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INTERNATIONAL NURSES DAY 2002

NURSES ALWAYS THERE FOR YOU:

CARING FOR FAMILIES

Information and Action Tool Kit


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All rights, including translation into other languages, reserved.No part of this publication may be reproduced in print, by photostaticmeans or in any other manner, or stored in a retrieval system, ortransmitted in any form without the express written permission of theInternational Council of Nurses. Short excerpts (under 300 words)may be reproduced without authorisation, on condition that thesource is indicated.

-----------------------------------------------------------------------------------------Copyright 2002 by ICN - International Council of Nurses,3, place Jean-Marteau, CH-1201 Geneva (Switzerland)

ISBN: 95005-42-2


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CARING FOR FAMILIES

Table of Contents

Message from ICN 1

Introduction 3

Chapter one Defining Family 5

Chapter two How Nurses Provide Family Care 9

Chapter three Caring for Poor, Displaced and Refugee Families 19

Chapter four Family-Friendly Policies and Services 23

Influencing public policy 31

Family-friendly activities 33

Sample press release 35

Media backgrounder 37

Sample survey 39

ICN Position Statements:

Participation of Nurses in HealthServices Decision Making and PolicyDevelopment

41

Nurses and Primary Health Care 43

Health Services for Migrants, Refugeesand Displaced Persons

45

Annex 1 47


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NURSES ALWAYS THERE FOR YOU:CARING FOR FAMILIES

Nurses render health services to the individual, the family and the community

and co-ordinate their services with those of related groups.

ICN Code of Ethics,2000

12 May 2002

Dear Colleagues,

Wherever nurses work, their focus is on the family - its health, its ability to grow, care

for itself, and contribute to the community. To emphasise the nurses role in familyhealth, the ICN has selected Nurses Always There for You: Caring for Familiesasthe theme for International Nurses Day (IND), 12 May 2002.

ICN has done considerable work in this area. The Caring for Familiesdocumentbuilds on this previous work, which includes several products. In 1994 ICN publishedthe Healthy Families for Healthy Nationskit as part of the years IND celebrations.The inaugural Virginia Henderson Fellowship in 1999 focused on the family nurseand most recently, ICN published The Family Nurse, a monograph outlining keyissues, roles and models in family nursing.

For most of the worlds people, health is served by community-based, primary care

services, delivered overwhelmingly by nurses. The communities are diverse as arethe places where nurses practice. However, the family, in one way or another, isalways a principal target for nursing care.

This years IND theme of Nurses Always There For You: Caring for Familiesaims to: Increase awareness of the nurses role in family care and family health,

including as the primary point of entry into the health care delivery system. Encourage nursing involvement in the development and implementation of

health and social policies that are family-friendly. Draw attention to the importance of the family and the role of family members

in their own health individually and as a family unit.

The trust and close relationship that exists between nurses and families means thatnurses can be powerful advocates in determining the best public policy for familyhealth. As part of your IND activities, we encourage your association to share yourknowledge and experience in caring for families with policy makers, the public andother health professions with a view to encouraging family friendly policies in healthcare delivery. We look forward to hearing about your subsequent successes.

over/


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The health of the family has never been more important in shaping a strong andvibrant society. As nurses help individuals and families to make healthy choices,cope with illness and chronic disability, manage stress and work with them in theirhomes, schools and workplaces, they are helping to ensure the strength of the mostfundamental building block of society.

Sincerely,

Christine Hancock Judith A. OultonPresident Chief Executive Officer


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NURSES ALWAYS THERE FOR YOU:

CARING FOR FAMILIES

Introduction

Caring for families is a central focus of nursing. Historically nurses have cared for

people at home within the context of the extended family, typically with several

generations living under one roof. As families became more nuclear and care

becomes more hospital oriented and specialised, this family focus lost attention. With

the return to community-based and home care, and with our enhanced

understanding of the importance of family relationships in health and illness, family

focused care is again emphasised.

