Since the 1980s there has been a sea change in the nature of children’s nursing, from a focus on giving direct, ‘hands on’ care to working in a partnership with the family, providing support in the family’s management of the care of the child and the impact that this has on their lives. There is a growing awareness that this facilitation can be more effective if the needs and resources of the family as a whole are understood (Whyte 1992).

Consideration of the family as the unit of care has been demonstrated for over a decade, in the work of American and Canadian writers (Friedemann, 1989, Friedman, 1998 and Wright and Leahey, 1994). More recently, this concept of family nursing entered the British literature through the work of Whyte, 1992, Whyte, 1996 and Whyte, 1997. Although a family-centred approach to the care of the sick child is not new to children’s nursing, the family was traditionally seen in relation to its ability to care for the child. In other words, the family was viewed as the context of the child. A family systems approach is a new orientation in that the focus of care is on the needs of the whole family. This demands an understanding of family dynamics in relation to a given situation, and the whole family becomes ‘the client’ (Friedemann 1989). Consider the needs of the family in the scenario below.

To work with this family in an effective, supportive and empowering way it would be necessary to understand how the family functions on both a practical and an emotional level. This understanding might be gained by spending time with the family and getting to know the individual family members. However, without a clear psychosocial assessment strategy, the family’s needs might not be fully explored and important factors that could influence the family’s coping might be missed.

Throughout this chapter, a systematic approach to the psychosocial assessment of child and family is advocated. This approach can be used in any setting and is valid for all children and families, including those requiring relatively short-term acute care, for example a child hospitalised for a tonsillectomy, and those requiring longer-term support, for example a child with cystic fibrosis.

Thinking about the family as a system is a helpful way of understanding how families function. Family systems theory underpins the approach to psychosocial assessment taken in this chapter. First postulated by Von Bertalanffy (1968), it provides the theoretical underpinning to family therapy and this in turn has formed the fundamental basis for understanding the family within family nursing (Wright & Leahey 1994). The family is seen as a system of humans in interaction with one another (Jones 1993). It is open, in that interaction occurs with the environment outside it and influences both the family system and the environment. Change in one part of the system, for example a child becoming ill, will influence interactions throughout the system.

Wright & Leahey (1994) have identified five concepts that provide a theoretical foundation for understanding the family as a system. The following explanation draws heavily on their work. Overall, it can be seen that communication and feedback mechanisms are important in the functioning of the family (Whyte 1997):

In summary there are there are three important concepts (Whyte 1997):

Assessment is not just about gathering information it is also about establishing a relationship with a family and conveying concern about them as individuals and as a unit. The two core beliefs underpinning the family nursing approach are that:

• the central nursing function is to empower the family

• the family is capable of identifying its own needs and devising ways of meeting them.

The form of assessment discussed here would be helpful to anyone working with children and families. Experience from teaching and practising this form of assessment as part of a multidisciplinary course suggests that it has value for a range of practitioners working in community and acute settings who aim to take a holistic view of the child and family. The approach is strongly influenced by Wright & Leahey’s (1994) work on family nursing but also draws on Erikson’s (1963) work on psychosocial development. It includes assessment of:

Each of these aspects will be addressed later in the chapter. Throughout the process, the practitioner works with the family and helps it to identify its problems and mobilise its own coping resources (Whyte 1997).

The practitioner shares his or her understanding that the health problem of the child is likely to have an effect on the whole family and that the practitioner is therefore interested in the health of the whole family. When undertaking an assessment it is important to transmit acceptance of the family as it is and to phrase questions in a way that is not discriminatory or value laden.