Working with families and children Flashcards
(36 cards)
1
Q
What is a family?
A
“A group of people who want to be involved in each other’s lives and are therefore bound together by emotional ties and a sense of belonging.”
- Families can change shape/meaning/definition based on situational context
- Can provoke different feelings for people
- Notion of social support; who are your supports that we can mobilize in the recovery and illness process
2
Q
Three commonalities of family
A
While there is no universally accepted definition, there is general agreement that every family:
- is a small social system
- has its own cultural values and rules
- has a structure & basic functions
3
Q
Family nursing
A
- In most clinical areas, nursing work involves supporting families through significant life transitions
What caring for families looks like is dependent on many factors:
- Philosophy of organization
- Care environment (type of care provided/level of acuity of patients)
- Particular dynamics/needs/ of each family
Goal is to SUPPORT AND STRENGTHEN THE RESILIENCY OF FAMILY MEMBERS AND THE FAMILY UNIT
4
Q
Guiding principles for family nursing care that strengthens family resilience
A
- Based off of strengths of family members
- What we can do to build on what families bring with them in the situation they are in to support them
- Don’t want to minimize what people are experience as problem; what’s this problem and what can we do about it
- Assessing what strengths do they have; how can we improve upon them
- Building resilience in the face of adversity
5
Q
Family as context
A
- Family seen as the larger social system of which the patient is a part
- The patient is the primary focus while their family members are the secondary focus
- May provide nursing care for different individuals within the same family but each member has their own plan of care
- The nursing work focuses on addressing the needs of the particular family member who is ill
6
Q
Family as client
A
- Focus on the family unit/group dynamics
- How the family structure contributes/affects family function
- What the patterns of interactions are amongst family members
- May provide care to subgroup within a family (e.g. parent-child dyad; siblings caring for aging parent)
- The nursing relationship is balanced between needs of client and primary caregivers, as well as other family members
7
Q
Assessing a family
A
- An exploration between the nurse and family to gain insight into the family’s perspective of the event [or situation], their strengths and need for support
- Needs for supports may be functional , educational, skill building, etc.
8
Q
Purpose of a family assessment
A
1) Understanding who the members of the family are
2) Understanding how the experience of illness is affecting the family as a whole
3) Understanding how the experience of illness is affecting each individual family member
4) Identifying the strengths, priorities, needs & goals of the family as a whole
5) Identifying the strengths, priorities, needs & goals of each family member
6) Understanding how broader social values/cultural practices/systems affect this family
7) Understanding the particular health beliefs
of the family
8) Understanding the particular cultural beliefs/practices of the family
9) Understanding the particular system(s) held by the family
10) Gaining a sense of what
the various relationships within the family are like
9
Q
Conducting a family assessment
A
- Create rapport/establish relationship
- Clarify roles; what you can do for them and what you can’t do for them
- Assure confidentiality while being honest about duties to report, & interprofessional communications
- Seek out information about the family’s
belief system(s) - organizational patterns
- communication processes
- How to mobilize resource and referrals
- Can be done more informally at the bed side or more formally in family meetings
- Acknowledging that trust with a stranger is not easy; can help with establishing a relationship and navigate it
10
Q
Assessment tools: genograms
A
- Visual representation of who’s in the family and what the relationships are like
- Can be first step in consciousness raising of what strengths and resource in their life that they haven’t thought about
- Particularly useful in the early stages of developing a relationship with a family
- For nurses- visually captures baseline information about the composition of the family and its resources (or lack thereof)
- For families- engages them as active participants in care and helps to ‘see’ their family and their resources/needs in a different way
- A graphic depiction of a family’s patterns over a period time, usually three generations.
- Purpose: to map the structure of a family; record information relevant to the issue.
11
Q
Assessment tools: ecomap
A
- A graphic depiction of family members’ contact with larger social systems.
- Purpose: to map the relationships of a family and people/organizations/institutions; identify connections to be made, resources to be sought
- Identify the possible resources they can mobilize that they haven’t thought about
12
Q
Assessment tool: McMaster Model of Family Functioning (MMFF)
A
- Dimensions of family functioning
1) Problem solving
2) Communication
3) Role function
4) Affective responsiveness
5) Affective involvement
6) Behavioural control
13
Q
MMFF: problem solving
A
- Get a sense of how well this family solves problems
- How do they solve problems
- Kinds of problems they solve better than others (i.e. instrumental vs interpersonal problems)
14
Q
MMFF: communication
A
- How do they communicate with one another
- Instrumental vs effective
- Is it clear
- Do they feel like they’re being understood by other members
- Do they shy away to protect each other or call it like they see it
- Combination of all kinds of things
15
Q
MMFF: role function
A
- Who is doing what in this family
- Resource, nurturing, support, mantinance and management of family system (emotional labour),
- Different roles in doing that
16
Q
MMFF: affective responsiveness
A
- Exploring how they respond emotionally to one another
- How do they respond to emotions expressed to one another
17
Q
MMFF: affective involvement
A
- How interested family members with what’s going on in the lives of other family members
18
Q
MMFF: behaviour control
A
- Rules orientated family
- Easy going family
- What’s the structure
- How rigid or flexible is the behaviour within this family
19
Q
Functional assessment questions (MMFF)
A
- What do you think are the most important problems for your family right now?
