Family Health Assessment
family health tree
gay or lesbian family
general systems theory
Additional Material for Study, Review, and Further Exploration
The four families described below depict broad contemporary definitions of family and are examples of families carried in caseloads by undergraduate community health nursing students. Assessments made by students during home, office, and hospital visits with these families triggered interventions that linked the families to resources provided by the community and, in turn, triggered questions about health needs of groups of families or larger aggregates living in the same communities.
Working with families has never been more complex or rewarding than now. Nurses understand the actual and potential impact that families have in changing the health status of Americans. Additionally, families have challenging health care needs that are not usually addressed by the health care system. Instead, the health care system most frequently addresses the individual. This holds true for nursing interventions within the health care system. This chapter will assist the nurse in understanding and addressing complex issues that impact family health and suggest methods to improve family health.
Understanding family nursing
Family nursing is not a new concept and has been taught in schools of nursing since Nightingale’s “district nursing” concept (Cook, 1913) and Lillian Wald’s (1904) principles on how to nurse families in the home. The National League for Nursing (NLN) has emphasized the importance of family nursing in standard curriculum guides for schools of nursing since 1917 (Beard, 1999; NLN, 1937). Early NLN publications directed nurses in “household science” and later required that 10 to 15 hours of study should be directed toward understanding the “modern family,” in which the nurse must consider the family as a unit (NLN, 1937). Modern nurse theorists such as Newman, King, Orem, Roy, and others extensively discuss the family and its importance to individuals and society. Previously, nurses defined the family conceptually in the following ways: as the environment affecting individual clients; as small to large groups of interacting people; as a single unit of care with definable boundaries; or as a unit of care within a specific environment of a community or society. Current family theorists recognize the diversity of American families. Hanson and Kaakimen (2005) defines family as “two or more individuals who depend on one another for emotional, physical, and economical support. The members of the family are self-defined” (p. 6). Wright and Leahey (2000) state, “the family is who they say they are” (p. 70). Current advocacy groups find these definitions even too narrow. The Human Rights Campaign (2009) urges that health professions acknowledge all types of families including gay, lesbian, and even grandparents as heads of family by using this definition:
“Family” means any person(s) who plays a significant role in an individual’s life. This may include a person(s) not legally related to the individual. Members of “family” include spouses, domestic partners, and both different-sex and same-sex significant others. “Family” includes a minor patient’s parents, regardless of the gender of either parent…without limitation as encompassing legal parents, foster parents, same-sex parent, step-parents, those serving in loco parentis, and other persons operating in caretaker roles (Human Rights Campaign, 2009, Inclusive Definitions of Family).
These later definitions are perhaps more useful to the nurse and allow the focus on the needs of the family. Family nursing care may be focused on the individual family member, within the context of the family, or the family unit. Regardless of the identified client, the nurse establishes a relationship with each family member within the unit and understands the influence of the unit on the individual and society.
The family is composed of many subsystems and, in turn, is tied to many formal and informal systems outside the family. The family is embedded in social systems that have an influence on health (e.g., education, employment, and housing). Many disciplines are interested in the study of families; interdisciplinary perspectives and strategies are necessary to understand the influence of the family on health and the influence of the broader social system on the family. Traditionally, nursing, and even community health nursing, has relied heavily, if not solely, on theoretical frameworks for intervention with families from the disciplines of psychology or social psychology, which target individuals (Cody, 2000; Duvall, 1977; Erikson, 1963; Maslow, 1970). This chapter addresses how community health nurses work with families within communities to bring about healthy conditions for families at the family, social, and policy levels. This chapter focuses on the following five areas:
The changing family
Definition of Family
Many definitions of family exist, from the traditional U.S. Census—“a family consists of two or more people, one whom is the householder, related by birth, marriage, or adoption and residing in the same housing unit” (2005) to the more inclusive. The nurse’s definition of family is influenced by personal involvement with his or her own family and clinical experiences. Definitions of family vary by professional discipline and type of family described. For example, psychologists may define family in terms of personal development and intrapersonal dynamics; the sociologist has used a classic definition of family in terms of a “social unit interacting with the larger society” (Johnson, 2000). Other professionals have classically defined family in terms of kinship, marriage, and choice: “a family is characterized by people together because of birth, marriage, adoption, or choice” (Allen, Fine, and Demo, 2000, p. 7). Friedman, Bowden, and Jones (2003) incorporate the idea of many nontraditional definitions: “a family is two or more persons who are joined together by bonds of sharing and emotional closeness and who identify themselves as being part of the family” (p. 10). Again, this definition supports the idea of letting the family define their composition and relationships (Wright and Leahey, 2005). The National Institute of Mental Health (2005) defines family simply as a “network of mutual commitment” (p. 2).
