Family Health Assessment The Green Family

Family Health Assessment: The Green Family Every family is unique. Each family has their structure, way of functioning, caring for its members, and cultural beliefs which influence the way they live. It is the responsibility of the community health nurse to approach each family individually and to understand how the family as a whole affects the health of its members. The purpose of this paper aims to demonstrate the role of a community health nurse serving a family as the client. This is accomplished by analyzing the qualitative data obtained through the interview process and applying the nursing process while using the Chronic Illness Framework. Presentation of the Family The family chosen for the interview was the Green family. The Green family consists of four members, the mother, father, son, and daughter. The mother, Nicole, is 38 years old. Nicole grew up in New York where she graduated from high school and culinary school. Nicole’s husband Scott, and father of Christopher and Saddie, is 31 years old. Scott also grew up in New York where he graduated from high school and went on to play lacrosse in college but did not receive a college degree. Nicole and Scott have been married since 2013 and moved to Georgia a year later. Their son, Christopher, is seven years old and is currently in kindergarten at the local elementary school. Nicole and Scott also have a daughter, Saddie, who is four years old and attends the local preschool at least three days a week. All members were present for the entire duration of the family interview. The Green family is an appropriate representation of how the structure and roles of family members have changed. Nicole is currently a waitress and building her own bakery business, making her the primary breadwinner for the family. Scott is the homemaker. Although he has worked in the past, Scott consistently finds himself in and out of work. His primary focus is currently on taking care of the kids and making sure the home runs smoothly. Interview The first step of applying the nursing process to the Green family began before stepping into their home. According to Rector (2017, p. 651), “The greatest barrier to a successful family health visit is lack of planning and preparation.” To initiate the planning phase a clear purpose and goal of the family interview was established. The goal of the interview was to build a baseline and learn about every aspect of the family to identify their specific needs and later formulate a nursing diagnosis and goals. The developmental conceptual framework was then utilized to help frame the interview questions which would be asked, to focus on both the internal relationships of the family and the family’s relationships to the external environment. A call was then made to the Green family. The phone call consisted of explaining the reason for the visit, what the family could expect during the home visit and interview, and finding the best time for the family when all members would be home. The Green family interview was conducted on February 15th at 3 p.m. at the family home. This time was chosen because all family members were home, and the interview would not interfere with any of the family’s daily routines. On the drive to the Green’s home notes were made about the community in passing and the environmental conditions. The Green family home is a split-level single-family home located off the main road on a small side street with about ten other houses. The community appeared to be a low socioeconomic area with most houses appearing run down and not well maintained. Upon arrival to the Green’s home, it was apparent Nicole and Scott had put in a lot of work to make their home look presentable and well-kept compared to the others. The interview began with greeting the Green family at the front door of their home. The first few minutes of the interview process were spent thanking the family for opening their home, becoming acquainted with the environment, and establishing trust and rapport to set the foundation for the following interview process. Based on the observations made, the family was initially asked how they feel about their community and if they feel their family is involved in the town. Nicole explained she knows the street their house is on may not appear as safe and inviting as living in a residential suburban neighborhood, but this house is all she could afford while Scott was in rehab for alcoholism, and she does love working on the house as a project to fix it up. Scott and Nicole both identified the apparent hazards within their community. For example, Scott stated, “By living on a side street instead of in a neighborhood, the busy traffic is a concern for the kids’ safety. Especially when cars speed down our street.” Scott and Nicole both described their involvement in the community as what they feel to be standard. They listed attending the community farmers market, going to the public library, riding their bikes on the Silver Comet Trail, and attending the holiday events put on by the town. Christopher and Saddie added their favorite activity is going to the public park just down the street. After establishing further rapport with the Green family and complimenting Nicole on the updates she has done to their home to keep it maintained and safe for the kids, the interview moved onto questions regarding the family's health and how well they feel the family functions. Initially, the family was asked about any current or past medical problems which affect the family members. Two substantial medical problems were mentioned. First, Scott explained his struggle with alcohol abuse and his history with rehab. Nicole then added her son, Christopher, has recently been diagnosed with autism spectrum disorder (AUD). When asked about family healthcare Nicole stated her work as a waitress provides minimal insurance coverage for her and the kids but does not cover Scott. The family was