Community Care
The Family and Culture
On completion of this chapter, the reader will be able to:
• Describe the main characteristics of contemporary family forms.
• Identify key factors influencing family health.
• Compare theoretic approaches for working with childbearing families.
• Relate the impact of culture on childbearing families.
• Discuss cultural competence in relation to one’s own nursing practice.
• Identify key components of the community assessment process.
• List indicators of community health status and their relevance to perinatal health.
• Describe data sources and methods for obtaining information about community health status.
• Identify predisposing factors and characteristics of vulnerable populations.
• List the potential advantages and disadvantages of home visits.
• Explore telephonic nursing care options in perinatal nursing.
• Describe how home fits into the maternity continuum of care.
• Discuss safety and infection control principles as they apply to the care of patients in their homes.
The Family in Cultural and Community Context
The family and its cultural context play an important role in defining the work of maternity nurses. Despite modern stresses and strains, the family forms a social network that acts as a potent support system for its members. Family care-seeking behavior and relationships with providers are all influenced by culturally related health beliefs and values. Ultimately, all of these factors have the power to affect maternal and child health outcomes. The current emphasis in working with families is on wellness and empowerment for families to achieve control over their lives. It is essential that nurses become culturally competent in order to provide the most appropriate care possible.
Defining Family
The family has traditionally been viewed as the primary unit of socialization—the basic structural unit within a community. The family plays a pivotal role in health care, representing the primary target of health care delivery for maternal and newborn nurses. As one of society’s most important institutions, the family represents a primary social group that influences and is influenced by other people and institutions. A variety of family configurations exist.
Family Organization and Structure
The nuclear family has long represented the traditional American family in which male and female partners and their children live as an independent unit, sharing roles, responsibilities, and economic resources (Fig. 2-1). In contemporary society, this idealized family structure actually represents only a relatively small number of families, and that number is steadily decreasing.
Many nuclear families have other relatives living in the same household. These extended family members include grandparents, aunts, uncles, or other people related by blood (Fig. 2-2). For some groups, such as African-American and Latin-American, extended family is an important resource in terms of preventive health behavior. The extended family is becoming more common as American society ages.
Multigenerational families, consisting of grandparents, children, and grandchildren, are becoming increasingly common. In 2010 they made up 4.4% of all households (Lofquist, Lugaila, O’Connell, et al., 2012). This may create stress as children must care for their parents as well as their own children. In other instances, the grandparents are supporting the children and grandchildren or are sole caregivers for the grandchildren.
No-parent families are those in which children live independently in foster or kinship care such as living with a grandparent. An estimated 5.4 million children in the United States live with grandparents (U.S. Census Bureau, 2010).
Married-parent families (biologic or adoptive parents) make up 48.4% of American families. By race and Hispanic origin, this family structure is represented as follows (Lofquist, Lugaila, O’Connell, et al., 2012):
Married-blended families, those formed as a result of divorce and remarriage, consist of unrelated family members (stepparents, stepchildren, and stepsiblings) who join to create a new household. These family groups frequently involve a biologic or adoptive parent whose spouse may or may not have adopted the child.
Cohabiting-parent families are those in which children live with two unmarried biologic parents or two adoptive parents. Hispanic children are almost twice as likely as African-American children to live in cohabiting-parent families and about four times as likely as Caucasian children to live in this kind of family arrangement (Lofquist, Lugaila, O’Connell, et al., 2012).
The single-parent family tends to be vulnerable economically and socially, creating an unstable and deprived environment for the growth of children. This in turn affects health status, school achievement, and high risk behaviors for these children.
Homosexual families (lesbian and gay) may live together with or without children. Children in lesbian and gay families may be the offspring of previous heterosexual unions, conceived by one member of a lesbian couple through therapeutic insemination, or adopted.
The Family in Society
The social context for the family can be viewed in relation to social and demographic trends that define the population as a whole. Racial and ethnic diversity of the population has grown dramatically in the past three decades, necessitating consideration of such diversity in provision of health care.
Theoretic Approaches to Understanding Families
Family Nursing
Family plays a pivotal role in health care, representing the primary target of health care delivery for maternal and newborn nurses. It is crucial that nurses assist families as they incorporate new additions into their family (see Nursing Care Plan). When treating the woman and family with respect and dignity, health care providers listen to and honor perspectives and choices of the woman and family. They share information with families in ways that are positive, useful, timely, complete, and accurate. The family is supported in participating in the care and decision making at the level of their choice.