In the past, the dominant American definition focused on the intact nuclear family. African-American families focus on a wide network of kin and community. The “nuclear” family does not exist for Italians. To them, family means a strong, tightly knit three- or four-generational family, which includes godparents and old friends. The Chinese go beyond this and include in their definition of family multigenerational family members and ancestors (Li, Lin, and Cao, et al., 2009).
The community health nurse interacts with communities made up of many types of families. When faced with great diversity in the community, the community health nurse must formulate a personal definition of family and be aware of the changing definition of family held by other disciplines, professionals, and family groups. The community health nurse who interacts with Mr. Hudson, the alcoholic who lives in a hotel, must have a broad conceptualization of the family. Both the surveillance activity of the hotel manager and the financial support of the minister could be accounted for in the definition of McDaniel and colleagues: “we define family as any group of people related either biologically, emotionally, or legally. That is, the group of people that the patient defines as significant for his or her well-being” (2005, p. 2).
Regardless of the definition of family accepted, what is evident is the importance of the family unit to society. The family fulfills two important purposes. The first is to meet the needs of society, and the second is to meet the needs of individual family members (Friedman et al., 2003). The family meets the needs of society through procreation and socialization of family members. “The basic unit (family) so strongly influences the development of an individual that it may determine the success or failure of that person’s life” (Freidman et al, p. 4). The family is the “buffer” between individuals and society. The family meets individual needs through provision of basic needs (food, shelter, clothing, affection). The family supports spouses or partners by meeting affective, sexual, and socioeconomic needs. For children, the family is the “first teacher,” instructing the children in societal rules and providing values needed for growth and development.
Characteristics of the Changing Family
The characteristics of the U.S. family continue to change. Historically the typical family, the nuclear family, has been defined as “the family of marriage, parenthood, or procreation; it is composed of a husband, wife, and their immediate children—natural, adopted or both” (Friedman et al., 2003, p. 10). The stereotypical view of this family as father, mother, and nonadult children while present currently represents only a portion of U.S. families (Annie E. Casey Foundation, 2009). In 1970, 85% of children younger than 18 years of age were living with two parents, defined as “mother and father.” In 2007, 74% of children younger than 18 years of age were living with two parents, defined as two adults including grandparents, same-sex partners, and other adults as parents (Annie E. Casey Foundation, 2009). In the last decade, recognition of various types of kinship families has resulted in available data that describe common types of families found in the United States. Table 20-1 presents significant family information.
|Married couple households||50,130,111 (68%)||49,932,000 (69%)|
|Father only households||4,425,000 (6%)||5,076,000 (7%)|
|Mother only households||21,138,000 (31%)||22,282,000 (32%)|
|Children in care of grandparents||3,194,000 (4%)||3,457,000 (5%)|
|Children living with co-habiting domestic partners||4,186,000 (6%)||4,343,000 (6%)|
|Children living with neither parent||4,126,000 (6%)||4,343,000 (6%)|
|Children living in married-couple immigrant families||10,935,000||12,774,000|
|Children living in single-parent immigrant families||2,944,000||3,680,000|
|Children living in single-parent immigrant families (U.S. born children)||17,967,000||18,602,000|
From Annie E. Casey Foundation: National Kids Count key indicators, 2009: www.kidscount.org.
