Family functioning is those behaviors or activities by family members that maintain the family & meet family needs, individual member needs, and society’s views of family.

Family health is concerned with how well the family functions together as a unit. It involves not only the health of the members and how they relate to other members, but also how well they ,relate to and cope with the community outside the family. In fact family health, like individual health, ranges along a continuum

from wellness to illness.

Family functioning is those behaviors or activities by family members that maintain the family & meet family needs, individual member needs, and society’s views of family.

Family health is concerned with how well the family functions together as a unit. It involves not only the health of the members and how they relate to other members, but also how well they relate to and cope with the community outside the family. In fact, family health, like individual health, ranges along a continuum from wellness to illness.

Universal Characteristics of FamiliesUniversal Characteristics of Families Universal Characteristics of FamiliesUniversal Characteristics of Families

Five of the most important family universals for community health nursing are

1. Every family is a small social system.

2. Every family has its own cultural values & rules.

3. Every family has structure.

4. Every family has certain basic functions.

5. Every family moves through stages in its life cycle

FAMILY CULTUREFAMILY CULTUREFAMILY CULTUREFAMILY CULTURE

• Birth, or adoption, whose central purpose is to create and maintain a common culture which promotes the physical, mental, emotional, and social development of each of its members

• is the acquired knowledge that family members use to interpret their experiences and to generate behaviors that influence family structure and function

• It arises from a significant body of literature in the social and behavioral sciences; cross-cultural comparisons and in-depth analyses demonstrate that each family has a “culture” that strongly influences its structure and function. Culture explains why families behave as they do

• Three aspects of family culture deserve special consideration:

(1) family members share certain values that affect family behavior; (2) certain roles are prescribed and defined for family members; (3) a family’s culture determines its distribution and use of power.

• Family structuresFamily structures or compositions comprise the collective characteristics of individuals who make up a family unit (age, gender, & number).

• A growing body of research on family structure & function shows that families have changed dramatically since the nuclear family was the dominant form. Family structures fall into two general categories: traditional & nontraditional

Implications for the CHNImplications for the CHNImplications for the CHNImplications for the CHN

First, CHN can no longer hold to a myth that idealizes the traditional nuclear family. They must be prepared to work with all types of families and accept them as valid.

Second, the structure of an individual’s family may change several times over a lifetime. A girl may be born into a kin-network, shift to a nuclear family when her parents move, and become part of a single-parent family when her parents are divorced.

Finally, each type of family structure creates different issues and problems that, in turn, influence a family’s ability to perform basic functions. Each particular structure determines the kind of support needed from nursing or other human service systems

FAMILY FUNCTIONSFAMILY FUNCTIONSFAMILY FUNCTIONSFAMILY FUNCTIONS

Six functions are essential for maintenance and promotion of family health:

(1) providing affection, (2) providing security, (3) instilling identity, (4) promoting affiliation,(5) providing socialization, (6) establishing controls

FAMILY LIFE CYCLEFAMILY LIFE CYCLEFAMILY LIFE CYCLEFAMILY LIFE CYCLE

• There are two broad stages in the family life cycle: one of expansion as new members are added and roles and relationships are increased, & one of contraction as family members leave to start lives of their own or age &die.

Stage 1: Married couplesMarried couples (without children)Stage 2: Childbearing familiesChildbearing families (oldest child, birth-30months)

Stage 3: Families with pre-school childrenFamilies with pre-school children (oldest child, 2 1/2-6years)

Stage 4: Families with schoolchildrenFamilies with schoolchildren (oldest child, 6-13 years)

Stage 5: Families with teenagersFamilies with teenagers (oldest child, 13-20 years)

Stage 6: Families as launching centersFamilies as launching centers (first child gone to last child leaving home)

Stage 7: Middle-age parentsMiddle-age parents (“empty nest” to retirement)

Stage 8: Aging family membersAging family members (retirement to death of both spouses

