Week 2B: Discussion on Texts and Articles Response
Post a reflective response to the prompts on the readings from Wright &Leaheych 2 & 3, with particular attention to pp. 77-87 where the Family Health Genogram is discussed.
Examine the Calgary assessment model. What do the readings say about how to assess families? Consider the concepts discussed in the readings, and identify key elements that enhance interviews in order to develop more effective interventions.
To create your own family genogram or to make one for your Case Study Family, feel free to use the powerpoint slides shapes or use internet resources such as http://www.ehow.com/how_6953335_make-genogram-family.html
Complete your initial response by the middle of the week. Be sure to return by the end of the week and engage thoughtful responses with at least two peers.
Readings taken from textbook
The Calgary Family Assessment Model (CFAM) is an integrated, multidimensional framework based on the foundations of systems, cybernetics, communication, and change theory and influenced by postmodernism and the biology of cognition. This text includes a discussion of the distinction between using the CFAM to assess a family and using the CFAM as an organizing framework, or template, for working with families to help them resolve health-related problems or other issues.
The CFAM has received wide recognition since the first edition of this book in 1984. It has been adopted by many faculties, schools of nursing, and other health science disciplines. It has been referenced frequently in the literature, especially the Journal of Family Nursing. In addition, the International Council of Nurses has recognized it as one of the four leading family assessment models in the world (Schober &Affara, 2001). Originally adapted from a family assessment framework developed by Tomm and Sanders (1983), the CFAM was substantially revised in 1994, 2000, and 2005.
The CFAM consists of three major categories:
Structural
Developmental
Functional
Each category contains several subcategories. It is important for each nurse to decide which subcategories are relevant and appropriate to explore and assess with each family at each point in time. That is, not all subcategories need to be assessed at the first meeting with a family, and some subcategories need never be assessed. If too many subcategories are used, the nurse may become overwhelmed by all the data. If the nurse and the family discuss too few subcategories, each may have a distorted view of the family’s strengths or problems and the family situation.
It is useful to conceptualize these three assessment categories and their many subcategories as a branching diagram (Figure 3-1). As the nurse uses the subcategories on the right of the branching diagram, the nurse collects more and more microscopic data. It is important for nurses to be able to move back and forth on the diagram in order to draw together all of the relevant information into an integrated assessment. This process of synthesizing data helps nurses working with complex family situations.
It is also important for a nurse to recognize that a family assessment is based on the nurse’s personal and professional life experiences, beliefs, and relationships with those being interviewed. It is useful for nurses to determine whether they are using CFAM as a model to assess a family or as an organizing framework for clinical work with a specific family to help the family address a health issue. When learning the CFAM, students and practicing nurses new to family work will likely find the model helpful for directly assessing families. Similarly, researchers seeking to assess families will find the model useful. This use of the model involves asking the family questions about themselves for the express purpose of gaining a snapshot of the family’s structure, development, and functioning at a particular point in time.
However, how we have used the CFAM is not in a research manner but rather in a clinical manner. Once nurses become experienced with the categories and subcategories of the CFAM, they can use the CFAM as a clinical organizing framework to help families solve problems or issues.
For example, a single-parent family in the developmental stage of families with adolescents will have many positive experiences from earlier developmental stages to draw from in coping with the teenager’s unexpected illness. The nurse, being reminded of family developmental stages by using the CFAM, will draw forth those resiliencies. The nurse will ask questions and collaboratively develop interventions with the family to enhance their functioning during this health-care episode.
Families do not generally present to health-care professionals to be “assessed.” Rather, they present themselves or are encountered by nurses while coping with an illness or seeking assistance to improve their quality of life. The CFAM helps guide nurses in helping families.
In this chapter, each assessment category is discussed separately. Terms are defined, and sample questions relevant to each CFAM category are proposed for the nurse to ask family members. We do not suggest that nurses ask these questions in a disembodied way. Rather, real-life clinical examples are provided in Chapters 4, 7, 8, 9, and 10 to further describe how to use the sample questions and apply the CFAM. The use of assessment and interventive questions will be discussed in Chapter 4 (The Calgary Family Intervention Model [CFIM]). We wish to emphasize that not all questions about various subcategories of the model need to be asked in the first interview, and questions about each subcategory are not appropriate for every family. Families are obviously composed of individuals, but the focus of a family assessment is less on the individual and more on the interaction among all of the individuals within the family.
