Ana Albuquerque Queiroz Professor coordenator School of Nursing Coimbra aaq@esenfc.pt

1. FAMILY NURSINGA VIEW…A VISION… A FUTURE… Ana Albuquerque Queiroz Professor coordenator School of Nursing Coimbra aaq@esenfc.pt TAMPERE, MAY 2008

2. Objectives Discuss the importance of family nursing in the community setting. The Portuguese experience; Compare and contrast the family nursing concepts; Describe the various barriers to family nursing; Explore issues of family nursing in the future.

4. The Portuguese experience • The Democratic Revolution occurred on 1975 ending a long period of political dictatorship and a process of health services nationalization began, aiming to give the whole population access to healthcare, independent of their ability to pay. • In 1979, the National Health Service (NHS) was created as a universal system, free at the point of use. In fact, until 1979 the Portuguese State had left the responsibility for paying for health care to the individual patient and his/her family. The care of the poor was the responsibility of charity hospitals and the Department of Social Welfare was responsible for the out-of-hospital care.

5. The Portuguese experience • After 1974, district and central hospitals owned by the religious charities were taken over by the State, as well as 2000 medical units or health posts across the country, which previously operated under the social welfare system for the exclusive use of social welfare beneficiaries and their families. • The public health services and the health services provided by social welfare were brought together, leaving the general social security system to provide cash benefits and other social services for namely the elderly and children.

6. The Portuguese experience The 1979, legislation established the right of all citizens to health protection, access to the NHS for all citizens, integrated health care including health promotion, disease surveillance and prevention and a tax-financed system of coverage in the form of the NHS.

7. The Portuguese experience • Since then, a number of reforms have been carried out. In 2002 a framework for the implementation of public/private partnerships aiming at building, maintaining and operating the health facilities was created. A Decree established the obligation of NHS drugs prescription using the common international denomination, as well as the conditions under which prescribed brands can be substituted by generics. Around 40% of all NHS hospitals were transformed into public enterprises.

8. The Portuguese experience • However, in the twenty-first century, the health care system in Portugal still faces many problems such as inadequate ambulatory services, long waiting lists, dissatisfaction of consumers and professionals, increasing expenditures with health and increasing demand for health care from vulnerable groups. In 2004, the percentage of poor was of 38%. One year later ascended to 42%. They are about people who survive with a average of 360 euros for month or little more than 4300 euros per year.

9. The Portuguese experience • In Portugal, there is an insufficient provision of community care services, including long term care and social services for the chronically ill, the elderly and other groups with special needs. In fact, the family has been assuming the first line of care, particularly in rural areas. Yet, the demographic pressures demand new solutions in what refers to the provision of social care.

10. The Portuguese experience Portugal, as many other European countries, faces a growing elderly population, which increases the pressure on institutions and professionals to provide social and medical care in the most cost-effective way. The health and social care sectors in Portugal need a major reorganization effort and the concept of integrated care emerges as a response to these challenges based on a coordinated work between independent institutions and professionals as a way to guarantee the continuity of care, improving health, quality of care and patient satisfaction, raising the efficiency and the effectiveness of social and health systems, and fostering patient's and families empowerment.

11. The Portuguese experience • Compared to the residential care provided by the public sector, the nursing homes run by Misericórdias and other non-profit institutions are usually of better quality and only request a nominal contribution from patients and their families. Nursing homes in the private sector are very expensive and the majority of the population cannot pay for them. • Home care is expanding in Portugal and in some regions infrastructures to deliver support to the elderly have been developed in partnership with municipalities, regional health administrations and non-profit institutions. Apparently, the establishment of social care networks is becoming a priority.

12. The Portuguese experience In fact, the Portuguese healthcare system has a significant number of regulations, but few measures have been fully implemented. In terms of supply, there is a reasonable range of services and professionals to satisfy the needs of health and care services for the elderly. However, they are so dispersed and fragmented that accessibility and efficiency become compromised.

13. Compare and contrast the family nursing concepts • Many terms have been used to describe nurses’ involvement with families including: • family-centered care; • family nursing; • family focused care; and, • the nursing of families.

14. Compare and contrast the family nursing concepts Family centered practice is based on the premise that individual's abilities to learn and develop are "inextricably intertwined" with the strengths, needs and philosophies of their family members. A guiding principle of family centered practice is the belief that Family is the experts regarding their family's needs and priorities.

15. How has the nursing of families evolved over time? • The focus of family nursing has changed from a model based on family dysfunction and problems to a model of family strengths and needs. • The restructuring of health care has increased the demands on family and often transferred the burden of care to them. • Nurses must advocate for families to obtain financial and human resources they need to support them in their caregiving roles. Nurses recognize that family dynamics exert a considerable influence on family members in terms of health and illness. Similarly, healthfactors strongly influence family relationships and functioning.

16. The WHO Europe Family Health Nursing Pilot in Scotland. Final Report. ISBN 0 7559 5199 9 http://www.scotland.gov.uk/Publications/2006/10/31141146/0

18. International Council of Nurses (ICN), Nurses always there for you: Caring for families. Information and action tool kit, Geneva, 2002.

19. Family Nursing Family Nursing: consists of nurses and families working together to ensure the success of the family and its members in adapting to responses to health and illness. Hanson (1987) gives the first definition of what family nursing is:"The purpose of family nursing is to promote, maintain and restore family health; it is concerned with the interaction between the family and society and among the family and individual family members." p 8.

20. Family Nursing The nursing of families and family systems nursing represent different types of practice that are distinct in theory. The approach is determined by the situation and by the knowledge and skill of the nurse involved.