Characteristics of Healthy FamilyCharacteristics of Healthy FamilyCharacteristics of Healthy FamilyCharacteristics of Healthy Family

1. A facilitative process of interaction exists among family members.

2. Individual member development is enhanced.

3. Role relationships are structured effectively.

4. Active attempts are made to cope with problems.

5. There is a healthy home environment and lifestyle

6. Regular links with the broader community are established

7. Legitimate source of authority that is supported and consistent over time,

8. Stable and consistent system of rules,

9. Consistent and regular nurturing behaviors,

10. Effective child-rearing practices,

11. Stable and well-maintained marriages,

12. Set of agreed-upon goals toward which the family and individuals work,

13. Sufficient flexibility to change in the face of both expected and unexpected stressors.

• An unhealthy family hasn’t recognized the value of establishing links with the broader community.

• This may be because of (1) a knowledge deficit regarding community resources, (2) previous negative experiences with community services, or (3) a lack of connection with the community because of family expectations or cultural practices.

• It is important for the community health nurse to assess the family’s relationship with the broader community, in addition to structural and developmental variations, interaction, coping strategies, and lifestyle.

• With a comprehensive family assessment, the nurse has a base from which to begin a plan of care.

Family Health Practice GuidanceFamily Health Practice Guidance

• Family nursing is a kind of nursing practice in which the family is the unit of service It isn’t merely a family-oriented approach in which family concerns that affect the health of an individual are taken into account. Family nursing asks how one provides health care to a collection of people.

Role of the Family Health NurseRole of the Family Health Nurse

• The Family Health Nurse will help individuals and families to cope with illness and chronic disability, or during times of stress, by spending a large part of their time working in patients homes and with their families.

• Such nurses give advice on lifestyle and behavioural risk factors, as well as assisting families with matters concerning health. Through prompt detection, they can ensure that the health problems of families are treated at an early stage.

• With their knowledge of public health and social issues and other social agencies, they can identify the effects of socioeconomic factors on a family's health and refer them to the appropriate agency.

Role of the Family Health NurseRole of the Family Health Nurse

• They can facilitate the early discharge of people from hospital by providing nursing care at home, and they can act as the lynchpin between the family and the family health physician, substituting for the physician when the identified needs are more relevant to nursing expertise.

• The four major types of intervention by Family Health Nurses ñ primary, secondary and tertiary prevention, and crisis intervention/direct care. At the level of primary prevention, they assess the possible presence of harmful stressors or threats to health and work pro-actively to prevent these from impinging on the family.

Role of the Family Health NurseRole of the Family Health Nurse

• They may help the family build up their resistance resources by providing health education and support, and by assisting them to mobilize other resources, monitoring the integrity of the system pro-actively by identifying potentially harmful stressors.

• At the level of secondary prevention, they may become actively involved in screening and vaccination programs. Because of their expert knowledge of their particular caseload of families, they will detect the onset of health problems at an early stage, prompting quick action to minimize disruption of the individual and the family and calling on other relevant expert resource personnel as necessary.

Role of the Family Health NurseRole of the Family Health Nurse • In tertiary prevention, they are involved in

rehabilitation and rebuilding the family's resistance resources.

• The fourth mode of intervention, the provision of direct care, is the traditional role of the nurse when the family's or individual's coping mechanism has been breached, for example by illness.

• Here, the Family Health Nurse works in partnership with the family or individual to achieve, as appropriate, cure, rehabilitation, palliation and/or support.

Five principles guide and Five principles guide and enhance family nursing practiceenhance family nursing practice

Five principles guide and Five principles guide and enhance family nursing practiceenhance family nursing practice

(1) work with the family collectively,

(2) start where the family is,

(3) adapt nursing intervention to the family’s stage of development,

(4) recognize the validity of family structural variations,

(5) emphasize family strengths

Emphasize Family StrengthsEmphasize Family StrengthsEmphasize Family StrengthsEmphasize Family Strengths

• CHN tend to focus their attention on family weaknesses, looking for & referring to them as needs or problems.