also asked to mention any health promotion habits they currently practice. Scott explained he tries to keep the kids as active as possible during the day, whether it be through their sports or just playing in the backyard after school. Nicole added she ensures the kids always receive their daily servings of protein, fruits, and vegetables and teaches the kids about healthy food choices. Nicole stated the kids attend their yearly health check-ups and are up to date on their vaccines. The following part of the family interview was focused on the family's psychological functioning. This appeared to be an area of concern. The family was first asked to identify what they felt are the strengths and weaknesses of their family. Nicole and Scott both identified their primary strength as placing Christopher and Saddie’s needs first before their own. Scott then mentioned he feels the family is good at spending quality time together. For example, Scott puts on movie nights with the kids. The primary weakness identified by both Nicole and Scott was their lack of agreement on roles and responsibilities within the family. Scott stated most arguments begin as a result of not receiving enough support in taking care of the kids and maintaining the home, while Nicole believes she should not have to help when she is the only person who works to support the family. Nicole also explained since their struggles with Scott's alcoholism, she has taken the role of the primary decision-maker and their marriage has suffered. She describes a lack of trust and support between her and Scott which they have not been able to overcome. Family strengths were identified during the interview process. Examples include praising the family for placing importance on the kids’ health, proving emotional support to the children, and utilizing community resources. A genogram and ecomap were then constructed, and the family was complimented on their involvement in the community. Modified Genogram and Ecomap The two major tools used to help analyze the family structure and relationship to the external environment were the genogram and ecomap. Together, these two tools provide the community health nurse and family with a detailed visual representation of the family’s support system, types of relationships, and how the energy and resources flow between the family and external environment (Rowe-Kaakinen et al., 2014). When constructing a family ecomap, a large circle is placed in the center with a modified genogram inside. This will show the basic family structure. Around the large circle are several smaller circles depicting the external environment with which the family interacts with. Several different types of lines and arrows connect the smaller circles to the family genogram and represent the type of relationship the family has with that particular element (Rowe-Kaakinen et al., 2014). Based upon the qualitative data obtained from the family interview, a family ecomap was constructed (as seen in the Appendix) to represent the Green family. Placed inside the larger circle is a modified genogram displaying all four members of the Green family and their ages. Several smaller circles surround the Green family structure, revealing a moderate amount of involvement with the community. The ecomap depicts primarily strong relationships with external factors and only three tense relationships. The tense relationships include those between Nicole's mother, Rose, and the Green family, work and Scott, and school and Christopher. Nicole described the family's relationship with her mother as tense due to her mother's cold nature and unaffectionate personality not only toward Nicole and Scott but also towards Christopher and Saddie. Scott characterized his relationship with work as tense due to his struggle with alcoholism. He explained the relationship was not only tense before rehab, but the relationship remains tense due to being seen as an un-hirable candidate based on his job history of multiple firings. Christopher was then asked to explain his feelings towards school. Christopher stated he loves to go every day and play with his friends and has a lot of fun but doesn’t always have good days. Scott then added that since being diagnosed with autism Christopher’s teacher will give him either a smiley face or a frowny face at the end of the day based on his behavior. This method helps Christopher to understand that his actions at school have consequences at home as well. Scott stated their main struggle with Christopher at school is his outrageous amount of energy which makes him difficult to control. Additionally, the ecomap provides a depiction of the healthcare resources the Green family currently utilizes. Serving the majority of the Green family is the family medicine practice. Nicole stated she receives minimal health insurance benefits from her work as a waitress, but the policy only covers her and the kids. Therefore, she ensures the kids have their yearly checkups, but she only goes to the doctor if she is sick, and Scott does not go unless necessary. The remaining healthcare resources, therapy, and Alcoholics Anonymous are both utilized by Scott. The therapist Scott currently meets with is the same professional his mother arranged for him to see when he was younger. Scott characterized his relationship with the therapist as weak because he does not feel the therapist's methods work for him. Since leaving rehab, Scott was instructed to attend Alcoholics Anonymous (AA) meetings to aid in his continued sobriety. However, Scott explained he does not attend AA meetings regularly because he does not like the idea of sharing his story in a crowded room. Scott also mentioned he does not currently have a sponsor from AA because he has not found one with whom he can connect with. Two main support systems were identified in the creation of the ecomap: friends and Scott’s parents. The lines and arrows connecting from friends and Scott’s parents to the Green