Nursing Care Plan
Because so many variables affect ways of relating, the nurse must be aware that family members may interact and communicate with each other in ways that are distinct from those of the nurse’s own family of origin. Most families will hold some beliefs about health that are different from those of the nurse. Their beliefs can conflict with principles of health care management predominant in the Western health care system.
Family Theories
A family theory can be used to describe families and how the family unit responds to events both within and outside the family. Each family theory makes certain assumptions about the family and has inherent strengths and limitations. Most nurses use a combination of theories in their work with families. A brief synopsis of several theories useful in working with families is included in Table 2-1. Application of these concepts can guide assessment and interventions for the family.
TABLE 2-1
THEORIES AND MODELS RELEVANT TO FAMILY NURSING PRACTICE
| THEORY | SYNOPSIS OF THEORY |
| Family Systems Theory (Wright and Leahy, 2009) | The family is viewed as a unit, and interactions among family members are studied rather than studying individuals. A family system is part of a larger suprasystem and is composed of many subsystems. The family as a whole is greater than the sum of its individual members. A change in one family member affects all family members. The family is able to create a balance between change and stability. Family members’ behaviors are best understood from a view of circular rather than linear causality. |
| Family Life Cycle (Developmental) Theory (Carter and McGoldrick, 1999) | Families move through stages. The family life cycle is the context in which to examine the identity and development of the individual. Relationships among family members go through transitions. Although families have roles and functions, a family’s main value is in relationships that are irreplaceable. The family involves different structures and cultures organized in various ways. Developmental stresses may disrupt the life-cycle process. |
| Family Stress Theory (Boss, 1996) | How families react to stressful events is the focus. Family stress can be studied within the internal and external contexts in which the family is living. The internal context involves elements that a family can change or control, such as family structure, psychologic defenses, and philosophic values and beliefs. The external context consists of the time and place in which a particular family finds itself and over which the family has no control, such as the culture of the larger society, the time in history, the economic state of society, maturity of the individuals involved, success of the family in coping with stressors, and genetic inheritance. |
| McGill Model of Nursing (Allen, 1997) | Strength-based approach in clinical practice with families, as opposed to a deficit approach, is the focus. Identification of family strengths and resources; provision of feedback about strengths; assistance given to family to develop and elicit strengths and use resources are key interventions. |
| Health Belief Model (Becker, 1974; Janz and Becker, 1984) | The goal of the model is to reduce cultural and environmental barriers that interfere with access to health care. Key elements of the Health Belief Model include the following: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and confidence. |
| Human Developmental Ecology (Bronfenbrenner, 1979; 1989) | Behavior is a function of interaction of traits and abilities with the environment. Major concepts include ecosystem, niches (social roles), adaptive range, and ontogenetic development. Individuals are “embedded in a microsystem [role and relations], a mesosystem [interrelations between two or more settings], an exosystem [external settings that do not include the person], and a macrosystem [culture]” (Klein and White, 1996). Change over time is incorporated in the chronosystem. |
Family Assessment
When selecting a family assessment framework, an appropriate model for a perinatal nurse is one that is a health-promoting rather than an illness-care model. The low risk family can be assisted in promoting a healthy pregnancy, childbirth, and integration of the newborn into the family. The high risk perinatal family has illness-care needs, and the nurse can help meet those needs while also promoting the health of the childbearing family.
A family assessment tool such as the Calgary Family Assessment Model (CFAM) (Box 2-1) can be used as a guide for assessing aspects of the family. Such an assessment is based on “the nurse’s personal and professional life experiences, beliefs, and relationships with those being interviewed” (Wright and Leahy, 2009) and is not “the truth” about the family but, rather, one perspective at one point in time.
The CFAM comprises three major categories: structural, developmental, and functional. Several subcategories are within each category. The three assessment categories and the many subcategories can be conceptualized as a branching diagram (Fig. 2-3). These categories and subcategories can be used to guide the assessment that will provide data to help the nurse better understand the family and formulate a plan of care. The nurse asks questions of family members about themselves to gain understanding of the structure, development, and function of the family at this point in time. Not all questions within the subcategories should be asked at the first interview, and some questions may not be appropriate for all families. Although individuals are the ones interviewed, the focus of the assessment is on interaction of individuals within the family.