• This negative emphasis can be devastating to a family and can undermine any hope of a truly therapeutic relationship between nurse and client.

• Instead, families need their strengths reinforced. Emphasizing a family’s strengths makes people feel better about themselves. It fosters a positive self-image, promotes self-confidence, and often helps the family address other problems.

FAMILY HEALTH ASSESSMENTFAMILY HEALTH ASSESSMENT

To assess a family’s level of health in a systematic fashion, three tools are needed:

(1) a conceptual framework on which to base the assessment,

(2) a clearly defined set of assessment categories for data collection,

(3) a method for measuring a family’s level of functioning.

Conceptual FrameworksConceptual Frameworks

• A conceptual framework is a set of concepts integrated into a meaningful explanation that helps one interpret human behavior or situations.

• Three frameworks that are particularly useful in community health nursing are presented here: the interactional, structural- functional, and developmental frameworks.

• The interactional framework describes the family as a unit of interacting personalities and emphasizes communication, roles, conflict, coping patterns, and decision-making processes.

• This framework focuses on internal relationships but neglects the family’s interactions with the external environment

• The structural-functional framework describes the family as a social system relating to other social systems in the external environment, such as church, school, work, and the health care system.

• This framework examines the interacting functions of society and the family, considers family structure, and analyzes how a family’s structure affects its function.

• The developmental framework studies families from a life-cycle perspective by examining members’ changing roles and tasks in each progressive life-cycle stage.

• This framework incorporates elements from interactional and structural-functional approaches so that family structure, function, and interaction are viewed in the context of the environment at each stage of family development.

Data Collection CategoriesData Collection Categories

(1) family strengths and self-care capabilities,(2) family stresses and problems, (3) family resources.

1.1. Family demographicsFamily demographics as a family’s composition, its SES & the ages, education, occupation, ethnicity, & religious affiliations of members.

2. Physical environmentPhysical environment data describe the geography, climate, housing, space, social and political structures, food availability and dietary patterns, and any other elements in the internal or external physical environment that influence a family’s health status.

3. Psychological and spiritual environmentPsychological and spiritual environment refers to affectional relationships, mutual respect, support, promotion of members’ self-esteem and spiritual development, and life satisfaction and goals.

4. Family structure and rolesFamily structure and roles include family organization, socialization processes, division of labor, and allocation and use of authority and power.

5. Family functionsFamily functions refer to a family’s ability to carry out appropriate developmental tasks & provide for members’ needs

6. Family values and beliefsFamily values and beliefs might deal with raising children, education, work, religion, making & spending money, health, & community involvement.

7. Family communication patternsFamily communication patterns include the frequency and quality of communication within a family and between the family and its environment.

8. Family decision-making patterns; Family decision-making patterns; how decisions are made in a family, by whom they are made, & how they are implemented.

9. Family problem-solving patternsFamily problem-solving patterns describe how a family handles problems, who deals with them, the flexibility of a family’s approach to problem-solving, and the nature of solutions.

10. Family coping patternsFamily coping patterns encompass how a family handles conflict & life changes, the nature & quality of family support systems, & family perceptions & responses to stressors.

11. Family health behaviorFamily health behavior refers to familial health history, current physical health status of family members, family use of health resources, and family health beliefs.

12. Family social & cultural patternsFamily social & cultural patterns comprise family discipline and limit-setting practices; promotion of initiative, creativity, and leadership; family goal setting; family culture; cultural adaptations to present circumstances; and development of meaningful relationships within and outside the family.

The genogramThe genogram• The genogram displays family information graphically in a way

that provides a quick view of complex family patterns.

• It is a rich source of hypotheses about a family over a significant period of time, usually three or more generations. Family relationships are delineated by genealogic methods, and significant life events are included (e.g., birth, death, marriage, divorce, illness).