Cohabitation, which is defined as “a living arrangement in which an unmarried couple live together in a long-term relationship that resembles a marriage,” has also increased over time (McLanahan and Percheski, 2008, p. 259). The number of cohabiting unmarried people increased from 523,000 in 1970 to 4.85 million in 2005 (U.S. Census Bureau, 2008). In 2007, 4,849,000 of the cohabiting-couple households included children (Annie E. Casey Foundation, 2009). Wydick (2007) found that 52% of American women currently in their 30s reported that their first relationship was cohabitation. Although these women generally reported that cohabitation was a prescreening situation before marriage, they reported lower relationship satisfaction when compared with the general population of married women and a higher divorce rate when marriage followed cohabitation. Hohmann-Marriott and Amato (2008) analyzed data from the Fragile Families and Child Well-being Study and reported that cohabiting partners were more likely to be what they termed “interethnic.” Interethnic couples were of either different ethnic or different racial backgrounds and were more likely to have relationship difficulties because of complications caused by different values and cultures. This did not mean the couples were less likely to be successful as partners, just that they were considered at risk or fragile. The nurse should be aware of the potential need for family support and intervention.
Single parenting has also increased over time. The increase in the teenage birth rate among this group raises concern. During the years 1980 to 2006, the birth rate for unmarried women 15 to 17 years of age increased from 21 to 41.9 per 1000 in the United States, representing a rise in 26 states (Centers for Disease Control and Prevention, 2009). The majority of teen parents raise their children alone. The proportion of children younger than 18 years of age who are living with their grandparents remains constant. In 2007, grandparent-headed families comprised 5% of all families. The American Academy of Child & Adolescent Psychiatry (2009) suggests that this is “due to serious societal issues and problems including increasing numbers of single parent families, the high rate of divorce, teenage pregnancies, AIDS, incarcerations of parents, substance abuse by parents, death or disability of parents, parental abuse and neglect” (p. 3). The gay or lesbian family is made up of a cohabiting couple of the same sex who have a sexual relationship. The homosexual family may or may not have children. Estimates of the number of children who live in lesbian- or gay-parented families, including children conceived in heterosexual marriages, range from 6% to 11% of children (Women’s Educational Media, 2005). These numbers are estimates because the U.S. Census Bureau does not count the number of lesbians and gay men. The University of California at Los Angeles (2009) reports that “more than one in every three lesbians have given birth and one in six gay men have fathered or adopted a child. An estimated 14,100 foster children are living with same-sex couples” (p. 8).
Single parenting is associated with greater risk associated with lesser social, emotional, and financial resources, which affect the general well-being of children and families. In 2007, 32% of all U.S. children lived in single-parent homes. Single parenting is a key indicator of well-being in children (Annie E. Casey Foundation, 2009). Table 20-2 shows statistics for single-parent families by ethnic group, and Table 20-3 shows teen birth rates by ethnic group.
|Black or African American||65%|
|Asian and Pacific Islander||17%|
|Hispanic or Latino||37%|
From Annie E. Casey Foundation: Kids Count data center, 2009: www.kidscount.org.
|Black or African American||62|
|Asian or Pacific Islander||17|
|Hispanic or Latino||82|
From Annie E. Casey Foundation: Kids Count data center, 2009: www.kidscount.org.
Approaches to meeting the health needs of families
Community health nursing has long viewed the family as an important unit of health care, with awareness that the individual can be best understood within the social context of the family. Observing and inquiring about family interaction enables the nurse in the community to assess the influence of family members on each other. However, direct intervention at the family rather than the individual client level is a new frontier for many nursing students, most of whom have experience in acute care settings before the community setting. A family model, largely a community health nursing or psychiatric–mental health intervention model, also includes the areas of birthing and parent-child interventions, adult day care, chronic illness, and home care. Nursing assessment and intervention must not stop with the immediate social context of the family, but it must also consider the broader social context of the community and society. Friedman et al. (2003, pp. 5-6) suggest reasons why it is important for nurses to work with families:
• “The family is a critical resource.” The importance of the family in providing care for its members has already been established. In this caregiver role, the family can also improve individual members’ health through health promotion and wellness activities.