Internal Structure
Internal structure includes six subcategories:
Family composition
Gender
Sexual orientation
Rank order
Subsystems
Boundaries
Family Composition
The subcategory family composition has many meanings because of the many definitions given to family. Wright and Bell (2009) define family as “a group of individuals who are bound by strong emotional ties, a sense of belonging, and a passion for being involved in one another’s lives” (p. 46).
There are five critical attributes to the concept of family:
The family is a system or unit.
Its members may or may not be related and may or may not live together.
The unit may or may not contain children.
There are commitment and attachment among unit members that include future obligation.
The unit caregiving functions consist of protection, nourishment, and socialization of its members.
Using these ideas, the nurse can include the various family forms that are prevalent in society today, such as the biological family of procreation, the nuclear family (family of origin), the sole-parent family, the stepfamily, the communal family, and the lesbian, gay, bisexual, queer, intersex, transgender, or twin-spirited (LGBQITT) couple or family. Designating a group of people with a term such as “couple,” “nuclear family,” or “single-parent family” specifies attributes of membership, but these distinctions of grouping are not more or less “families” by reason of labeling. Rather, attributes of affection, strong emotional ties, a sense of belonging, and durability of membership determine family composition.
Nurses need to find a definition of family that moves beyond the traditional boundaries that limit membership using the criteria of blood, adoption, and marriage. We have found the following definition of family to be most useful in our clinical work: the family is who they say they are (Wright &Leahey, 2013). With this definition, nurses can honor individual family members’ ideas about which relationships are significant to them and their experiences of health and illness.
Although we recognize the dominant North American type of separately housed nuclear families, our definition allows us to address the emotional past, present, and anticipated future relationships within the family system. It is important to note that our definition of family is based on the family’s conception of family rather than who lives in the household. Family configurations continue to evolve in society, for example, LGBQITT families, adoptive and foster families, stepfamilies, multigenerational families, and sole-parent families.
Changes in family composition are important to note. These changes could be permanent, such as the loss of a family member or the addition of a new person into the family home, such as a new baby, a nanny, a boarder, or an elderly parent who can no longer live independently. Changes in family composition can also be transient. For example, stepfamilies commonly have different family compositions on weekends or during vacation periods when children from previous relationships cohabit. Families with a child in placement or those experiencing homelessness often temporarily live with other relatives and then move on.
Losses tend to be more severe depending on how recently they have occurred, the younger some of the family members are when the loss occurs, the smaller the family, the greater the numerical imbalance between male and female members of the family resulting from the loss, the greater the number of losses, and the greater the number of prior losses. The circumstances surrounding the loss may be of exquisite concern for the nurse. For example, some parents of severely mentally ill children have reported that they were encouraged to give up custody of their children to foster care as a way of securing intense health-care treatment for them.
Serious illness or death of a family member, violence or war, and natural disasters can lead to profound disruption in the family and have long-term impacts. These situations often result in aunts and uncles raising nieces and nephews, or grandparents raising grandchildren, or friends or faith-based communities raising children and are often overlooked in regard to family structural arrangement. The extent of the impact of a member’s death on the family depends on the social and cultural meaning of death, the history of previous losses, the timing of the death in the life cycle, and the nature of the death (Becvar, 2001, 2003).
Every family touched by tragedy faces the task of making sense of what happened, why it happened, and how to adjust to the changed landscape. Families can find inspiration from many sources to cope with unprecedented tragedy.
The position and function of the person who died in the family system and the openness of the family system must also be considered. We have found it useful to note the family’s losses and deaths during the structural assessment process, but not necessarily to make an immediate assumption that these losses are of major significance to the family. By taking this stance, we disagree with the position taken by some clinicians who assert that it is important to track patterns of adaptation to loss as a routine part of family assessment even when it is not initially presented as relevant to the chief complaints.
Genogram
After inquiring about the nuclear family, the nurse can continue to inquire about the extended family. It is generally not very important to go into great detail about these relatives, but clinical judgment should prevail. If, for example, the grandparents are involved in a child’s colostomy care, then a three-generational genogram should be constructed. On the other hand, if a child has a sprained wrist or something relatively minor, then a two-generational genogram is sufficient. After asking questions about the husband’s parents and siblings, the nurse should then inquire about the wife’s family of origin. It is important for the nurse to gain an overview of the family structure without getting sidetracked or inundated by a large volume of information. Box 3-1 contains helpful hints for constructing genograms.