• Identifying characteristics (e.g., race, religion, social class), occupations, & places of family residence are also noted. Again, this tool is used jointly with the family.

• It encourages family expression and sheds light on family behavior & problems

HEALTH ASSESSMENTHEALTH ASSESSMENT

An assessment of family health will be most accurate if it incorporates the following five guidelines:

1. Focus on the family as a total unit.2. Ask goal-directed questions.3. Collect data over time.4. Combine quantitative and qualitative data.5. Exercise professional judgment.

Nursing Process Components Nursing Process Components Applied to Families as ClientsApplied to Families as Clients

• Assessing, planning, implementing, and evaluating nursing care are steps used to deliver care to clients in acute care settings and in the extensive clinic system. These same steps are used with families & aggregates in CHN.

• The steps do not change, but because the context and client focus are different, external variables that have not been encountered in other contexts must now be considered.

Assessment of Home Environmental Assessment of Home Environmental ConditionsConditions

• Conditions in the neighborhood and home environments reveal important assessment information that can guide planning and intervention with families. While traveling to and arriving at the family home, you have been gathering information about resources and barriers encountered by the family.

• This information is used during planning with the family.

• It is important to remember that neighborhood conditions and even the physical appearance of the apartment or house may belie the family’s values, resources, and goals. They have little control over the neighborhood or, frequently, the building they live in, especially if they are renting.

Planning to Meet the Health Needs of Planning to Meet the Health Needs of Families During Home VisitsFamilies During Home Visits

• The greatest barrier to a successful family health visit is a lack of planning and preparation. A visit is not successful just because the nurse enters a home or other setting where clients are present.

• A successful family health visit takes much planning and preparation & requires accurate documentation and follow-up.

• In addition, safety measures must be followed, not only while traveling in the neighborhood, but also in the home.

Implementing Plans Implementing Plans for Promoting the for Promoting the Health of FamiliesHealth of Families

Assessing, Teaching,& ReferringAssessing, Teaching,& Referring

• Assessing family health may be done informally through observation and occasional questioning, or it can take a more formal approach.

• Specific questions may be asked of each family member, and such information as health data and family history may be included. Physical data such as height, weight, pulses, temperature, and blood pressure are recorded on an assessment tool.

• With young children, specific assessment questionnaires or tests may be conducted to measure how well they are meeting growth and developmental tasks. One familiar test that has been used for decades is the Denver Developmental Screening Test (DDST).

• The results of this gross assessment screening test provide the nurse with information about the child’s growth and developmental progress and can be used to teach families anticipatory guidance, as well as how to provide growth-enhancing experiences

Important characteristics of Healthy families

1. A facilitative process of interaction exists among family members.

2. Individual member development is enhanced.

3. Role relationships are structured effectively.

4. Active attempts are made to cope with problems.

5. There is a healthy home environment and lifestyle.

6. Regular links with the broader community are established

Empowering FamiliesEmpowering FamiliesEmpowering FamiliesEmpowering Families

• The ultimate goal is to assist the family in becoming independent of your services. This is accomplished by the approach used in conducting the visit. How you structure the nurse–client relationship also influences the outcomes. Four thoughts will help to clarify your working relationship with families:

1. The family functioned in a manner that worked for them before you ever met them.

2. If you ever feel obliged to do something for a family, consider who did this before you were available.

3. Find family strengths even in the most deprived family situation.

4. If you were in a similar situation, would you manage, cope, or function as well as the members of this family?

Evaluating Implemented Evaluating Implemented Family Health PlansFamily Health Plans

Evaluating Implemented Evaluating Implemented Family Health PlansFamily Health Plans

• The evaluation process leads to a reassessment of your work with the family & a determination of what is needed in preparation for the next visit. This reassessment helps you in further individualizing services to the family.

• Evaluation of the structure- process of the visit and your self-evaluation can be done informally in a reflective manner. Outcomes are documented in the client record, and the evaluation becomes formalized.