- How do you resolve problems?
- How would you describe the ways you communicate with one another?
- How would you describe your ability to provide for your family?
- Who makes the decisions in your family?
- How do family members express and receive feelings like warmth, affection, frustration, sadness?
- How do family members show interest in each other’s activities and interests?
- What kind of rules or standards does your family have about how to behave with one another? How to behave outside the family? Could you give me an example?
20
Q
Young families and serious parental illness in Canada (statistics)
A
- Canadians are having children later in life
- National average is 29.6yrs
- Ontario average is 30.2yrs
- With increasing age comes increased risk of families experiencing a serious parental illness
- 1 of every 20 North American children will experience the death of a parent before the age of 15
- As RNs, meaning we will be caring for someone with a child at some point in our career
21
Q
What is psychosocial distress?
A
- An unpleasant experience of an emotional, psychological, social, or spiritual nature that interferes with the ability to cope with [daily life]
- It extends along a continuum, from common normal feelings of vulnerability, sadness, and fears, to problems that are disabling, such as true depression, anxiety, panic, and feeling isolated or in a spiritual crisis
- All encapsulating term we use to talk about someone we see who’s feeling quite distressed about the situation
- Inability to cope with daily life
- Broad spectrum of psychosocial stress; can be just fear provoking or may not be able to participate in daily life
22
Q
What are the different manifestations
A
- Physiological
- Behavioural
- Psychological
- Spiritual
- Social
23
Q
Manifestations of psychosocial distress in children
A
- Appetite disturbances (poor appetite, c/o ‘feeling sick’)
- Sleep disturbances (insomnia, nightmares, night waking
- Inability to focus on tasks
- Temper tantrums (increased frequency, duration, intensity)
- Mood swings (intense sadness, anger, guilt)
- Increased aggressive behaviour (social/physical violence)
- Social withdrawal
- Feelings of anxiety
- Increased separation anxiety
- Developmental regression (thumb sucking, bed wetting)
- Poor performance in school
- Drug and alcohol use
- Physical symptoms (headaches, nausea/vomiting)
- Consider developmental age
24
Q
Persistence of psychosocial distress in children of people with serious illness
A
- Functional and clinical depression/anxiety scores of children are largely unaffected by a parental diagnosis of serious illness
- Due to the scored being base don tools that have been completed by the children’s parents not the children themselves
- Kids don’t want to stress their parents out or add to the burden; they won’t disclose or tell their parent or at out in front of them
- Possible correlation between (cis?) mothers experiencing depression/distress and children experiencing psychosocial distress
- Poorer family communication/expressiveness and family cohesion associated with higher levels of child self-reported anxiety and depression
- Length of time since diagnosis is not associated with improvement in child functioning or decreasing levels of psychosocial distress
- Impact of parental illness is not limited to period immediately following diagnosis
- As a parent visibly physically declines due to treatment or progressing illness, children typically experience a marked increase in psychosocial distress but this is often under-reported to parents/caregivers
25
What kids worry about
Is my parent going to die?
Why is this happening to us?
Is something bad going to happen to them? Are they going to get sicker?
What if other people in my family get sick? What will happen to me?
Is my other parent okay? Are my siblings okay? What can I do to help them?
My parent looks really sick- are they getting worse?
Will my parent ever be the same again?
Will my parents get mad or be upset if I talk about their illness or ask a question?
Will I get sick some day too?
