Family Centered Care Student Version PDF

Family Centered care legal/ethical variations assessment of the family maltreatment Objectives Discuss therapeutic communication and techniques when working with children and their families Discuss family functioning Differentiate discipline from punishment Discu...

Family Centered care legal/ethical variations assessment of the family maltreatment Objectives Discuss therapeutic communication and techniques when working with children and their families Discuss family functioning Differentiate discipline from punishment Discuss ethical/legal variations of pediatric nursing Discuss sources of violence and how it affects children Discuss signs and symptoms of child maltreatment Pediatric Nursing Three basic components of pediatric nursing care Provide care by: Focus on family centered care Provide atraumatic care Use evidence-based practice Family Centered care The child receives the highest quality care when healthcare providers work with the parents and family. Must respect parent's views Address concerns- may not have the answer and have to help them comprise a list of questions to ask the physician Regard parents as important participants in child’s health **Always take parents concerns seriously Family Centered care Family assessment assignment Family into which a child is born greatly influences his/her development and health Considerations: Child and parent temperament Family Structure (structure ex: nuclear; special family situations) Lifestyle choices (inactivity, ETOH/drugs) Socioeconomic status (poverty greatly increases risk of poorer child health) Nutrition Environmental exposure (air pollution, smoke, water contaminants) Access to healthcare (insurance, transportation, location, sociocultural barriers etc..) Culture Community connections/support Spirituality Family Centered care Assess parental roles/style Authoritarian- “My way or the high way” Expects obedience and discourages child questioning family rules Low support- high control Child has little to no decision making Authoritative- The child has a voice Expects child to adhere to rules Respect for child’s opinions Promotes individualization Permissive-“Laisse Faire or Passive” aka Gentle Parenting Little control over child’s behavior Inconsistent, unclear rules Little discipline Uninvolved- neglect Basic needs are not met Family Centered care Assess family use of discipline Discipline- increasing desirable behaviors and decreasing undesirable Positive reinforcement… “time- in” Extinction … “time-out,” ignoring Punishment- negative or unpleasant experience Verbal- scolding, disapproving statements Nonverbal- spanking Recommendations Clear, consistent expectations Avoid spanking Role model desired behavior “more is caught then taught” GIVE ATTENTION and praise desired behavior Provide consequence of (positive or negative) behavior immediately Pediatric nursing Legal/Ethical considerations Generally consent gained from individuals over the age of majority (>18) Informed consent Legal age and competent Voluntary Fully understood Emancipated minor may consent self In armed service Married Court appointed Financially independent and lives without parents' support College attendance Pregnancy Mother younger than 18 Runaway Pediatric nursing Legal/Ethical considerations Mature minor doctrine Very fuzzy area Healthcare provider determines Mature minor can receive confidential/consent to services related to: Pregnancy Prenatal care Contraceptives STI treatment Substance abuse Mental illness Pediatric nursing Legal/Ethical considerations Assent/dissent Child’s participation in decision making related to research and treatment Child’s opinion should be listened to and used in plan of care Again fuzzy area…age depends on child’s maturity, developmental level Approximately 7 years and older Family Centered care- Maltreatment Assess for violence in and around home Suicide- take all threats seriously Violence in community- gangs School violence (frequent absence; headaches, stomach aches) Violence in home (how does the child react when their parents are in the room) Children questions: “Do you feel afraid in your home?” “What happens to you when you get in trouble?” Parent “Do you feel afraid in your home?” “How do you discipline your children?” Family Centered care- Maltreatment Maltreatment may be: (83% of maltreatment is by parent alone or with someone) Physical Sexual (ANY sexual behavior toward a minor) Emotional Neglect Physical and emotional Most common type of abuse Family Centered care- Maltreatment Warning signs of maltreatment: Physical evidence *History incompatible with injury* Vague explanations Multiple fractures in different stages of healing and/or other injuries Delay in seeking care Caregiver reports Family Centered care- Maltreatment Parental