• A thorough evaluation also assists you in making the most appropriate referrals and contacting key resources to meet family needs.

Families in CrisisFamilies in CrisisFamilies in CrisisFamilies in Crisis• Facing Violence from Within and Outside

the Family

• Family crisis is a stressful and disruptive event (or series of events) that comes with or without warning and disturbs the equilibrium of the family. A family crisis can also result when usual problem-solving methods fail.

Developmental CrisesDevelopmental CrisesDevelopmental CrisesDevelopmental Crises

• When developmental crises occur, people feel threatened by the demands placed on them and have difficulty making the changes necessary to fit the new stage of development.

• During the process of normal bio-psychosocial growth, people go through a succession of life cycle stages, from birth through old age.

• Each stage is quite different from the previous one, and transitions from one stage to the next require changes in roles and behavior. There are periods of upset and disequilibrium.

• Developmental crises arise from both physical and social changes. Each new life stage confronts people with changed relationships, responsibilities, and roles.

• The transition to parenthood, for example, demands a change in role from caring for oneself and one’s mate to include nurturing, caring for, and protecting a completely helpless infant. Relationships with adults, children, and even one’s own parents also change.

Situational CrisesSituational CrisesSituational CrisesSituational Crises• Is a stressful, disruptive, event arising from external circumstances that occurs

suddenly, often without warning, to a person, group, aggregate, or community.

• Typically, the external event requires behavioral changes & coping mechanisms beyond the abilities of the people involved. Such events are not predicted, expected, or planned.

• CHN see an almost infinite variety of situational crises, including debilitating disease, economic misfortune, unemployment, physical abuse, divorce, unwanted pregnancy, sudden death of a loved one.

• In each situation, people feel overwhelmed and need help to cope. Skilled intervention can make the difference between a healthy and an unhealthy outcome.

Family Violence Againest Children

• As a cause of morbidity among children, communicable diseases “are coming under control through a combination of health promotion, prevention and simplified standard treatment regimens.

• But at the same time, the healthy G&D of many children is threatened by very rapid, often disruptive social, cultural and economic changes”

Major Differences between developmental Major Differences between developmental crisis and situational crisiscrisis and situational crisis

Developmental CrisisSituational Crisis

Part of normal growth and development that can upset normalcy

Unexpected period of upset in normalcy

Precipitated by a life transition point

Precipitated by a hazardous event

Gradual onsetSudden onset

Response to developmental demands and society’s expectations

Externally imposed “accident

Child abuseChild abuseChild abuseChild abuse

• Is the maltreatment of children. It may include any of the following: physical, emotional, medical, or educational neglect; physical punishment or battering; and emotional or sexual maltreatment and exploitation. Types can occur alone or in combination

MythMythTruthTruth

Violence in families is rareFamily violence is common and increasing

Violence occurs most frequently among low-income families

Family violence occurs across all incomes

Violence occurs more frequently in some racial and cultural groups

Family violence occurs across all racial & cultural groups

Violence in families does not coexist with love

Love may exist but is unable to be displayed appropriately due to conflicting emotions

Men who batter women are mentally ill

The percentage of batterers who are mentally ill is the same as in the general population

Women who accept battering are mentally ill

The percentage of battered women who are mentally ill is the same as in the general population; however, they have low-esteem and a damaged spirit

Violence occurs only in heterosexual relationships

Domestic violence has no gender or sexual boundaries; it can occur among all people

Abused women instigate the battering

Quite the contrary, they go out of their way not to agitate or confront the abuser

Children should not be taken from their parents

In some violent families, the safest place for the child is with another family member or a foster home (temporarily or permanently)

Even abusive parents are better for a child than a child living elsewhere

Children must be protected, and living away from abusive parents may save their lives

Abused children become abusive adults

Some may, but most can learn how to channel their emotions positively if the cycle of violence is broken

Child NeglectChild NeglectChild NeglectChild Neglect• Neglect occurs when the physical, emotional, or

educational resources necessary for healthy growth and development are withheld or unavailable. Neglect is obvious to an observer if a very young child is playing unattended outside, is not dressed appropriately for the weather, or has an unkempt appearance.