Graphic Representations of Families
A family genogram (family tree format depicting relationships of family members over at least three generations) (Fig. 2-4) provides valuable information about a family and can be placed in the nursing care plan for easy access by care providers. An ecomap, a graphic portrayal of social relationships of the woman and family, may also help the nurse understand the social environment of the family and identify support systems available to them (Fig. 2-5). Software is available to generate genograms and ecomaps (www.interpersonaluniverse.net).
The Family in a Cultural Context
Cultural Factors Related to Family Health
Culture of an individual is influenced by religion, environment, and historic events and plays a powerful role in the individual’s behavior and patterns of human interaction. Culture is not static; it is an ongoing process that influences a woman throughout her entire life, from birth to death.
Cultural knowledge includes beliefs and values about each facet of life and is passed from one generation to the next. Cultural beliefs and traditions relate to food, language, religion, art, health and healing practices, kinship relationships, and all other aspects of community, family, and individual life. Culture has also been shown to have a direct effect on health behaviors. Values, attitudes, and beliefs that are culturally acquired may influence perceptions of illness, as well as health care–seeking behavior and response to treatment. The political, social, and economic context of people’s lives is also part of the cultural experience.
Culture, shared beliefs, and values of a group play a powerful role in an individual’s behavior, particularly when the individual is sick. Understanding a culture can provide insight into how a person reacts to illness, pain, and invasive medical procedures, as well as patterns of human interaction and expressions of emotion. The effect of these influences must be assessed by health care professionals in providing health care and developing effective intervention strategies.
Many subcultures may be found within each culture. Subculture refers to a group existing within a larger cultural system that retains its own characteristics. A subculture may be an ethnic group or a group organized in other ways. For example, in the United States and Canada, many ethnic subcultures such as African-Americans, Asian-Americans, Hispanic-Americans, and Native Americans exist. It is important to note that subcultures also exist within these groups. In addition, the Caucasian population in America has multiple subcultures of its own. Because every identified cultural group has subcultures and because it is impossible to study every subculture in depth, greater differences may exist among and between groups than is generally acknowledged. It is important to be familiar with common cultural practices within these subgroups. However, it is also important to avoid the generalization that every person practices every cultural belief within a group.
In a multicultural society, many groups can influence traditions and practices. As cultural groups come into contact with each other, acculturation and assimilation may occur.
Acculturation refers to the changes that occur within one group or among several groups when people from different cultures come into contact with one another. People may retain some of their own culture while adopting some cultural practices of the dominant society. This familiarization among cultural groups results in overt behavioral similarity, especially in mannerisms, styles, and practices. Dress, language patterns, food choices, and health practices are often much slower to adapt to the influence of acculturation. In the United States, acculturation generally is thought to take three generations. An adult grandchild of an immigrant is usually fully Americanized.
During times of family transitions such as childbearing or during crisis or illness, a woman may rely on old cultural patterns even after she has become acculturated in many ways. This is consistent with the family developmental theory that states that during times of stress, people revert to practices and behaviors that are most comfortable and familiar.
Assimilation occurs when a cultural group loses its cultural identity and becomes part of the dominant culture. Assimilation is the process by which groups “melt” into the mainstream, thus accounting for the notion of a “melting pot,” a phenomenon that has been said to occur in the United States. This is illustrated by individuals who identify themselves as being of Irish or German descent without having any remaining cultural practices or values linked specifically to that culture such as food preparation techniques, style of dress, or proficiency in the language associated with their reported cultural heritage. Spector (2013) asserts that in the United States, the melting pot, with its dream of a common culture, is a myth. Instead, a mosaic phenomenon exists in which we must accept and appreciate the differences among people.
Implications for Nursing
As our society becomes more culturally diverse, it is essential that nurses become culturally competent. Nurses must examine their own beliefs so that they have a better appreciation and understanding of the beliefs of their patients. Understanding the concepts of ethnocentrism and cultural relativism may help nurses care for families in a multicultural society.
Ethnocentrism is the view that one’s own way of doing things is best (Giger, 2013). Although the United States is a culturally diverse nation, the prevailing practice of health care is based on the beliefs and practices held by members of the dominant culture, primarily Caucasians of European descent. This practice is based on the biomedical model that focuses on curing disease states.