family members depict a primarily strong and bidirectional energy flow. Scott explained his relationship with friends is weak due to his past with alcohol abuse and struggling to meet new friends after moving to Georgia from New York as well as being unemployed and acting as the primary caregiver for the kids keeps him feeling isolated. Nicole identifies a strong support group of friends from work and explains although Christopher has been diagnosed with autism, he appears to be making friends without any struggles. Scott's parents are identified as the primary support system for the Green family. Although his parents live in Florida, Scott explained they are always the first to come to help the family when it is needed and is always looking for time to spend with Christopher and Saddie. The remaining outside elements are community resources utilized by the Green family, which are also characterized as strong relationships. Nicole explained the community farmers market is an event held once a week to provide resources for the community members, as well as an opportunity to set up a booth and promote her new bakery business. Christopher and Saddie described how much they love going to the community park and the public library to check out books. Christopher then mentioned how much fun he has playing on the little league community baseball team and Saddie spoke about how much she loves her new dance class and getting to go to the local preschool to make friends. Theoretical Framework The applied theoretical framework used to aid in the analysis of the Green family was The Chronic Illness Framework. This framework was chosen as the guide to analyzing the Green family in response to Scott’s current struggle with chronic alcoholism. The Chronic Illness Framework explores how three major elements of the chronic illness affect each family. The three major elements of interest include the illness type, the time phase of the illness, and the functionality of the family. These elements can then be further broken down to uncover additional details of the family member's illness and how the family is affected by each aspect. The type of illness element is categorized by the onset, whether gradual or acute, the course of the illness, whether progressive, constant, or relapsing, and the outcome of the illness, whether the illness is fatal or not. The second element, the time phase, refers to the effects of the illness on the family depending on how long the family member has been diagnosed with or managing the illness. The time phases are divided into the initial/crisis time phase, which represents when the family member is first diagnosed and accepts their illness, the mid-time phase, defined by the longest period and includes the illness management and family adjustment, and lastly the terminal phase in which the family works through the death of their family member. The final element of the Chronic Illness Framework is family functioning. This element focuses on assessing the family's strengths and vulnerabilities concerning how the family can adapt and cope with the illness (Rowe-Kaakinen et al., 2014). The Chronic Illness Framework was applied to Scott's diagnosis of alcohol use disorder. Scott has struggled with alcohol use for several years, making the onset of his illness gradual. He described always going out to party with friends in college and even meeting Nicole for the first time at a bar where she was a bartender. Scott stated it was not until moving to Georgia that he noticed a substantial increase in the amount of alcohol he was consuming and the consumption becoming an everyday occurrence. It was not until the birth of his second child, Saddie when Scott felt the push to seek help and was diagnosed with alcohol use disorder (AUD). However, since completing rehab in November of 2018, Scott admits to relapsing several times, characterizing his course of illness as relapsing/episodic and placing the Green family in the midtime phase. The outcome of Scott's chronic illness is characterized as unpredictable. This conclusion was made due to Scott's history of relapsing. Currently, Scott claims he is sober, making his chronic illness non-fetal, however, should Scott relapse again to a dangerous degree, his chronic illness has the potential to become fetal. The Green family has adjusted to Scott’s illness in several ways. The parental roles have been redefined with Scott remaining home as the primary caregiver of Christopher and Saddie and Nicole becoming the primary breadwinner. Consequently, Scott reports feeling an abundance of stress due to the number of responsibilities required to care for the kids and keep the home in order with no support. Nicole and Scott's marriage has also become strained and has led to a lack of trust. Initially, Nicole was Scott's main supporter but has become less involved each time Scott relapses and is burnt out. Sustaining autonomy was identified as another struggle for Scott. Although Scott does take care of himself and the kids, when it comes to the decision-making process for the family concerning major decisions, Nicole makes all the decisions on her own. For example, Nicole oversees the family finances completely. The Green family strengths which have helped adjust to Scott’s illness include the ability to seek help and openly talk about Scott’s illness, focusing on core family values of love and respect, and support from Scott’s parents. For example, Scott’s parents remain a primary support system by helping take care of the kids and provide Scott with access to a therapist if he ever feels the need. Nursing Diagnosis Identify Strengths and Weaknesses of the Family Through the analysis of the Green family by the Chronic Illness Framework, the strengths and weaknesses of the family were identified. The community health nurse utilizes the method of strengthening, a technique of listing the positive points about an otherwise negative situation, to empower the family