• However, neglect is not always so obvious. Parents may refuse to buy eyeglasses for a child who needs them (medical neglect).

Physical AbusePhysical AbusePhysical AbusePhysical Abuse

• Physical abuse is intentional harm to a child by another person that results in pain, physical injury, or death. The abuse may include striking, biting, poking, burning, shaking, or throwing the child.

• Corporal punishment, which involves violence against a child as a form of discipline, was an acceptable form of discipline earlier in our country’s history and is still condoned in some subgroups.

Signs & Symptoms of NeglectSigns & Symptoms of Neglect

• Neglect may be suspected if one or more of the following conditions exist:

The child lacks adequate medical or dental care.

The child is often sleepy or hungry.The child is often dirty, demonstrates poor

personal hygiene, or is inadequately dressed for weather conditions.

There is evidence of poor or inadequate supervision for the child’s age.

The conditions in the home are unsafe or unsanitary.

The child appears to be malnourished.The child is depressed, withdrawn, or

apathetic; exhibits antisocial or destructive behavior; shows fearfulness; or suffers from substance abuse or speech, eating, or habit disorders (e.g., biting, rocking).

Sexual AbuseSexual Abuse

• Sexual abuse of children includes acts of sexual assault or sexual exploitation of a minor and may consist of a single incident or many acts over a long period.

• Emotional abuse of children involves psychological mistreatment or neglect, such as when parents do not provide the normal experiences that produce feelings of being loved, wanted, secure, and worthy

S & S of Emotional abuseS & S of Emotional abuse

• Emotional abuse should be suspected if the child displays the following behavioral indicators:

Is withdrawn, depressed or apathetic.Is clingy and forms indiscriminate attachments.“Acts out” & is considered a behavior problem.Exhibits exaggerated fearfulness.

Is overly rigid in conforming to instructions of teachers, doctors, and other adults.

Suffers from sleep, speech, or eating disorders.Displays signs of emotional turmoil that include

repetitive, rhythmic movements (rocking, whining, picking at scabs).

Pays inordinate attention to details or exhibits little or no verbal or physical communication with others.

Suffers from enuresis and fecal soiling.

Munchausen Syndrome by ProxyMunchausen Syndrome by Proxy

• Munchausen syndromeMunchausen syndrome is a psychological disorder in which a client fabricates the symptoms of a disease in order to undergo medical tests, hospitalization, or even medical or surgical treatment. Clients with this disorder may intentionally injure themselves or induce illness in themselves.

• Munchausen syndrome by proxyMunchausen syndrome by proxy, a parent or caretaker suffering from Munchausen syndrome attempts to bring medical attention to himself or herself by injuring or inducing illness in his or her children.

Levels of PreventionLevels of Prevention

Crisis Intervention & Family Violence

• Family violence is a family crisis and needs interruption. Community health nurses are in a unique position to prevent, detect, and intervene during crisis situations.

Primary PreventionPrimary Prevention

• Planned activities, undertaken by the nurse, to prevent an unwanted event from occurring, to protect current states of health and healthy functioning

• Promote desired states of health for the members of a particular community. For the CHN, any activity that fosters healthful practices, counteracts unhealthful influences

• Increases empowerment can help prevent a crisis. Health promotion should take into account physical, psychological, socio-cultural, and spiritual needs.

• First, social problem-solving skills for both partners and assertiveness skills for women provide a foundation on which additional programs can build. Many people have not learned positive problem-solving skills that are socially acceptable.

• Women have learned passivity and submissiveness, perhaps in response to their own inadequate parenting or abusive upbringing. Men and women can benefit from these two types of skill development.

• Second, people need to have the self-esteem that improved education and occupational success can bring.

• If poverty is a related factor to the violence, educational preparation and a successful employee role may eliminate this stressor.