• “In a family unit any dysfunction (illness, injury, separation) that affects one or more family members will affect the members and unit as a whole.” Also referred to as the “ripple effect,” changes in one member cause changes in the entire family unit. The nurse must assess each individual and the family unit.
• “Case finding” is another reason to work with families. As the nurse assesses an individual and family, he or she may identify a health problem that necessitates identifying risks for the entire family.
Moving from Individual to Family
Community health and home care nurses have traditionally focused on the family as the unit of service. With the move to managed care throughout the United States, most of these nurses continue to focus their practice on individuals residing in the home. As a result of the current era of cost containment, constraints on the community health nurse and on nurses working within hospitals and in other settings will increase. For example, reimbursement, which is almost entirely calculated for services rendered to the individual, is a major constraint toward moving toward planning care for the family as a unit. Various creative approaches to meeting the health needs of families are needed, reflecting interventions appropriate to the needs of the population as a whole.
Approaches to the care of families are needed and must be creative, flexible, and transferable from one setting to another. Community health nurses are generalists who bring previous preparation in communication concepts and interviewing to the family arena. Wright and Leahey (2005) proposed the realm of family interviewing rather than family therapy as an appropriate model. In this model, the community health nurse uses general systems and communication concepts to conceptualize the health needs of families and a family assessment model to assess families’ responses to “normative” events such as birth or retirement or to “paranormative” events such as chronic illness or divorce. Intervention is straightforward, as in helping parents educate prepubescent teenage family members about sex by providing appropriate educational materials or making a referral to another health professional, if the level of intervention is beyond the preparation of the nurse. For the purposes of this text, the model is extended to include intervention at the level of the larger aggregate. For example, the index of suspicion based on the health needs of a particular family would prompt the community health nurse to assess the need for similar information and the resources for intervention with other families in the community, schools, churches, or other institutions. Family interviewing requires thinking “interactionally,” not only in terms of the family system but also in terms of larger social systems.
Wright and Leahey (2005) identify the following critical components of the family interview: manners, therapeutic conservation and questions, family genogram (and ecomap when indicated), and commendations. With experience, they believe that the family interview can be accomplished in 15 minutes.
Manners are common social behaviors that set the tone for the interview and begin the development of a therapeutic relationship. Wright and Leahey (2005) believe that erosion of these social skills prevents the family nurse from collecting essential data. Many nurses argue that too much formality establishes artificial barriers to communication; however, studies identify that the essentials of a therapeutic relationship begin with manners. The nurse introduces himself or herself by name and title, always addresses the client (and family members) by name and title (i.e., Mr., Mrs., or Ms., unless otherwise directed by client), keeps appointments, explains the reason for the interview or visit, and brings a positive attitude. Other behaviors (manners) that invite rapport include being honest with the client and checking attitude (the nurse’s) before each client encounter.
The second key element in the interview is the therapeutic conversation. This type of conversation is focused and planned and engages the family. The nurse must listen and remember that even one sentence has the potential to heal or help a family member. The nurse encourages questions, engages the family in the interview and assessment process, and commends the family when strengths are identified. Every encounter, whether brief or extended, has “healing potential.” Therapeutic conversation may initiate further discussion that brings the family together on issues (Wright and Leahey, 2005).
Genogram and ecomap
The genogram and ecomap constitute the third element and are described in detail later in this chapter. These tools provide essential information on family structure and are an efficient way to gather information, such as family composition, background, and basic health status, in a way that engages the family in the interview process.
Therapeutic questions are key questions that the nurse uses to facilitate the interview. The questions are specific for the context or family situation but have the following basic themes (Wright and Leahey, 2005): family expectations of the interview or home visit; challenges, concerns, and problems encountered by the family at the time of the interview; and sharing information (e.g., who will relate the family history or information).