characteristics: Young, single, isolated parents Low income and lack of education Low self esteem Substance abuse History of being abused Characteristics of child: Infants, especially premature or requiring special care Unwanted children Hyperactive children Environmental characteristics: Chronic stress Divorce, low support, addiction, poverty, inadequate housing/food Family Centered care- Maltreatment Some assessment findings: Physical neglect FTT; lack of hygiene; frequent injuries; dull affect; self stimulating Physical abuse Bruises, welts, fractures in different stages of healing; aggression, lack of emotion Emotional neglect/abuse FTT, enuresis (bed wetting), sleep disturbances, self-stimulating, delayed development Sexual Lacerations around mouth, genital area, anus STI; UTI Regressive behaviors; Personality changes Family Centered care- Maltreatment Maltreatment assessment findings particular to infants: Bruising Fractures Shaken baby syndrome/shaken impact syndrome Vomiting, poor feeding, bulging fontanel, retinal hemorrhages, seizures, apnea, bradycardia Family Centered care- Maltreatment Diagnostic procedures: X-ray CT/MRI Ophthalmology consult Nursing care: Identify and report abuse early Priority is to keep child safe Document clearly and objectively Photograph injuries Provide support for child and family Family Centered care- Maltreatment Munchausen syndrome by proxy Type of abuse Parent (often healthcare provider) creates symptoms of illness Adult meeting his/her psychological need by having ill child S/S: 1 or more illness that doesn’t respond to treatment Symptoms that don’t make sense or disappear when parent not present (separation test) Physical/lab findings that do not correlate with history Repeated hospitalization Multiple providers Review Family is important part of child's life Establish trust/rapport Listen to concerns Consider ethical/legal principles Assess family Reinforce good parenting skills Identify risk in family assessment and provide education Report suspicion of maltreatment *infant injuries *incompatible injuries and history Let us revisit our objectives Discuss family functioning Discuss ethical/legal variations of pediatric nursing Differentiate discipline from punishment Discuss sources of violence and how it affects children Discuss signs and symptoms of child maltreatment Describe the major principles and concepts of atraumatic care Discuss therapeutic communication and Atraumatic Care of Children and Families Principles of Atraumatic Care Prevent or minimize physical stressors, including pain, discomfort, immobility, sleep deprivation, inability to eat or drink, and changes in elimination Prevent or minimize parent–child separation Promote family-centered care, treating the family as the patient Promote a sense of control Adapted from Wong, D. L. (2013). Adapted from Wong, D. L. (n.d.). Innovative approaches for atraumatic cancer care. Retrieved August 25, 2013, from http://www.authorstream.com/presentation/Carolina-48857- op077-INNOVATIVE-APPROACHES-ATRAUMATIC-CANCER-CARE-DEFINITION-SOURCES-PATIENT-FAMILY- STRESSORS-as-Entertainment-ppt-powerpoint Question #1 Is the following statement true or false? The nurse is providing atraumatic care to a child who is undergoing surgery and the child’s family. The focus of this type of care is solely on meeting the physical needs of the child. Answer to Question #1 False. The focus of atraumatic care is minimizing or eliminating the psychological and physical distress experienced by children and their families in the health care system (Hockenberry & Wilson, 2009; Wong, n.d.). Rationale: Atraumatic care involves guiding children and their families through the health care experience using a family-centered approach by promoting family roles, fostering family support of the child, and providing appropriate information. Techniques for Providing Atraumatic Care Therapeutic communication Goal directed Focused and purposeful Therapeutic play- to play is to learn Provides emotional outlet or coping devices Child education Helps child understand the reason for the hospitalization/procedures in developmentally appropriate ways Parental education Engages parents as active participants in health care team  Role of Child Life Specialists in Atraumatic Care Provide programs to prepare children for hospitalization and painful procedures Provide support during medical procedures Therapeutic play and activities to support normal growth and development Sibling support; advocacy for the child and family Grief and bereavement support Preventing/Minimizing Physical Stressors Minimize physical distress during procedures Engage the child in identifying what would make him or her comfortable Use positions that are comfortable to the child Therapeutic hugging Use distraction methods (music, conversation) Distraction Methods Have the child point toes inward and wiggle them Ask the child to squeeze your hand Encourage the child to count aloud Sing a song and have the child sing along Point out the pictures on the ceiling Have the child blow bubbles Play music appealing to the child Focus of Family-Centered Care #1 Respect for the child and family; family may extend beyond parents and siblings Recognition of the effects of cultural, racial, ethnic, and socioeconomic diversity on the family’s health care experience Identification of and expansion of the family’s strengths Support of the family’s choices related to the child’s health care Maintenance of flexibility American Academy of Pediatrics, Committee on Hospital Care, Institute for Patient and Family-Centered Care. (2012). Policy statement: Patient and family-centered care and the pediatrician’s role. Retrieved August 26, 2013 from http://pediatrics.aappublications.org/content/129/2/394.full.pdf+html. doi: 10.1542/peds.2011—3084. Focus of Family-Centered Care #2 Provision of honest, unbiased information in an affirming and useful approach; convey information in formats consistent with successful learning Assistance with the emotional and other support the child and family require Collaboration with families; encourage parents to report their observations related to changes in the child Empowerment of families  Positive Outcomes of Family-Centered Care for Children Anxiety is decreased Children are calmer and pain management is enhanced Recovery times are shortened Families’ confidence and problem-solving skills are improved Communication between the health care team and the family is also improved A decrease in health care costs is seen Health care resources are used more effectively Family-Centered Approach to Health Care Providing a Sense of Control for the Hospitalized Child Provide effective communication and teaching Find a balance between neutral and effective communication Use verbal communication and nonverbal communication Use developmental techniques for communicating with children Assess parental and child learning needs and create educational plan based upon individual needs and learning styles Assist family to obtain necessary information and resources Question #2 The nurse is providing atraumatic care to a child hospitalized for cardiac surgery. Which of the following is a recommended guideline when communicating with the child’s parents? a. do not cause undue stress by providing details of the surgery b. direct the focus of the parent from providing routine care of the child to preparing for the surgery c. direct the parents to the physician if they have questions about the surgery d. treat the parents as equal partners in the care of their child by allowing them to perform as much care as possible Answer to Question #2 d. treat the parents as equal partners in the care of their child by allowing them to perform as much care as possible. Rationale: The nurse should allow the parent to express concerns and ask questions, as well as explain equipment and procedures thoroughly. The nurse should also teach and encourage the parent to perform as much of the child’s care as is reasonable and permitted. This helps to give the parents a sense of value and control. Working with an Interpreter #1 Help the interpreter prepare and understand what needs to be done ahead of time The interpreter is the communication bridge, not the content expert; the interpreter’s timing may not match that of others involved Speak slowly and clearly; avoid jargon Pause every few sentences so the interpreter can translate your information Talk directly to the family, not the interpreter Give the family and the interpreter time to respond Ask family to repeat back their understanding of the topic Working with an Interpreter #2 Express the information in two or three different ways if needed. Use metaphors to illustrate points Use an interpreter to help ensure the family can read and understand translated written materials Avoid side conversations during sessions Remember that just because someone speaks another language, it doesn’t mean he or she will be a good interpreter Do not use children as interpreters Goals of Child and Family Education Improve the child and family’s health literacy Encourage communication with physicians or nurse practitioners Improve health outcomes and promote healthy lifestyles Encourage involvement of child and family in care and decision making about care Improve compliance with care and treatment plan Promote a sense of autonomy and control  Specific Learning Principles Related to Children Establishing rapport with the child is the first step The age and developmental level of the child will determine the amount, format, and timing of the information given Create a teaching plan