Cultural relativism is the opposite of ethnocentrism. It refers to learning about and applying the standards of another’s culture to activities within that culture. The nurse recognizes that people from different cultural backgrounds comprehend the same objects and situations differently. In other words, culture determines viewpoint.
Cultural relativism does not require nurses to accept the beliefs and values of another culture. Instead, nurses recognize that the behavior of others may be based on a system of logic different from their own. Cultural relativism affirms the uniqueness and value of every culture.
Childbearing Beliefs and Practices
Nurses working with childbearing families care for families from many different cultures and ethnic groups. To provide culturally competent care, the nurse must assess the beliefs and practices of patients. When working with childbearing families, a nurse considers all aspects of culture including communication, space, time orientation, and family roles.
Communication often creates the most challenging obstacle for nurses working with patients from diverse cultural groups. Communication is not merely the exchange of words. Instead, it involves (1) understanding the individual’s language, including subtle variations in meaning and distinctive dialects; (2) appreciating individual differences in interpersonal style; and (3) accurately interpreting the volume of speech as well as the meanings of touch and gestures. For example, members of some cultural groups tend to speak more loudly when they are excited, with great emotion and with vigorous and animated gestures; this is true whether their excitement is related to positive or negative events or emotions. It is important, therefore, for the nurse to avoid rushing to judgment regarding a person’s intent when the patient is speaking, especially in a language not understood by the nurse. Instead, the nurse should withhold an interpretation of what has been expressed until it is possible to clarify the patient’s intent. The nurse needs to enlist the assistance of a person who can help verify with the patient the true intent and meaning of the communication (see Critical Thinking Case Study).
Critical Thinking Case Study
Providing Culturally Appropriate Care
Elisabeth, a 22-year-old first-generation Mexican-American, comes into your office for her initial prenatal visit. You are concerned because Elisabeth’s fundal height is consistent with 32 weeks of gestation and this is her first prenatal visit. Elisabeth, who lives with her husband, four children (ages 6, 4, and 3 years and 15 months), her mother, her aunt, and her uncle, states that she has been doing well this pregnancy and did not start prenatal care in her previous pregnancies until she was almost ready to give birth. She also comments that all the babies were full term with uneventful labors and births. In obtaining the history you note the presence of a safety pin in Elisabeth’s shirt and wonder what this is for. You want to provide culturally competent care to this woman and her family.
1. Evidence—Is there sufficient evidence to support the components of culturally competent care for Elisabeth?
2. Assumptions—Describe an underlying assumption about culturally competent care for Elisabeth in relation to these topics:
a. The view of pregnancy in Elisabeth’s culture
b. The role of family in Elisabeth’s culture
c. The acceptability for women of Elisabeth’s age to begin having children at such young ages
d. The religious beliefs that Elisabeth may have that affect contraception
3. What implications and priorities for nursing care can be made at this time?
Inconsistencies between the language of patients and the language of providers present a significant barrier to effective health care. For example, there are many dialects of Spanish that vary by geographic location. Because of the diversity of cultures and languages within the U.S. and Canadian populations, health care agencies are increasingly seeking the services of interpreters (of oral communication from one language to another) or translators (of written words from one language to another) to bridge these gaps and fulfill their obligation for culturally and linguistically appropriate health care (Box 2-2). Finding the best possible interpreter in the circumstance is critically important as well. Ideally, interpreters should have the same native language and be of the same religion or have the same country of origin as the patient. Interpreters should have specific health-related language skills and experience and help bridge the language and cultural barriers between the patient and the health care provider. The person interpreting also should be mature enough to be trusted with private information. However, because the nature of nursing care is not always predictable and because nursing care that is provided in a home or community setting does not always allow expert, experienced, or mature adult interpreters, ideal interpretive services sometimes are impossible to find when they are needed. In crisis or emergency situations or when family members are having extreme stress or emotional upset, it may be necessary to use relatives, neighbors, or children as interpreters. If this situation occurs, the nurse must ensure that the patient is in agreement and comfortable with using the available interpreter to assist.