Commending family or individual strengths
The fifth element of the family interview is commending the family or individual strengths. Wright and Leahy (2005) suggest identifying at least two strength areas and, during each family interview, sharing them with the family or individual. Sharing strengths reinforces immediate and long-term positive relationships between the nurse and family. Interviews that identify and build upon family strengths tend to progress toward more open and trusting relationships and often allow the family to reframe problems, thereby increasing problem solving and healing (Wright and Leahey, 2005).
Issues in family interviewing
Creative family interviewing requires interviewing families in many types of settings. The prediction of decreased hospitalization, supplemented by a wide variety of health care settings ranging from acute to ambulatory to community centers, calls for flexible, transferable approaches. Clinical settings for family interviewing are reviewed by Wright and Leahey (2005) and include inpatient and outpatient ambulatory care and clinical settings in maternity, pediatrics, medicine, surgery, critical care, and mental health. According to Wright and Leahey, community health nurses have many opportunities besides the traditional home visit to engage the family in a family interview. Community health nurses are employed in ambulatory care centers, occupational health and school sites, housing complexes, day care programs, residential treatment and substance abuse programs, and other official and nonofficial agencies. At each of these sites, community health nurses meet families and can assess and intervene at the family and community levels.
The community health nurse can implement preventive programs for family units. The family is particularly appropriate because it experiences similar risk factors (i.e., physiological, behavioral, and environmental). Studies have documented the familial predisposition to the three major diseases resulting in morbidity and mortality in the United States: cardiac disease, cancer, and diabetes. Family health practices also influence lifestyle habits among family members. Recognizing the importance of a family health history related to individual and public health, the U.S. Surgeon General initiated the National Family History Initiative in 2003 with a goal to educate individuals about inherited predispositions to disease (McNeill et al., 2008). A study by Ehrensaft (2009) documented how the family of origin influenced antisocial or aggressive behaviors among family members. Such programs can occur in community health settings and demonstrate the need to go beyond intervention with the individual family to groups of families, serving the population as a whole.
Another example would be a Hispanic-American family in which a family member has diabetes; the nurse could implement a family health promotion plan based on the needs of the individual within an at-risk family. The family plan for diabetes prevention is based on the nurse’s understanding that the National Institutes of Health (NIH) reports that this group has the highest rate of diabetes among a nonwhite ethnic group in the United States (NIH, 2009).
Involving family members in newborn assessments can aid the community health nurse in determining the family’s adjustment to the newborn and parenthood. The nurse can do this in the home, clinic, or other health care center. Family members should be involved during the first contact or visit, and, if they do not attend, a telephone call explaining the nurse’s interest in them should take place (Wright and Leahey, 2005).
The community health nurse working with single-parent families may face particular challenges. Single-parent families report a higher incidence of children’s academic and behavioral problems and health problems than do two-parent families (Spencer, 2005). Children and parents in these families need a chance to express their concerns; the family interview is important and may provide the nurse with necessary information needed to care for these families.
The school nurse has a unique opportunity to compare the child in the school system with the child in the family system. The school nurse is becoming increasingly involved in planning special programs in the schools. Astute assessment of children’s needs within the context of their families in interviews at school or in the home can lead to innovative interventions such as support groups for children with chronic illness. Other areas of assessment and intervention that benefit from a family approach include learning or behavioral problems and absenteeism (Wright and Leahey, 2005).
Occupational Health Nurse
The nurse in the occupational health setting also can use a family approach to improve the health of the worker and contribute to overall productivity. For example, alcohol and chemical abuse account for much absenteeism in the workplace. Effective intervention with these families has been demonstrated. Assessment of occupational hazards may involve conducting reproductive histories in an effort to determine the effects of a chemical or agent on the reproductive capacity of the couple. Toxic agents can also transfer to family members from the workplace via clothes and equipment.
