For example, when explaining how one learns how to give oneself insulin injections, monitor blood glucose, or manage the diet during daytime hours while at school, the nurse could state that Christine, one of her 16-year-old patients, often will excuse herself from her friends, go to the restroom to check her sugar levels, and give herself insulin if needed. The nurse could also mention that Christine has told her friends that she is diabetic, wears a med alert bracelet, and always carries hard candy in her purse.

Storytelling

Storytelling is another effective communication strategy that nurses may use to promote therapeutic environments with children. Storytelling techniques can be used to establish rapport, to assess and help resolve children's anxieties and fears, to explain treatments and procedures, to teach health, and to prepare for painful or emotional events. The nurse can devise or use stories so that the child can adopt either of the two storytelling roles: teller and listener. For example, a child can be read or told a story about a boy who had surgery, or be asked to tell a story about a boy who has had surgery. The former might be used to explain what will happen when going to surgery. The latter might be used to elicit information about the child's experience when the nurse devises a story and takes turns with the child to fill in the content. Called "mutual storytelling" (Gardner, 1986), the nurse might say, "I'll start the story, and when I nod, you fill in the next part of the story." The nurse begins with, "Once upon a time a boy broke his leg and had to have surgery. He ..." The nurse nods to the child to fill in the blank. The nurse then uses the child's response to extend the story a bit, followed by nodding to the child to elicit another response. The nurse then analyzes the themes presented by the child, which may reveal important feelings.

BOX 13-3 Using a toy to communicate

A 4-year-old boy is sitting in bed holding a stuffed bear. Instead of directly addressing the child, the nurse approaches and uses the toy as a medium for introduction

Nurse: Hi Mr. Teddy Bear! How are you? My name is _____. What is your name? (wait for an answer). Oh, I guess I'll have to call you Mr. "no name" bear. Mr. "no name" bear, who is your friend?

Child: His name is Billy Bear! (in clinical practice, it has been found that even shy children will not let their friend be called Mr. "No Name" and will quickly provide their teddy bear friend's name.)

Nurse: Billy Bear! What a nice name. I bet he is fun to play with.

Children begin to experience storytelling as infants and toddlers. It is a natural part of their early lives, and the use of story plots helps a child to make the transition from pre-operational to concrete operational thinking (Arnold & Boggs, 1995). For nurses, however, storytelling is a skill, and confidence and competence are gained through use and practice. Storytelling may be carried out in a variety of ways, for example, by telling stories from books related to the subject at hand, telling stories based on previous experiences with children or told to you by other children, and telling stories adapted from articles printed in nursing journals. Composing a story specific to the child and content area can be useful as well. Using drawings, dances, mime, poetry, or cut-outs from newspapers, comics, or magazines for illustration may also encourage communication between children and nurses. Refer to Box 13-4 for further information.

BOX 13-4 Principles of effective communication in pediatric settings

1. Talk to caregivers initially if child is shy or appears
hesitant.

2. Use objects (toys, dolls, stuffed animals) instead
of questioning child directly.

3. Provide opportunities for older children and ado
lescents to talk privately with the nurse or other
care provider.

4. Use clear, specific, simple phrases in confident,
quiet, unhurried speech.

5. Position yourself so that communication is at eye
level.

6. Allow expression of thoughts and feelings.

7. Provide honest answers.

8. Offer choices only if they exist.

9. Use a variety of age-appropriate methods and
techniques.

DEVELOPMENTAL FACTORS AFFECTING COMMUNICATION

Effective communication will enhance the preparation of a child and the caregivers for their experiences related to health and illness (Rushforth, 1999). However, the nurse must incorporate knowledge of human growth and development when communicating with children. Children should be encouraged to become active contributors to their health as soon as they are developmentally able to understand and carry out health-promoting behaviors. Until then, the nurse works directly with caregivers and reinforces their self-confidence in caring for and teaching the child. Refer to Chapter 31 for additional information on language development, which is critical when communicating with children, and to Table 13-1 for general principles for communicating with children of various ages.

