Family Assessment and Interventions in Nursing

Family Assessment and Intervention of the Rogers’

The purpose of this paper is to expand on the interview conducted with a selected family while using the Calgary Family Assessment Model (CFAM) to create a nursing diagnosis, teaching plan as well as strength-based nursing interventions based on Calgary Family Intervention Model (CFIM).  The selected family was referred to the nursing student by a close friend and colleague.  The initial meeting took place at the Roger’s home where informed consent was signed, and a relationship of trust was established by introducing myself,  followed by a brief explanation for the meeting (Kaakinen, Coehlo, Steele & Robinson, 2018).  A 15-minute interview using the CFAM (structural, developmental and functional assessment) as a data collection guide was used to gain a better understanding of the family’s story.  The Roger’s family consists of Sandra, who is a single mother of two children, Ashton and Jordon.   Since the estrangement of the children’s father, Sandra has a difficult time asking for help outside of extended family and close friends which in turn increases her stress levels and causes a significant impact on the family.  Because of this, Sandra often struggles with the many disadvantages of single parenthood, despite the family’s strong emotional bond.  With the help of the grandmother, Mary, the family can meet many of the daily challenges. Since Sandra’s recent diagnosis with Fibromyalgia (FM), she is struggling with her management of increased stress due to the disease process which is affecting her activities of daily living (ADLs) and the functioning of the family. Findings within this assessment represent a glimpse of this family and are subject to change.  For confidentiality purposes, pseudo names were used throughout the paper.

Structural Assessment

The structural assessment, according to Wright and Leahy (2013), examines the members of the family, and their connections by reviewing the internal structure, external structure and family content.

Internal Structure

The Roger’s family internal composition consists of a self-identified heterosexual 41-year-old mother Sandra as well as her two children Ashton and Jordon.  Ashton is a 13-year-old adolescent female just graduating grade 8 and Jordon is a 6-year-old boy graduating from kindergarten this year.  Aside from Sandra, Ashton and Jordon have strong emotional ties to their grandmother, Mary, who is recently retired at 68 years of age and an integral part of their lives by assisting with childcare and accommodations when needed.  In terms of gender, Sandra facilitates both mother and father roles since the birth of Jordon in 2014.  During the interview, the differences in ages between the two children were noted.  Also, to understand the families rank order and the impact on the children’s development, the family was asked if the difference in birth spaces between children were involuntary or were the pregnancies planned.  Sandra indicated by verbalizing that “Her pregnancy with Jordan was accidental and the biological father, Michael, has been estranged since the announcement providing no emotional or financial support to the family until recently” (S. Rogers, personal communication, May 30, 2019).  Within the past few months, 41-year-old father, Michael, has attempted to reconcile with his family.  Sandra also explained how the unexpected estrangement contributed to the current subsystems within the Roger’s family by leaving Sandra to be the primary parental subsystem for each child and the grandmother, Mary, accepting the role when Sandra was unable to. This estrangement has also left Ashton to take on more of an adult role, at times, by assuming a surrogate-spouse subsystem in the absence of the father (Wright and Leahy, 2013).  A long history of trauma has affected Sandra’s boundaries, both internally and externally. Over the years, Sandra has developed difficulties with establishing trusting relationships outside of her extended family and close friends, especially since the estrangement of the children’s biological father. Her boundaries are closed/rigid, and she has a difficult time accepting or asking for help, which often increases her fatigue and stress levels. The genogram for this family is in Appendix A of this paper.

External Structure

The external structure includes extended family and larger family systems (Wright & Leahey, 2013).  Sandra is the youngest of three siblings, and unfortunately, their relationship has been severed due to its toxicity.  Whereas Sandra’s ambiguous relationship with her father has been the cause of childhood trauma, and although she still has contact with him periodically, he has been absent for the majority of her adult life.  Currently, her father resides within the same urban centre but will only contact Sandra and her children when he needs something. The remainder of the extended family lives in Ontario and have minimal contact with her and the children; however, Mary goes to visit them yearly.  The lack of extended family in Sandra’s life often leads to her dealing with problems alone, especially when larger support systems are problematic and not accessible.  Since becoming a single parent family, financial resources have drastically reduced.  The previous unsettled battles with the Provincial Family Justice system regarding defunct child support payments were exceptionally frustrating.   Combined with, Sandra’s battles with her family physician regarding her FM symptoms that were disregarded, prior to diagnosis by a new family physician helped to create hesitancy, resistance and distrust in our provincial/regional services provided to her and her family.

Additionally, the lack of understanding and work schedule discrimination that have been imposed by numerous employers because of her sociological status is relevant to the number of jobs Sandra has held within the past six years.  Not to mention, the time and energy needed to ensure that Ashton and Jordon are in activities, spend time with their friends, and get homework done for school often leaves Sandra very little time for her wellbeing.  Sandra stated that her “close friendships have been a saving grace and play a vital role in the comfort and emotional support” (Rogers, 2019). The ecomap of this family is in Appendix B of this paper. 

