4.7 Applying the Nursing Process to Caring for Clients in the Context of Family

This section will describe how nurses incorporate family considerations while using the nursing process.

Assessment

When initiating client interactions, nurses first establish cultural safety and privacy. Cultural safety refers to the creation of safe spaces for clients to interact with health professionals without judgment or discrimination. The nurse recognizes that the client and their family members bring a cultural context to the health care setting. If more information is needed about a client’s cultural beliefs to tailor the nursing care plan, nurses use an open-ended question that allows the client to share what they believe to be important. For example, the nurse may ask, “I am interested in your cultural background as it relates to your health. Can you share with me what is important about your cultural background that will help me care for you?”^[1]

Nurses consider who makes the decisions regarding a client’s care. Although nurses advocate for autonomy (i.e., the ability of an adult to make their own decisions), there are circumstances when family members make or influence care decisions. For example, when caring for a child under age 18, the parents or legal guardians are generally the decision-makers. In circumstances where an adult client has an established power of attorney (POA) for health care who makes decisions for them, the nurse interacts with the POA when providing nursing care. In some circumstances, the client’s cultural beliefs may defer to an elder to make their care decisions.

Nurses also protect the client’s privacy if family members or friends are present during an assessment. Nurses ask clients in private whom they would like to have present during care. If the client prefers to be alone, it is the nurse’s role to ask others to leave the room because clients may not feel empowered or safe to do so.^[2]

Nurses perform a general survey as part of their assessment. During the general survey, nurses use all of their senses to observe the client and family members and listen to what they are saying. They observe the client’s and family members’ hygiene, affect and mood, communication, nutritional status, and fluid status for signs of potential neglect, abuse, or substance misuse. As part of this process, nurses observe family dynamics, including family roles, relationships, interaction patterns, and emotional support. Observation findings that indicate healthy family dynamics are good communication patterns where the family members demonstrate mutual respect, trust, and caring. If family members communicate with each other in an unfriendly, disrespectful, or hostile manner, the nurse should notify the health care provider and initiate referrals with a social worker or case manager according to agency policy. If signs of suspected abuse are present, the nurse must follow state mandated reporting and agency policy.^[3]

Nurses also collect the following information to assess the effects of family on the client^[4]:

• What do family members and significant others know about the client’s illness?
• How does the family respond to the client’s illness? Are they overprotective, frustrated, or anxious?
• Is the family familiar with family support groups, respite, and other community resources?

Nurses can use the American Psychiatric Association’s evidence-based Cultural Formulation Interview (CFI) to incorporate the perspectives of the individual and family members in the assessment. Questions from the CFI that pertain to family are as follows^[5]:

• Are there any kinds of support that make this health problem better, such as support from family, friends, or others?
• Are there any kinds of stresses that make this health problem worse, such as difficulties with money or family problems?
• Sometimes aspects of people’s background or identity can make their health problem better or worse, such as the communities they belong to, the languages they speak, where they or their family is from, their race or ethnic background, their gender or sexual orientation, or their faith or religion. Are there any aspects of your background or identity that make a difference to this problem?
• Are there other kinds of help that your family, friends, or other people have suggested that would be helpful for you now?

The nurse analyzes data gathered from the assessment for clinically significant cues to formulate nursing diagnoses related to family processes.

Diagnosis

Several NANDA nursing diagnoses are related to family dynamics, parenting, and caregiving and how these factors may impact a client’s health and wellness. Table 5 summarizes selected NANDA nursing diagnoses, their definitions, and selected defining characteristics related to family dynamics, parenting, and caregiving. As always, refer to a current, evidence-based nursing care planning resource when providing client care.

Table 4.7. NANDA Nursing Diagnoses Related to Family Dynamics^[6]

Outcome Identification

Nurses collaboratively set goals and identify outcome criteria with clients and their families based on their values, cultural beliefs, and preferences. Sample goals related to enhancing family processes are as follows^[7]:

• Family members will identify ways to cope effectively and use appropriate support systems.
• The family will meet physical, psychological, and spiritual needs of its family members or seek appropriate assistance.
• Family members will demonstrate knowledge of potential environmental, lifestyle, and genetic risks to health and use appropriate measures to decrease possibility of risk.
• The client and family members will focus on wellness, disease prevention, and health maintenance.
• The client and family members will seek balance among exercise, work, leisure, rest, and nutrition.

SMART outcomes are specific, measurable, achievable, realistic, and time oriented. Sample SMART outcome criteria related to enhancing family processes are as follows:

• After the teaching session, family members will describe three preferred, healthy coping strategies. 
• After the teaching session, the parent(s) will describe available support system(s) or community resources. 
• After the teaching session, the parent(s) will describe three potential safety risks in the home for children.

Interventions

If a family-related nursing diagnosis is established, the nurse may perform additional focused assessments, as well as nursing interventions, to assist clients and families. Examples of additional assessments and interventions include the following^[8]:

Assessments

• Assess client’s and family members’ understanding of the medical condition.
• Assess family members’ understanding of the client’s medical needs.
• Assess the family’s economic resources and social support.
• Assess the client and family members for adverse childhood experiences that may affect their long-term health and wellness.
• Assess the family’s strengths and weaknesses.

Interventions

• Establish rapport with the client and family members present during care.
• Recognize formal and informal roles in medical decision making by family members.
• Acknowledge the range of emotions that may be experienced when the health status of a family member changes.
• Encourage families to express their feelings.
• Encourage family members to visit the client (with permission from an adult client).
• Allow and encourage family members to assist in the client’s treatment (with permission from an adult client).
• Adopt a strength-oriented, psychoeducational approach to enhance family functioning.
• Acknowledge and support the spiritual needs and resources of clients and their families.
• Provide family members with educational and skill-building interventions to alleviate caregiving stress, enhance coping, and facilitate adherence to prescribed plans of care.
• Help family members mobilize social support.
• Refer family members to family therapy and other family-oriented resources, as indicated.
• Provide information on community resources specific to client’s and family’s situation.
• Model good communication, nurturing, and emotional regulation so family members can observe and imitate these behaviors.
• Involve the family in discharge planning.

During the implementation stage, the nurse considers if the planned interventions and teaching topics are still safe and appropriate based on the client’s current priority conditions and problems. Planned nursing interventions are prioritized according to the current circumstances and client needs.

Evaluation

After implementing nursing interventions, the nurse analyzes their effectiveness for the client and family by considering the following questions.

• Was the nursing diagnosis accurate and complete?
• Has the client and family met the collaborative goals and outcome criteria according to the timelines established? If not, are they progressing toward meeting the goal or have they not met the goal?
• The nurse decides if the nursing diagnoses, goals, outcomes, or interventions should be kept, modified, or deleted, or if additional assessment data is needed.