that addresses the developmental stage of the child Adolescents are particularly sensitive about maintaining body image and feelings of control and autonomy  Specific Learning Principles Related to Parents Adults are self-directed Adults are problem focused and task oriented Adults want an immediate need satisfied Adults value past experiences and beliefs Knowles (1990) Question #3 Is the following statement true or false? The nurse preparing discharge teaching for the parents of a hospitalized child should base this teaching on the fact that adults are present focused and do not value past experiences. Answer to Question #3 False. The nurse preparing discharge teaching for the parents of a hospitalized child should base this teaching on the fact that adults are problem focused and value past experiences and beliefs. Rationale: Adults value independence and want to learn on their own. Adults learn best when they perceive there is a gap in their knowledge base and want information and skills to fill the gap. Adults bring an accumulated wealth of experiences to each health care encounter; this provides a rich base for new learning. Components of Learning Needs Assessment Assessment must include child and family Follows nursing process: assess, plan implementation, evaluate, and document teaching Identify learning styles and preferences, and potential barriers to learning Consider cultural factors that may impact learning Assess health literacy  Questions Appropriate to Ask When Performing a Cultural Assessment Who is the person caring for the child at home? Who is the authority figure in the family? What is the social support structure? Are there any special dietary needs and concerns? Are any traditional health practices used? Are any special clothes or other items used to help maintain health? What religious beliefs, ceremonies, and spiritual practices are important on a daily basis or as they relate to health? Red Flags Indicating Poor Literacy Skills Difficulty filling out forms Frequently missed appointments Noncompliance and lack of follow-up with treatment regimens History of medication errors Responses such as “I forgot my glasses” or “I’ll read this when I get home” Inability to answer questions about treatment or medicines Avoiding asking questions for fear of looking stupid  Cone of Learning Adapted from Dale, E. (1969). Audio-visual methods in teaching (3rd ed.). Austin, TX: Holt, Rinehart, and Winston. Techniques to Improve Learning Slow down and repeat information often Speak in conversational style using plain language; consider using metaphors to illustrate complex points “Chunk” information and teach in small bites Prioritize information and teach “survival skills” first Use visuals Teach using an interactive, “hands on” approach Evaluating Learning The child or family demonstrates a skill The child or family repeats back or teaches back the information in own words The child or family answers open-ended questions The child or family responds to a pretend scenario in their home  Documentation of Child and Family Teaching The learning needs assessment Information on the child’s medical condition and plan of care Goals of child education; date goal is met Teaching method used and how received by child and family Medications, including drug–drug and drug–food interactions Modified diets and nutritional needs Safe use of medical equipment Follow-up care and community resources discussed Factors Influencing Child Health Genetic Influences on Child Health Gender Race Genetically linked diseases Temperament Effect of Gender on Child Health Gender May influence physical appearances (e.g., clothing, personal grooming) Development of personality formed by parental and social expectations (gender identification) Predisposition to certain diseases/condition based upon gender (e.g., hemophilia more prevalent in males) Effect of Race on Child Health Race Membership in particular group of humans who have shared biologic traits transmitted by genetic inheritance Physical characteristics including skin color, bone structure, blood type Predisposition to certain diseases/condition based upon racial heritage Recent evidence suggest that effects of certain medications may vary among racial groups Effect of Genetically Linked Diseases on Child Health Genetically linked diseases Cytogenetics is the study of genetics at the chromosome level Ability to diagnosis and treat genetically linked diseases is a result of the knowledge derived from the Human Genome Project Assessing for chromosome abnormalities is now possible Can identify groups at high risk for genetic problems Temperament Theory: Describes how a child interacts with the environment The child’s temperament has a corresponding influence on those around the child (positive or negative) Parents react to the