26
Measuring psychosocial distress: self-report clinical tools for Ax children
- Child Behavioural Checklist (CBCL) (6-18yrs)
- Youth Self Report (YSR) (11-18yrs)
- Brief Symptom Inventory (BSI) (13yrs+)
- Child Depression Inventory (CDI) (7-17yrs)
- Multi-score Depression Inventory for Adolescents and Adults (MDI) (13yrs+)
- Multi-score Depression Inventory for Children (MDI-C) (8-12yrs)
- Weinberg Depression Scale for Children and Adolescents (WDSCA) (5-21yrs)
- Beck Anxiety Inventory (BAI) (7yrs+)
- Spence Children's Anxiety Scale (SCAS) (2.5-12yrs)
- Beck Self-Concept Inventory (BSCI-Y) (7yrs+)
- Resiliency Scales for Children & Adolescents (RSCA) (9yrs+)
- Most take <10minutes to administer
- Can indicate the severity of the suffering that the child is going through
- Help mobilize support
- It’s standardized
- No parental bias; that could miss what’s really happening with the child
27
Myths/misconceptions about talking to children about serious illness
- Children don’t have the capacity to understand explanations about serious illnesses, particularly young children
- Children need to be protected from difficult things
- Conversations about serious illness should be initiated by the child- if they aren’t talking about it, then neither should we
- If we talk about serious illness with a child, that’s all they’ll ever think about
Children can’t live with uncertainty
- We can have difficult discussion with children of any age; tailor it appropriately
- These myths come out of wanting to 'protect' the child
- Have these conversations with patients; help them move the conversation forward
28
Reasons for parental/HCP hesitancy
- Parents experience anxiety re: when, how and what to tell their children about their diagnosis and prognosis
- Impulse/desire to shield their children from worry
- Balancing demands of the day-to-day
- Desire to wait for reassuring information/good news
- Honouring wishes/needs of the ill parent
- Professionals are often inhibited by their anxieties about saying or doing the wrong thing and causing lasting emotional damage
- No parents who disclose their illness to the children experienced regrets about doing so
- Those who did not disclose (47%) expressed regret about that decision
- This is where we can play a vital role; prepping the family or telling a child about an ill parent or death
- Requires a lot of bravery, deep breathes, it never gets easier
29
Impact of truth telling
- Children’s level of anxiety and psychosocial distress is related to whether they are told about the illness and to the quality of the communication with their parent(s)
- Trust is a significant factor in childhood resiliency
- Truth-telling sustains sense of security within the family unit
- It’s really important to foster that sense of security through truth telling
- Even if that truth telling can be very difficult
- Important to communicate with the person you’re working with; while telling the truth can be difficult it will result in less psychosocial distress for the child(ren)
- Belief in honesty goes along way in cultivating trust, building resiliency, and coping
30
Where to start when having a conversation about a serous illness within a family group
Start with the parent(s)
- Who are the key members of this family? How old is the child/are the children?
- Have they shared any information with the child/children yet? If so, what have they shared?
- What concerns/fears do they have about disclosing information to their child(ren)?
- What’s their family’s communication style?
- If there multiple children, what are their individual communication styles/emotional needs?
- What support do they feel they’ll need from us when sharing information with their children?
- The earlier the children know the better
- Want the parents to tell them as opposed to us
31
How to prepare for a discussion with children about a serious illness within a family
Prepare for the discussion with the kids
- Support the parent(s) in planning out what they are going to say and prepare answers for questions the child(ren) may have
- Create an appropriate space that has minimal disturbances
- Think about anticipated questions
Talking to the child(ren)
- Get on the level of the child(ren)
- Start the conversation by asking what the child(ren) understands at this point about what’s been going on with their parent
32
Explaining the illness to children
- Name and explain the illness
- Use simple, developmentally appropriate language
- Avoid euphemisms
- Describe the treatments for the illness
- Address the 4 ‘C’s
- Describe signs of disease progression; what they might look like
- If they can trust that as things change they will be told, kids can live with uncertainty
33
The 4 C's
1) Can it be cured
2) Did I cause it
3) Can I catch it
4) Who is going to take care of me
34
Cultivating an atmosphere fo optimal communication
- Tell the child(ren) who they can talk to if they have questions- give them different resources and ways of asking
- Remember it’s not a one time conversation; can become more normalized part of family engagement
- If you make a mistake, or something doesn’t go well, try again; apologies go a long way with children
35
Assess children and conveying knowledge through play
- To play it out is the most auto-therapeutic measure childhood affords
- Whatever other roles play may have in the child’s development, the child uses it to make up for defeats, sufferings and frustrations
- Can be writing a story, playing with dolls, draw a picture and tell you about it, etc.
- This can provide a window into what they’re thinking about, what their fears are, etc.
36
Children's understanding of death
<2yrs: no real concept (but still react to separation)
3-4yrs: death is a changed state but don’t understand finality- can engage in magical thinking
5-6yrs: grasp finality of death- may not recognize personal mortality
>9yrs: full understanding of death
- The language you want to use; that they body doesn’t work anymore, and it will never work again
- The heart stops beating, and it never will again, the brain stops thinking, and it never will again, the body stops moving, and it will never move or hug again
- Like jumping in puddles; when they’re in the puddle its tough and they’re wet; when they’re out of the puddles it’s fine (but still present)