An awareness and a high degree of suspicion about the risks of occupational hazards in community industry are necessary. Obtaining an occupational history from all family members who have entered the workplace and obtaining referrals for family members’ screening and health education will contribute to unraveling occupational hazards and effects in the future. In addition, the community health nurse should be aware of the many family-related work issues that may trigger stress-related illness, such as job promotion, job loss, or shift work.
Intervention in Cases of Chronic Illness
Perhaps as many as 80% of families are dealing with chronic illness in a family member (Hopia, Paavilainen, and Astedt-Kurki, 2004). Also significant is the fact that resources such as third-party reimbursement cause most of these families to learn to manage the chronic problems with limited or infrequent intervention by health professionals. The community health nurse working with families coping with chronic illness in a child, adult, or older adult is aided by the family interview. As Glaser and Strauss (1975) stated, chronic illness interjects change into various areas of family life:
Sex and intimacy can be affected. Everyday mood and interpersonal relations can be affected. Visiting friends and engaging in other leisure time activities can be affected. Conflicts can be engendered by increased expenses stemming from unemployment and the medical treatment…different illnesses may have different kinds of impact on such areas of family life, just as they probably will call for different kinds of helpful agents. (p. 67)
Changes in family patterns, fears, emotional responses, and expectations of individual family members can be assessed in the family interview. Special needs of the primary caretaker (i.e., often the spouse, daughter, or daughter-in-law) can be assessed. The community health nurse making family visits to older adults and the terminally ill is able to assess intergenerational conflict and stress and influence family interaction positively (Wright and Leahey, 2005).
Moving from Family to Community
The health of families can affect the health of society as a whole, in both positive and negative ways. The health of a community is measured by the well-being of its people and families. Circumstances such as low-birth-weight infants, lack of health insurance, homelessness, violence, poverty, and low employment rates provide a description of families and nations. Community health nurses provide family nursing to improve individual and family health; however, the potential result is that of improving the health of society. The care of entire populations is the major focus, as stated by Freeman in her classic work (1963).
The selection of those to be served…must rest on the comparative impact on community health rather than solely on the needs of the individual or family being served.…The public health nurse cannot elect to care for a small number of people intensely while ignoring the needs of many others. She must be concerned with the population as a whole, with those in her caseload, with the need of a particular family as compared to the needs of others in the community. (p. 35)
The challenge to the community health nurse is to provide care to communities and populations and not to focus only on the levels of the individual and family. The community health nurse, who traditionally carries a caseload of families, extends his or her practice to the community. To do so, an aggregate, community, and population focus must serve as a backdrop to the entire practice.
For example, families must be viewed as components of communities. The community health nurse must know the community. As stated in previous chapters, a thorough community assessment is necessary to practice in the community. By way of review, the nurse must remember that communities must be compared not only in terms of different health needs but also in terms of different resources to effect interventions that influence policies and redistribute resources to ensure that community and family health needs are met.
Community health nurses must then compare city data with county data and then county data, state data, and national data. In addition, they may need to compare local census tract data and areas of a city or county with other areas of the city or county.
For example, community health nursing students in San Antonio, Texas, who were planning home visits to families of pregnant adolescents attending a special high school, compared local, state, and national statistics on infant mortality rates as a part of a community assessment. They found higher rates of infant mortality in San Antonio in census tracts on the south side of the city in which the population was predominantly Mexican American. They also found the population to be younger, to have a higher rate of functional illiteracy among adults, to be less educated, to be more likely to drop out of high school, to have higher fertility rates, to have higher birth rates among adolescents, and to be more likely to be unemployed. They found that specific health needs varied among census tracts. Common major health needs of this subpopulation were identified from the community assessment, which assisted the students in planning care for these families. For example, their goals were broadened from carrying out interventions at the individual level to interventions at the family and community levels. In addition to targeting good perinatal outcomes for the individual teenage parent, nursing students planned to include assessments of functional literacy at the individual and family levels and arranged for group sessions in clinic waiting rooms that informed and referred individuals and family members to alternative resources to enable teenage parents to complete school, take classes in English as a second language, and use resources for family planning and employment at the community level.