21. Family Health Family Health: a dynamic changing relative state of well-being that includes the biological, psychological, sociological, cultural, and spiritual factors of the family system. Families are neither all good nor all bad; therefore nurses need to view family behavior on a continuum of need for intervention when the family comes in contact with the health care system. All families have both strengths and difficulties. All families have seeds of resilience.

22. three levels of family nursing Friedmann, M-L. (1989) The concept of family nursing. Journal of Advanced Nursing. Vol 14, pp211-216.

23. Family as the context, or structure: has a traditional focus that places the individual first and the family second; Level 1: The individual is the focus within the context of the family, with the family recognised as a resource for the individual (Wright and Leahey, 1990).

24. Family as the client: family is first, and individuals are second; Level 2: The family unit is the focus of care, with the individual giving context to the situation. Wright and Leahey (1994) describe this level as assessing how all the family members are coping with the individual's illness, and meeting their needs separately.

25. Family as a system: focus is on the family as client, and the family is viewed as an interacting system in which the whole is more than the sum of its parts; simultaneously focuses on individual members and the family as a whole; Level 3: At this level the focus is on the individual and the family at the same time. The assumption is that if anything happens to one part of the system the other parts are affected. The interdependent relationships of family members are acknowledged and intervention is aimed at helping each individual and their interactions with other family members. The ultimate goal is to empower the family (Robb, 1998). Wright and Leahey (1994) call this family systems nursing.

26. Family as a component of society: family is seen as one of many institutions in society, along with health, education, religious, or financial institutions.

27. What knowledge and skills are involved in the nursing of families? Nurses need knowledge and skills to be family-centered – to help families change in ways they want to change. As a result of increased research and theory development about family nursing, there are now models of family nursing that integrate theory and practice to provide nurses with a framework for family assessments and nursing interventions. As a first step, all nurses need to be able to conduct a family interview or meeting and complete a family assessment. Perceptual, conceptual and executive knowledge

28. Bring forth facilitating beliefs; challenge your constraining beliefs about families Constraining Beliefs of Nurses: Collaboration Impossible Family members are not able to make decisions for themselves when a family member is ill. Families do not visit their hospitalized family member often enough. Families are often dysfunctional, resistant, unmotivated, and non-compliant. The care provided by nurses is safer and more competent than family members can provide. There is no time to involve family members in my practice. (Wright, 2005)

29. Bring forth facilitating beliefs; challenge your constraining beliefs about families Facilitating Beliefs of Nurses: Collaboration Possible • Illness is a family affair. • All family members are affected by illness but mothers experience the greatest illness burden and illness work. • The most stressful problem for family members is repeated hospitalizations. • Families who experience serious life-threatening, chronic or mental illness are developmentally out of sync with other families and their lives are changed forever. • Serious illness often invites suffering, which usually leads one into the spiritual domain as the meaning/purpose of life is questioned or reviewed. • Embrace the belief that talking is healing!

30. Assessing the Strengths and Needs of Families Nursing has tended to adopt a variety of family assessment models from other disciplines. A Canadian contribution to family assessment frameworks is the Calgary Family Assessment Model, which guides nurses in assessing structural, developmental and functional dimensions of the family.Within this model, tools such as genograms and ecomaps are used to help nurses increase their understanding of the whole family.

31. International Council of Nurses (ICN), Nurses always there for you: Caring for families. Information and action tool kit, Geneva, 2002.

32. Calgary Family Assessment Model (Wright & Leahey, 2005) Family Composition Gender Sexual Orientation Rank Order Subsystems Boundaries Internal Structural External Extended Family Larger Systems Context Ethnicity Race Social Class Religion Environment Stages Developmental Tasks Attachments Instrumental Activities of daily living Functional Emotional communication Verbal Communication Nonverbal communication Circular communication Problem-solving Roles Influence/power Beliefs Alliances/coalitions Expressive

33. Family intervention Intervening with families to help them meet the needs they have identified is the essence of clinical nursing practice. A wide range of family nursing interventions has been identified that can be offered to families. Some – such as family support, caregiver support, and parent education – are general; others are more specific and often involve therapeutic communication and family interviewing skills.

34. Individual Family Plan

35. Is family nursing always appropriate? “Thinking family” is always important; acknowledging the individual client as a member of a family is always appropriate even when the nurse has no opportunity to involve thefamily. Love is opening space for the existence of another beside us in daily living. Maturana & Varela, 1992

36. 10 Hot Tips to Increase Collaboration 1.Bring forth facilitating beliefs; challenge constraining beliefs. 2. Embrace the belief that talking is healing! 3. Maximize the first 60 seconds. 4. Message sent  message received. 5. Show insatiable curiosity! 6. Assess what is relevant for this family at this time. 7. Be a strengths detective! 8. Ask interventive questions. 9. Understand that problems reside between, not within people. 10. Remain open to the gift.

39. Thanks Very much!!

40. International Council of Nurses (ICN) (2002). Nurses always there for you: Caring for families. Information and action tool kit, Geneva. • Friedmann, M-L. (1989) The concept of family nursing. Journal of Advanced Nursing. Vol 14, pp211-216. • Hanson, SMH. (1996). Family assessment and intervention In:HANSON, SMH; BOYD, ST. Family health care nursing:theory, practice, and research. Philadelphia, F. A. Davis, Cap.7, p.147-72:. • Whyte, D. (1997) Explorations in family nursing. London. Routledge. • Wright, L.M. and Leahey, M. (1990) Trends in nursing of families. Journal of Advanced Nursing. Vol 15, pp148-154. • Wright, L.M. and Leahey, M. (1994) Nurses and families: a guide to family assessment and intervention. 2nd Edition. Philadelphia. FA Davis Company. • Wright, LM; Watson, WL; Bell, JM. (1996). Beliefs: the heart of healing in families and illnes. New York, Basic Books.