Infants

Infancy is a time when communication is achieved through nonverbal means. Even though the adult may use language to relate to an infant, the tone, pitch, and speed of words as well as touch and the bodily movements accompanying the words generate meaning to the infant rather than the words used. However, loud, sudden noises may cause startle reactions and crying, while soft, song-like tones delivered in an upbeat tempo may soothe and comfort. Gentle rubbing or patting while securely holding an infant is also a method to communicate pleasure and security. Infant responses are nonverbal, such as vocal cues, including crying, cooing, and whining, and body language, such as stiffness or relaxation, arm or leg movement, pushing away with hands and feet against the adult, opening or closing the mouth, and gripping or pushing objects such as rattles and blankets. Infant expressions of comfort and discomfort become more direct and overtly explicit with age. That is, a 2-week-old infant will cry and flail arms and legs when hungry, while a 6-month-old infant may kick the legs and arm-wave, or suck on toys, fingers, or blankets when hungry. Caregivers soon learn to distinguish their infant's cries and will differentiate the cry of hunger from the cry of pain or anger. As the caregiver understands the meaning of infant behavior, satisfaction and attachment increase. As the caregiver learns how to turn the infant's tears into satiation, contented sleep, or cooing wakefulness, interactions and communication are positively reinforced.

Prior to developing stranger anxiety, infants will respond positively to the nurse and other strangers who provide comforting behaviors through feeding, diapering, rocking, and other forms of nonverbal communication. After the onset of stranger anxiety, incorporating the caregiver into the health care procedures reduces the infants discomfort. Whenever the nurse needs to hold or give an infant care, caregivers should be involved. If this is not possible, the nurse should hold the infant so that the caregiver is in view. The nurse's movement should be firm and gentle, allowing time for the infant to get to know the nurse; abrupt movements will only increase the infant's distress. Using calm, soft, and soothing vocalizations and purposeful, slow movements enhances therapeutic communication with infants (Figure 13-4). For more information, refer to Chapter 8.

Figure 1 3-4 When communicating with infants, nurses often need to move slowly, and interact with parents initially.

Toddlers

The toddler continues to experience the world through hearing, seeing, smelling, tasting, and touching, and remains dependent on caregivers. Independence emerges, and satisfaction is derived from repetition and routine as the environment is explored. Language in the form of two-word combinations emerges as well as the ability to participate in turn-taking rules of social communication, such as the fact that an answer follows a question and that someone listens when someone speaks. Gestures and simple language are used to convey wants and needs. One-word sentences that are part babble with "bye-bye" may be used to express whole ideas, aided by accompanying gestures that provide clues to the meaning. "Bye-bye" with hat in hand may mean "I want to go out and play," while "bye-bye" after being kissed by dad prior to walking out the door, may mean "I want to go bye-bye with Dad." Two-word utterances become common at about 2 years of age. The two-word sentence consists of a noun and verb such as "me do." By the age of 3 years, complete sentences are constructed using all parts of speech, and the child's vocabulary has progressed to approximately 900-1,000 words. Toddlers also engage in monologues as a way of practicing speech, and as they mature, egocentric thought and monologue speech become more socialized. Increasingly, they engage in more conversation with others (Berkowitz, 2000).

Nurses interacting with toddlers should be observant of the situation surrounding one-word utterances and gestures. Learning the words that toddlers use for common items or behaviors, and using them in conversation is recommended. For instance, instead of saying it is "time for bed," the nurse may want to use an expression that for the child means bedtime, such as "it is time to hear the night-night angel sing." Using the expression that indicates bed- or naptime, while following the child's ritual of falling asleep while a music box plays is a comforting, familiar way of interacting that brings safe and familiar experiences to the child's mind. Using play or books to demonstrate or describe activities or procedures immediately before they are to occur is a good way to prepare toddlers for experiences. Refraining from wordy explanations and preparing for procedures well in advance are not toddler friendly. Being aware of the child's response and approaching the child calmly and positively are important.

Preschoolers

During the preschool years, a child's articulation becomes clearer, there are improvements in correct grammatical usage, and an expansion of word combining occurs. The child's vocabulary rapidly expands, and the child is able to use words appropriately even when the meaning is not fully appreciated. Since the preschooler is striving for independence, but still needs adult encouragement and support, it is important to allow the child to initiate activities and make choices if possible. For example, let the child decide whether to have "water or a mouthful of Jell-O after your medicine." Nurses may need to remind the children how to cooperate in an activity or to wait for their turn. Asking the child's cooperation by giving them something to do or hold may engage them cooperatively and allow the procedure to be performed. Using picture books, stuffed toys, and puppets to prepare a child for a procedure will allow the child to experience the procedure in a nonthreatening way (Figure 13-5). A child may also answer the nurse's question through a teddy bear: "Hi, Mr. Teddy bear, do you think your friend, Johnny, would like some Jell-O after his medicine or would a mouthful of chocolate pudding be better?"