In addition to the cross-comparison of communities, the community health nurse also cross-compares the needs of the families within the communities and sets priorities. The nurse in the community finds that specific health needs vary among families. The nurse must account for time spent with families and choose those families on the basis of their needs compared with the needs of others in the community.
Delegation of Scarce Resources
Although the community health nurse serves the community or population as a whole, fiscal constraints hold the nurse accountable for the best delegation of scarce resources. Time spent on home visits has traditionally allowed the community health nurse to assess the environmental, social, and biological determinants of health status among the population and the resources available to them. Fiscal accountability, nevertheless, means setting priorities. In 1985, Anderson, O’Grady, and Anderson listed the factors that influence public health nursing practice, especially home visits, as “the need to justify personnel costs in a time of fiscal constraint, the increasing number of medically indigent who turn to local public health services for primary care, and the change in reimbursement mechanisms by the federal government and some states” (p. 146). Anderson’s observations still hold true. In 2009, more than 46 million Americans, including 9 million children, lacked health insurance (Robert Wood Johnson Foundation, 2009). Many of these individuals are Americans working in low-paying jobs and their families. The Children’s Health Insurance Program (CHIP) of 1997 has greatly increased access to health care for many low-income children. When the CHIP program was initiated, there were 10 million children in the United States and 14% were uninsured; in 2008, 7.4 million children were enrolled in state CHIP plans (Centers for Medicare and Medicaid Services, 2009). The majority of these children lived in families with working, low-income parents. On February 4, 2009, President Obama signed the Children’s Health Insurance Program Reauthorization Act (CHIPRA), which renews and expands coverage of the CHIP from 7 million children to 11 million children (2009).
Double standard in public health
A double standard is tolerated in public health. Although the government is responsible for the maintenance of health, a minimal amount of health care is guaranteed to each person because public resources are limited.
A minimum is established for all; however, as demonstrated with Medicare and Medicaid, unequal care exists as a result of differences in income (i.e., Medicare) and geographic location (i.e., Medicaid). In a market system, the wealthy can purchase all the health care services they desire and the poor cannot afford these services. The few supplemental resources provided by the government to ensure a minimum for all vary among communities, states, administrations, and counties.
In a period of cost containment, the focus of community health nurses on prevention and health maintenance, which are difficult areas to justify, must carefully legitimate home visiting services by identifying aggregates in need of care.
Prioritizing groups at highest risk and using home visits in conjunction with planning for larger aggregates’ needs are necessary. Working for social and policy changes to alter the conditions that place these families at high risk goes hand-in-hand with this activity. More research needs to be done that documents the importance of family nursing through home visits or community-based programs.
Many populations at high risk benefit from family nursing through home visits. Cornell University’s Family Life Development Center houses the Prenatal/Early Infancy Project. This project began in 1977 and involves a home visiting program for high-risk families having their first child. Registered nurses provide supportive and educational services. Nurse researchers reviewing the program noted that, among the participants, the program outcomes included 46% fewer verified reports of child abuse or neglect, 31% fewer subsequent births, 30 months less use of federal aid, 44% fewer behavioral problems from alcohol and substance abuse, and 69% fewer maternal arrests (Cornell University, 2009).
Approaches to family health
Many schools of thought regarding the approaches to meeting family health needs exist among community health, community mental health, and public health nursing professionals. Dreher (1982) stated that the traditional basis for community health nursing intervention has a focus that has long endorsed psychological and social-psychological theories to explain variations in health and patterns of health care, such as those set forth by Erikson (1963), Maslow (1970), and Duvall (1977). Dreher (1982) stated that what is needed are “more encompassing theories which explain the relationship between society and health [and]the policies which will be most effective in assuring health and health care” (p. 508). To help bridge this gap, four frameworks are presented (i.e., meeting family health needs through the application of family theory, systems framework, structural-functional conceptual framework, and developmental theory).
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