Context

  Sandra considers her ethnicity as North American culture, whereas her children’s ethnicity is deemed to be indigenous because of their fathers’ Cree ancestry.  Sandra has taken the necessary steps to ensure that both children have been legally identified as indigenous and issued a status card, so they are recognized as aboriginal by society.  Conversely, the children take taekwondo as their weekly activity attend a Catholic school; have chosen to learn French as a second language and know very little about their indigenous heritage.  When asked about social class, Sandra responded that “there were times when money was tight and being a single parent everything has to count because you have to juggle your time, money and work” (Rogers, 2019).  Sandra felt that she is often looked on by society as low to lower middle class due to her the education level, and her children’s ethnicity or race.  However, she is always thankful to be able to clothe, feed and care for her children to the best of her ability thanks to the assistance of Mary and the various supports available to her within her community such as low-income housing.  Michael’s efforts to reconcile with the family by upholding his financial obligations and finally paying his allotted monthly child support payments has lightened the financial burden on the family.  Sandra considers herself spiritual; however, she does not choose to attend a place of worship.  Sandra believes that spirituality has many perspectives.  Her ideology of spirituality is that happiness, strength and blessings in life are gifts from a higher power that are unique to each of us. 

Development Assessment

As previously indicated, Michael, has been estranged from the family following the announcement of Sandra’s pregnancy until recently.  The complexities involved with childrearing by a single parent can be very challenging.  According to Wright and Leahey (2013), single-parent families must accomplish most of the same developmental tasks as families consisting of two parents, with limited resources.  Sandra has accepted the role of both mother and father; therefore left to tackle responsibilities involving the emotional, psychological and developmental growth of each child as well as her own. 

Functional Assessment

The functional assessment, according to Wright and Leahy (2013), consists of two parts instrumental and expressive functioning.   It looks at the interaction between family members and the operation of everyday life for the family.

Instrumental Functioning

This section covers family routine, activities of daily living such as cooking, cleaning, shopping (Wright & Leahy, 2013).

When asked how she manages the daily challenges, Sandra stated: “I am not sure how I do it, but every day is different, and some are harder than others.” (Rogers, 2019). On days that Mary, the grandmother is there to assist with the before and after school childcare, she does assist in household duties and prepares supper.  As a single parent, Sandra has the sole responsibility for all day-to-day aspects, and although Ashton does help out, Sandra tries to avoid exploiting her efforts.  In regards to family decision making, the family acknowledges having a shared responsibility consulting each other in many family decisions. 

Expressive Functioning

The Expressive functioning of CFAM Models includes nine subcategories such as: “emotional communication, verbal/nonverbal communication, circular communication, problem-solving, roles, alliances and coalitions of the family” (Kaakinen et al. 2018, p124).  Sandra admits to habitually finding herself unable to relinquish the self-destructive behaviours of not always discussing her emotions when needed in fears of being judged.  These emotional barriers have increased stress levels and contributed to her health problems. Sandra has sought professional support to facilitate relief for her anxiety and stress caused by these behaviours.  

        Despite this, the interactions between the children and her demonstrate that they have strong communication skills and a good relationship.  The children are affectionate toward Sandra, and Sandra frequently speaks about their feelings and opinions.  Jordon has a mild form of ADHD (Attention deficit hyperactivity disorder) that requires Sandra to repeat instructions, and ensure her verbal and non-verbal communications are clear and directed, so Jordon remains focused.  Jordon is encouraged to use his inside voice when speaking verses yelling. Also, lots of facial expressions, eye contact and gestures are often used when Sandra is busy and cannot give Jordon his required attention.  Whereas, Sandra mentioned that more Therapeutic communication is used with Ashton because she is in her adolescent years.  When youth experience circular communication as a result of increased, anger and defiance problems in family functioning occurs (Liermann & Norton, 2016).  Sandra believes that is it important to try and maintain communication because with positive communication emerges positive relationships. 

        The family believes that they can solve problems with perseverance and communication. The challenges faced sometimes vary according to circumstances, but when in doubt, grandma, Mary is called to help.  When considering the subcategory roles within the family, as mentioned previously, Sandra has maintained the roles of both mother and father within the family unit.  Sandra also values Ashton’s contribution and assistance in preserving family function but does watch to ensure that she does not take on the parental role.  Despite this family’s challenges, they function very well as a unit.  Influence and power, as well as beliefs, were not assessed during the interview. 

In terms of the family’s alliances and the coalition, they fall into a triangular alliance with Grandmother, Mary, deemed helpful and unhelpful at times when boundaries/ roles are being challenged because of intensified tensions. 