• As stated earlier, violence occurs across all socioeconomic levels of society; however, if a family is so impoverished that their basic needs cannot be met, stress can lead the more vulnerable family members to seek out illegal ways to solve their financial problems. This happens especially in neighborhoods in which criminal activity is easily accessed.

Secondary PreventionSecondary Prevention

• Early diagnosis and prompt treatment of the effects of family crisis or violence is the focus of the secondary level of prevention. It seeks to reduce the intensity and duration of a crisis and to promote adaptive behavior.

• By creating a positive relationship with family members and seeing them in their homes, the community health nurse can often uncover and intervene in a crisis or stop abusive situations.

1. Establish rapport2. Assess the individual & the problem for

lethality3. Identify major problems and intervene4. Deal with feelings5. Explore alternatives and coping mechanisms6. Develop action plan7. Follow up, including anticipatory planning for

coping with future crises

Tertiary PreventionTertiary Prevention

• Tertiary prevention of family violence focuses on the rehabilitation of the family. The family may never again be the same unit of service, because the partners may separate by choice, motivated by fear or hate;

• If the family chooses to stay together, long-term intervention for all family members is needed to establish a climate conducive to family normalcy.

• Many of the services discussed as part of the secondary level of prevention are continued into tertiary prevention to heal, restore, and promote the growth of the family.

Family assessmentFamily assessment

• It’s assessment of patterns of interaction among all individual within the family. So the focus on the family as one unit is usually done by interviewing all the family members together.

Indication of assessmentIndication of assessment:(1). Emotional disruption caused by crisis. (2). Emotional disruption caused by developmental problem. (3). Families perception of the problem.(4). Presence of a child or adolescent and elderly as a patient in the family. Contraindication of assessment:Contraindication of assessment:• If only one individuals is always available in the family. • If one individual shows extreme psychic pathology. • If the family perceives the C>H>N be a member of other organization e.g.

(court agent).

• Emotional CommunicationEmotional Communication • Range & types of emotions or feelings expressed • Generally a wide range from happiness, to sadness to anger • Families with emotional difficulties often have a narrow range of expression

• Verbal CommunicationVerbal Communication • Direct vs. Indirect: •     Direct message sent to intended target• Clear vs. masked • “Say what you mean & mean what you say” to the intended recipient leads to

clear & direct communication •     Masked communication give distorted messages • Nonverbal CommunicationNonverbal Communication • Highly influenced by culture • Body posture (e.g. slumped, fidgeting) • Eye contact (e.g. intense, minimal) • Touch, gestures, facial expressions • Proximity & distance between family members • Para-verbal communication – crying, tone

• Circular CommunicationCircular Communication  • Reciprocal communication between people • Three components: • Affect (emotional state) • Behavior • Cognition (thoughts, ideas or beliefs)

• Problem SolvingProblem Solving • Strongly influenced by family’s beliefs about its

abilities and past successes • Who identifies the problem? • What are the families solution patterns? • What resources are relied upon for help – inside the

family or external?

• Roles Roles • Established patterns of behavior for family members • How do family members cope with their roles? • Formal vs. informal roles • Is there role conflict or role strain? • Does family believe that roles need to be altered?

• BeliefsBeliefs  • Attitudes, values and assumptions • Beliefs influence behavior. • Explore beliefs about: etiology of the health problem,

treatment, prognosis, religion & spirituality

• Influence and PowerInfluence and Power  • Power may present as overt acts of domination • Note power differences among family members • Instrumental influence:  use of objects or privileges as rein

forcers (e.g. money, TV. viewing, use of computer, etc.) • Psychological influence: use of words or feelings (e.g. praise;

criticism; threats; guilt) • Corporal control: use of body contact (e.g. hugging; spanking,

etc) • Alliances & CoalitionsAlliances & Coalitions • Directionality, balance & intensity of relationships between

family members • Note any triangles & shifting alliances