When using an interpreter, the nurse respects the family by creating an atmosphere of respect and privacy. Questions should be addressed to the woman and not to the interpreter. Even though an interpreter will of necessity be exposed to sensitive and privileged information about the family, the nurse should take care to ensure that confidentiality is maintained. A quiet location free from interruptions is ideal for interpretive services to take place. Culturally and linguistically appropriate educational materials that are easy to read, with appropriate text and graphics, should be available to assist the woman and her family in understanding health care information. To ensure understanding and avoid liability issues, it is important to make certain that the material has been translated by someone who is trained appropriately.
Personal Space
Cultural traditions define the appropriate personal space for various social interactions. Although the need for personal space varies from person to person and with the situation, the actual physical dimensions of comfort zones differ from culture to culture. Actions such as touching, placing the woman in proximity to others, taking away personal possessions, and making decisions for the woman can decrease personal security and heighten anxiety. Conversely, respecting the need for distance allows the woman to maintain control over personal space and support personal autonomy, thereby increasing her sense of security. Nurses must touch patients. However, they frequently do so without any awareness of the emotional distress they may be causing patients.
Time Orientation
Time orientation is a fundamental way in which culture affects health behaviors. People in cultural groups may be relatively more oriented to past, present, or future. Those who focus on the past strive to maintain tradition or the status quo and have little motivation for formulating future goals. In contrast, individuals who focus primarily on the present neither plan for the future nor consider the experiences of the past. These individuals do not necessarily adhere to strict schedules and are often described as “living for the moment” or “marching to their own drummer.” Individuals oriented to the future maintain a focus on achieving long-term goals.
The time orientation of the childbearing family may affect nursing care. For example, talking to a family about bringing the infant to the clinic for follow-up examinations (events in the future) may be difficult for the family who is focused on the present concerns of day-to-day survival. Because a family with a future-oriented sense of time plans far in advance, thinking about the long-term consequences of present actions, they may be more likely to return as scheduled for follow-up visits. Despite the differences in time orientation, each family can be equally concerned for the well-being of its newborn.
Family Roles
Family roles involve the expectations and behaviors associated with a member’s position in the larger family system (e.g., mother, father, grandparent). Social class and cultural norms also affect these roles, with distinct expectations for men and women clearly determined by social norms. For example, culture may influence whether a man actively participates in pregnancy and childbirth, yet maternity care practitioners working in the Western health care system expect fathers to be involved. This can create a significant conflict between the nurse and the role expectations of very traditional Mexican or Arab families, who usually view the birthing experience as a female affair (see Cultural Competence box). The way that health care practitioners manage such a family’s care molds its experience and perception of the Western health care system.
Cultural Competence
Questions to Ask to Elicit Cultural Expectations About Childbearing
1. What do you and your family think you should do to remain healthy during pregnancy?
2. What can you do to improve your health and the health of your baby?
3. What foods will help make a healthy baby?
4. Who do you want with you during your labor?
5. What can your labor support person do to help you be most comfortable during labor?
6. What actions are important for you and your family after the baby’s birth?
7. What do you and your family expect from the nurse(s) caring for you?
8. How will family members participate in your pregnancy, childbirth, and parenting?
In maternity nursing, the nurse supports and nurtures the beliefs that promote physical or emotional adaptation to childbearing. However, if certain beliefs might be harmful, the nurse should carefully explore them with the woman and use them in the re-education and modification process. Strategies for care delivery and providing appropriate care are presented in Box 2-3.
Box 2-3
Strategies for Care Delivery and Providing Culturally Appropriate Care
From Mattson S: Providing culturally competent care: strategies and approaches for perinatal clients, AWHONN Lifelines 4(5):37–39, 2000.
Table 2-2 provides examples of some cultural beliefs and practices surrounding childbearing. The cultural beliefs and customs in the table are categorized on the basis of distinct cultural traditions and are not practiced by all members of the cultural group in every part of the country. Women from these cultural and ethnic groups may adhere to a few, all, or none of the practices listed. In using this table as a guide, the nurse should take care to avoid making stereotypic assumptions about any person based on sociocultural-spiritual affiliations. Nurses should exercise sensitivity in working with every family, being careful to assess the ways in which they apply their own mixture of cultural traditions.
TABLE 2-2
TRADITIONAL* CULTURAL BELIEFS AND PRACTICES: CHILDBEARING AND PARENTING