child based upon the child’s temperament  Infants are characterized as “easy,” “difficult or challenging,” or “slow to warm up”  Not strict categories—a child may be a combination of these types Parameters Activity level of Temperament Rhythmicity Approach and withdrawal Adaptability Threshold of responsiveness Intensity of reaction Quality of mood Distractibility Attention span and persistence Effect of Temperament on Child Health The child’s temperament has a corresponding influence on those around the child (positive or negative) Parents react to the child based upon the child’s temperament Child’s temperament may affect the family unit and parenting resources (e.g. “difficult or challenging” children may tax parental resources) Consider the consequences of different types of temperament on social, or school environments Assessing temperament should be made after multiple encounters Societal expectations for childhood temperament favor “easy” temperaments Question #1 Is the following statement true or false? A child who is highly reactive and reacts to new experiences by withdrawing in frustration is classified as having a “slow to warm up” temperament. Answer to Question #1 False. A child who is highly reactive and reacts to new experiences by withdrawing in frustration is classified as having a “difficult (“challenging or highly reactive”) temperament. Rationale: Children with a “slow to warm up” temperament may initially complain, may react to new experiences with mild but passive resistance and may need more time to warm up. “Easy” children more readily adapt to new experiences. Lifestyle Influences on Child Health Affects children early on via their mother’s behaviors (in utero, as infants and young children) and directly (older children by their own behaviors) Patterns of eating Exercise Use of tobacco Drugs Alcohol Methods of coping with stress Biologic Influences on Health Genetics In utero exposure to teratogens Postpartum illness (mother cannot care for child) Nutrition Exposure to hazardous substances Maturation Exposure to stressful events Stress and Coping in Children Types of stressors affecting children: o Social (starting school, new babysitter) o Family stress (conflict in the home, divorce, new baby) o Societal (poverty, lack of basic needs) o Physical (illness, trauma, normal growth and development) How Children Cope with Stress? Behaviors suggestive of stressful feelings may vary by developmental stage May be expressed as somatic symptoms Prior experience with stress may drive ability to respond positively to stress Coping is influenced by temperament and developmental stage Developing a sense of resiliency enables effective coping Protective Factors Promoting Resiliency Internal Having ability to take control, be proactive and having responsibility for own decisions Understanding and accepting own limits and abilities Being goal-directed and knowing when to continue or stop External Having caring relationships Having a positive learning environment and positive influences in the community Barriers to Health Care Financial (e.g., lack of insurance, cost of medications) Ethnic (e.g., cultural expectations encourage obesity in children) Sociocultural (e.g., language or cultural barriers) Health care delivery system (e.g., fragmented care) The Role of Family in Child Health Family is considered the basic social unit Provides physical and emotional care for the child as well as to convey rules of appropriate social interaction Defined by U.S. Census Bureau as a group of two or more persons related by birth, marriage, or adoption and living together Traditional nuclear family is no longer considered the only family structure—family structures and roles can be highly variable!  Major Theories Related to Family as a Social Unit Theories and models about family as a basic unit of society are useful to: Define family units and roles Characterize family structure and function, and Describe family’s coping and adaptation styles Examples of Major Theories Related to Family Friedman’s structural functional theory−family as a social system Duvall’s developmental theory−developmental stages of family Von Bertalanffy system theory−family as a system of interdependent parts Family stress theory−how families respond to stressors Resiliency model−adaptation to stress model Adapted from Friedman, M. M. (1998). Family nursing: Theory and practice (4th ed.). Stanford, CT: Appleton & Lange; Duvall, E. (1977). Marriage and family development (5th ed.). Philadelphia, PA: J. B. Lippincott; Von Bertalanffy, L. (1968). General systems theory. London: Penguin Press; Boss, P. (2001). Family stress management: A Contextual Approach (2nd ed.). Thousand Oaks, CA: Sage Publications, Inc.; and Patterson, J. (2002). Integrating family resilience and family stress