Preschoolers are egocentric, and magical thinking predominates during the preschool years; these children see things only from their perspective. When they lack information or do not understand something, they fill in the gaps with their imagination. Since an avid imagination can be far worse than any reality, it is better to communicate with honesty, in simple sentences using concrete language. The nurse should never smile or laugh when giving an injection, say something won't hurt when it will, or use words with double or literal meanings such as a "shot" or a "stick in the arm." It is also not helpful to tell the child about others or what "good boys or girls" do. Allowing the preschooler to touch and manipulate equipment they will see and experience is essential. Telling preschoolers how it will feel when they come in contact with the equipment (cold, warm, pressure, tickles, etc.) and how they can behave is also important. For example, tell them that it is okay to squeeze the teddy bear, cry, or bang on the bed with their hand, etc.

Figure 13-5 Establishing rapport with preschoolers often can be done by reading a story.

School-Aged Children

A school-aged child's relational experiences expand to include people and environments outside the family and home. They are taught rhymes, chants, and rituals by other children, which can serve as a means of emotional-social control in frightening and confusing contexts. We all remember examples, such as "cross your heart and hope to die," "star light, star bright, first star I see tonight," and "knock on wood," which we used to minimize the bad that could befall us. Humor and riddles are tension releasers and assist a child with their social identity, i.e., "knock, knock, who's there?" During early school years, interaction with other children increases and close friendships are developed. Children of this age group may be verbally aggressive, bossy, opinionated, and argumentative.

School-aged children learn to accept responsibility for their actions, they understand rules, and they become oriented to rules and sanctions. They are interested in learning and have increased attention spans. They learn to master classification, serialization, and spatial, temporal, and numerical concepts. Concrete thinking emerges and predominates. They learn to focus on more than one aspect of an experience and to explore and consider many alternatives to a problem. They are increasingly able to understand their body and their environment and to use language as a means

of control and appreciate it as a method used by others to control them. School-aged children also have expanding vocabularies that enable them to describe feelings, thoughts, and concepts. They are able to carry on conversations with others and to appreciate their viewpoints. However, words with multiple meanings and words that describe things they have not experienced are still not thoroughly understood.

When working with the school-aged child, the nurse should spend time with the child to explain treatments and procedures well in advance of the scheduled time (Figure 13-6). Photographs, books, drawings, and videos may be used to aid understanding and assist in answering questions that may follow. Immediate and subsequent opportunities should be allowed for questions, and repetition of explanations and enhanced details of what will happen to them should be provided. Fears and concerns about body integrity should be assessed and truthfully answered. Conversation that encourages critical thinking should be promoted.

Figure 13-6 When communicating with school-aged children, nurses need to assume a relaxed demeanor and convey interest.

Adolescents

Adolescents are able to think logically and abstractly, and are able to verbalize and comprehend most adult concepts. They are able to create hypothetical situations and generate explanations for and about situations they encounter. Privacy and independence are sought in activities and relationships. The adolescent makes personal discoveries about their relationships and events, and will discuss these discoveries with peers and trusted adults in an effort to construct ideals.

An adolescent's preoccupation with what should or could be produces conflict in relationships with people who are unwilling to listen to them express their thoughts. They need to verbalize what the world should be like in order to analyze their own ideas and come to their position short of the ideal. The ideal world they construct must be merged with the real world by listeniiig to themselves and others.

Attentiveness and acceptance are necessary. Caregivers and other adults need to be patient and actively listen to matters that the adolescent considers significant, even if trivial to adults (Figure 13-7). The adolescent should be allowed the freedom to work through issues and should be provided the guidance necessary to develop and decide on a positive course of action. Since adolescents may be moody and argumentative, interactions between adolescents and caregivers or other adults will be more cooperative when the adolescent participates in working toward a solution and is permitted to participate in the selection of the final decision and subsequent course of action. The nurse should communicate support during interactions with adolescents by actively listening, without demonstrating surprise, disapproval, or trivialization. The nurse should avoid questioning, giving personal advice, or taking sides. It may be necessary for the nurse to initiate multiple interactions before an adolescent feels safe and secure enough to ask questions or discuss concerns. Short, nonthreatening contacts may serve as icebreakers, which may lead to involved conversations.