Rogers’ Family Nursing Diagnosis and Interventions

According to Kaakinen et al. (2018), the family reasoning web is useful in analyzing data from the family assessment into meaningful data groups.  The nurse asked the family to identify their strengths and weakness so that competent care could be implemented (Silva, Moules, Silva, & Bousso, 2013).  The family determined that their strengths were respect and love for one another, and their weaknesses were poor knowledge of disease process, together with decreased activities of daily living (ADLs) which is affected by ineffective stress management. These recognized areas were used to collaborate with the family appropriate family-based nursing diagnosis and interventions based on the CFIM (Calgary Family Intervention Model). There was two family nursing diagnosis and two interventions identified. 

The first nursing diagnosis identified is deficient knowledge related to lack of information related to disease process, as evidenced by patient’s inquiry about the management of daily challenges needed for health recovery, maintenance and health promotion (Gulanick & Myers 2014 p. 115).   Education provided to patients and their families within this cognitive domain by healthcare professionals plays a substantial part in patients obtaining the best possible health outcomes.  Patients with FM often rank cognitive dysfunctions such as memory and mental alertness high in terms of the disease process; however, they also experience pervasive pain and tender points, extreme fatigue, accompanied by anxiety, and sleep problems (Årestedt, Benzein, & Persson, 2015).   By working with the patients to increase knowledge, deficient nurses can assist in health promotion and alleviate frustrations associated with the disease process.    Setting goals and discussing management of symptom expectations with therapeutic communication by healthcare professionals not only establishes trust, but self-management strategies personalized to that individual enhances better quality of life (Wayne, 2016 p. 1).  

        The other nursing diagnosis is ineffective coping strategies related to her recent diagnosis of FM as evidenced by increased stress and anxiety (Ladwig, Ackley & Makic, 2019).  Based on the CFAM assessment, Sandra is having a difficult time managing her stress levels. Sandra’s stress levels and decreased activities of daily living (ADLs) is directly related to FM and the vicious cycle of non-restorative sleep, pain and increased anxiety (Davis et al. 2017).   By recognizing the need for appropriate strategies through active listening, commendations and empathetic communication, we established a supportive environment.  Healthcare professionals can teach patients how to focus on the present, let go of any emotional barriers, and how to use available resources (Gulanick & Myers 2014). By doing so, Sandra will recognize her strengths, which can facilitate improved coping and reduce stress. FM is a very complex disorder with no apparent cause and no cure; I commended Sandra for her strength and perseverance in overcoming her daily challenges associated with this disease process. 

Teaching Plan Rationale

The information attained from the CFAM (Structural, developmental and functional assessment) data collection we created a recommended teaching plan for the Roger’s family.   Sandra’s FM symptoms are currently increasing because of the stress associated with her inability to complete ADLs.  Because Sandra is stressed, the children will also be stressed based on the concept of the family system theory by (Kaakinen et al. 2018).  The author believes that the family is a system, all parts are interconnected and what affects one area will ultimately affect the other parts of the system (Kaakinen et al. 2018).  Once Sandra can achieve a state of wellbeing by managing her symptoms of FM, the family’s functions and processes will also benefit.  The teaching will focus on Sandra reducing or maintaining her stress levels, which in turn will reduce symptoms associated with her illness and enhance the wellbeing of the entire family. 

Mindfulness-based Stress Reduction Techniques

A Mind-body therapeutic approach called Mindfulness-based stress reduction (MBSR) will teach Sandra how to reduce her stress-related symptoms of FM.  This practice integrates mindfulness meditation, in addition to, complementary Mind-body therapies such as body scanning, hypnosis, reflexology and several other relaxation techniques (Chadi et al. 2016).  MBSR focuses on calming your emotional- related brain activity, which has been linked to the reduction of pain, stress and anxiety, through increased self-awareness and body sensations (Cash et al., 2015).  According to Koçak & Kurt (2017), MBSR provides effective treatment for treating symptoms related to FM and is frequently recommended as an alternative approach to traditional remedial therapies.   This teaching plan will teach MBSR techniques to Sandra and assist her in identifying stressful events, increasing her ADLs; by reducing symptoms of FM and the impact on the family. The Teaching Plan for this Family is in Appendix C of this paper.

Conclusion

In conclusion, the CFAM Model has been used to assess the Roger’s family.  Although the family assessment and interventions in this paper are just a current snapshot of the Roger’s family the CFAM and CFIM has allowed the nurse to recognize, interpret and implement change strategies for the family to promote positive family outcomes (Wright & Leahy, 2013).  The Roger’s family have a strong family bond based on good communication and an excellent relationship.  The Roger’s family identified their strengths as respect and love for one another and their weaknesses as ineffective stress management and decreased ADLs related to Sandra’s recent diagnosis of FM. Nursing diagnoses were developed to address some of the family concerns.  The nursing diagnoses were: deficient knowledge related to Sandra’s current diagnosis and Ineffective Coping Strategies, which exacerbates symptoms of the disease process.  In the area of health promotion, the CFIM Model was used to develop family centred interventions.  Both individual and family strengths were commended, along with therapeutic communication maintained.  Finally, to assist in the family’s wellbeing, as well as a reduction in the symptoms of FM exacerbated by increased stress, a teaching plan was presented to Sandra.

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