theory. Journal of Marriage and Family, 64(2), 349–360. Types of Family Structures Each family unit has unique strengths and challenges! Consider the following types of families, and their challenges in raising children: Adolescent families- babies having babies Grandparent-as-parents Foster families Same-sex families Blended families Question #2 Is the following statement true or false? The role of the family is limited to providing physical care to the child. Answer to Question #2 False. Rationale: Parents (or those acting in the parental role) impart the rules and expected behaviors of society through teaching and discipline techniques as well as caring for the physical and emotional needs of the growing child. Typical Parental Roles Nurturer Provider Decision maker Financial manager Problem solver Health manager Gatekeeper Educator Four Major Parenting Styles Authoritarian Authoritative Permissive Rejecting-neglecting Question #3 A parent sets rules for a child and expects the child to follow them without asking questions or complaining. What style of parenting is this parent displaying? a. Authoritarian b. Authoritative c. Permissive d. Rejecting-neglecting Answer to Question #3 a. Authoritarian. A parent setting rules for a child and expecting the child to follow them without asking questions or complaining is displaying an authoritarian parenting style. Rationale: An authoritative (democratic) parent shows respect for the child’s opinions, but has ultimate authority over the child. A permissive (laissez-faire) parent has little control over the child and a rejecting- neglecting parent is indifferent or uninvolved in parenting the child. Discipline versus Punishment Discipline derived from the Latin word disciplina meaning “teaching, learning” (Merriam-Webster Dictionary, 2015) Discipline is teaching and rewarding desirable behavior and decreasing or eliminating undesirable behavior. It is an ongoing process. Punishment is a negative consequence applied for undesirable behavior. It is a finite process. Discipline Strategies Maintain a positive, supportive, nurturing caregiver– child relationship Use positive reinforcement to increase desirable behaviors Remove positive reinforcements for negative behaviors Use negative consequences (punishment) to reduce or eliminate undesirable behaviors Punishments can be defined as verbal or corporal (physical) Distinguishing Factors of Ethnic Groups Customs Characteristics Language Family structures Food preferences Moral codes Health care practices Beliefs and Practices of Cultural Groups that Impact Health Care Cultural groups have often have well-defined roles for: Roles of family members including children Roles and responsibilities for extended family members Models of health, disease, and causes of disease Expression of pain and causes of pain Role of foods that promote health or cure illnesses Role of spirituality Beliefs and Practices of Selected Cultural Groups Adapted from Rector, C. (2010). Chapter 5: Transcultural nursing in the community. In J. A. Allender, C. Rector, & K. D. Warner (Eds.), Community health nursing. Promoting and protecting the public’s health (7th ed., pp. 91–112). Philadelphia: Wolters Kluwer Health/Lippincott Wilkins & Williams. Components of Cultural Competence Adapted from Andrews, M. M., & Boyle, J. S. (2008). Transcultural concepts in nursing care (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Elements of a Child’s Community Affects many aspects of a child’s health, development, and general welfare Consists of the family, school, neighborhood, youth organizations, and other peer groups Social Capital Refers to the bonds between individuals that assist communities to achieve a variety of goals, including child health care Requires norms of reciprocity, mutual assistance, and trust (Putnam & Feldstein, 2003) It is a mechanism by which the resources of a community can be mobilized by and from the people, not for them (Looman & Lindeke, 2005) Common interests and relationships propel neighborhoods and communities toward engagement Type of Violence Affecting Child Health School violence (bullying) Exposure to violence in the media Domestic violence (to self or as witness to abuse) Suicide Violent crimes Exposure to violence in the media  Major Components of Society Influencing Child Health Changes in social roles Socioeconomic status The media (television, Internet, social media) Expanding global nature of society can affect children at home as well as travelers  UNICEF Identified Major Problems for Global Child Health Malnutrition, including micronutrient deficiency HIV/AIDS Acute respiratory infections, such as pneumonia Diarrhea related to lack of clean water and sanitation Vaccine-preventable diseases such as measles Malaria Poor health care of pregnant and nursing mothers