and enhance the therapeutic relationship (Rector, 2017). While the Green family does have weaknesses, Nicole and Scott have established a healthy family environment for their kids. The Green family strengths include creating family values, providing affection, and meeting the family’s basic physical needs, providing security, and fostering the development of the children through completing the developmental tasks and providing normalization in response to Christopher’s diagnosis. It is essential to address the family weaknesses along with their strengths to formulate a nursing diagnosis and goals and to help foster growth within the family. The weaknesses of the Green family include inadequate communication, insufficient problem-solving skills, and decision-making power, as well as inadequate role identifications and role conflict and strain. Primary Need Based on the family interview, applying the Chronic Illness Framework, and identifying the family strengths and weaknesses, it appears the primary problem for the family is role conflict, strain, and overload. As a result of Scott's alcohol use disorder, it was essential for the roles of the family to be modified. However, by adjusting the family roles while Scott was away at rehab, the result was a lack of knowledge and consensus of role responsibilities and a lack of structure and consistency in parental roles upon Scott's return home. Role conflict and strain then occurred due to the inadequate communication on role expectations. Scott also claims he experiences role overload. He explains he feels role overload when taking on both the role of primary caregiver of the children and primary homemaker with very minimal support. Nursing Diagnosis The nursing diagnosis for the Green family is, interrupted family processes related to alcoholism as evidenced by alteration in parental roles, role conflict, and role strain, inadequate communication, changes in the participation of decision making, and decrease in emotional support. Desired Outcome The desired outcome and goals of the family are established in collaboration with the family. It is imperative the family agrees with the proposed family diagnosis and views the desired outcomes and goals as attainable. The desired outcome for the Green family is the family will develop effective communication skills which can be used to establish family roles and responsibilities resulting in consistency and clear expectations for all family members. Nursing Interventions The nursing interventions for the Green family focus on methods to aid in developing effective communication and establishing trust and support among members which will result in mutually established family roles and family structure consistency. The first nursing intervention is to help the family establish a specific time in their routine to openly discuss their feelings and emotions and educate the family members on available support groups within their community. In a study completed on the effects of parental alcohol abuse on children within the family, it was found there is an increase in the amount of anger and distress in the home and the child-parent relationship is characterized by less intimacy and emotional ties to one another (Iacopetti et al., 2021). Allowing for a time of open communication and engaging in active listening will help guarantee all family members are being heard and feel supported. This will lead to all concerns about family roles being addressed and allow for each member to clearly understand their roles and responsibilities in the family and make sure each member has the same expectations for one another. Attending support groups will provide family members with an extra outlet for releasing their feelings, as well as a place to gain knowledge from others who are in the same situation and what methods they have found to be helpful. The second nursing intervention includes aiding the family in establishing clear and consistent family routines, which will be followed daily, through shared decision-making. In a study published by McAuliffe et al. (2017), a professor of occupational therapy specializing in research of family routines and chronic illness, she states, “Effective family routines assist in organizing, sustaining, and propagating a family’s everyday life and provide stability and continuity to the household.” Creating clear family routines provides structure to the family, ensures all members know their roles, responsibilities, and what is expected of them. By creating these routines through shared decision-making, the Green family can take steps towards sharing responsibilities between the parents and begin to move towards dividing up the power. This intervention may also result in a decrease in role overload. Conclusion The purpose of this paper was to demonstrate the role of a community health nurse serving a family as the client. This was completed by assessing the Green family through the interview process and applying the Chronic Illness Framework. The analysis resulted in a nursing diagnosis of interrupted family processes related to alcoholism as evidenced by alteration in parental roles, role conflict, and role strain, inadequate communication, changes in the participation of decision making, and a decrease in emotional support. The family strengths were also identified and communicated to the family. The strengths included establishing adequate social support and family values, providing affection, and meeting the family's basic physical needs, providing security, fostering the development of the children through completing the developmental tasks and being involved in their community. Appendix A: Ecomap Alcoholics Anonymous/ Sponsor Friends Farmers Market Nicole’s Mother Therapist Bakery Work Recreational Activities Scott’s Parents Ecomap and Genogram Key Male Female School Strong Relationship Weak Relationship Tense Relationship Community Park/Library Family Medicine Office Direction of Energy