Today we have new definitions of family, a new understanding of their role in health,

and new expectations of health care providers as we strive towards healthier people

in a healthier world. The current increased global recognition of the importance of

family nursing is exciting. This International Nurses Day kit ICN aims to build on and

amplify this dynamic trend.

The main document of Caring for Familiespresents four chapters, each highlighting a

separate aspect of caring for families.

Chapter One: Defining Family. We begin with an overview of the various

family structures and functions.

Chapter Two: How Nurses Provide Family Care. This section looks at the

role of nurses as the central point for the health promotion, disease

prevention, care and rehabilitation of families.

Chapter Three:Caring for Poor, Displaced and Refugee Families. This

chapter examines the role of nurses working with families challenged by

poverty and displacement.

Chapter Four:Family-Friendly Policies and Services. Find out how nurses

can work towards family friendly health services and policies that enhance

family involvement and self-care.

Other tools for action included:

Influencing public policy: Action for developing and influencing policy.

Family-friendly health care: Activities to promote family centred care.

Sample press release: A template for media outreach.

Sample media backgrounder: A fact sheet on nurses and family care.

Sample survey: An informal survey of the families using your health care facility.

Related ICN Position Statements


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CHAPTER ONE

Defining Family

Families have diverse structures and functions that can vary from one country and

culture to another. This rich variety of family structures reflects both individual

choices and societal values. To be effective, nurses need to understand family

concepts and functions.

Family structures and functions are constantly changing and adapting to external

environmental and societal trends. However, whatever the changes, the concept of

family survives as an important social unit in almost all societies.

The aim of family nursing is to work with all family types as well as with individualfamily members, so as to promote health, prevent illness, and provide cure, care and

rehabilitation services. Nurses work with families:

Family Structures

The family is the basic unit of society and exists in different social, cultural, legal and

political systems. In the past, the stereotype for a family tended to be two parents

living together with their biological children and perhaps the older parents of one or

both spouses. Today society accepts various family types and structures. Family

may refer to people linked by marriage or kinship or to people of common ancestors,

tribe or clan. The International Classification for Nursing Practice (ICNP) defines

family as An assemblage of human beings seen as a social unit or collective

whole composed of members connected through blood, kinship, emotional or legalrelationships.. 1

People may form and extend families by having children, adopting or fostering

children or by establishing consensual relationships. The family may range from the

traditional nuclear and extended family to such family structures as single parent,

families with foster children, stepparent and remarried families with children from

previous relationships. In other family types the couple cohabit or live together

without the legal link of marriage.

To reduce the factors that damage health

To enhance good health and well being

To strengthen self-care and coping skills


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Other non-traditional family structures include same sex or homosexual couples who

have committed themselves to each other and are demanding the same legal rights

as heterosexual couples. There is also a growing trend of families where

grandparents raise grandchildren for a number of reasons mothers are working,

parents are unable to care due to illness or drug use, or children are throwawaykids. The devastation of HIV/AIDS in many countries has led to an increasing number

of AIDS orphans who are being raised by their grandparents or their older siblings, or

in community supported facilities.

As family structures and functions evolve, the legal framework is adapting and

becoming more accommodating to non-traditional families. In a number of countries,

new laws define the rights of unmarried partners and allow cohabiting couples to

have joint custody of children or to receive benefits in the same way as married

couples. Similar trends are appearing in regards to same sex couples.

Types of Families

Nurses caring for families require an understanding of the different family structures

and functions. The typology below outlines the common family structures.

Common traditional family forms Common non-traditional family forms

Nuclear family one parent, living in the same

household.

a) first marriage families

b) blended or step-parent families

Unmarried parent and child living alone,

usually mother and child

Nuclear family husband, wife and children living

together.

a) first marriage families

b) blended or stepparent families

Unmarried couple and child living together

usually a common law marriage

Nuclear family husband and wife living alone;

childless or no children living at home.

a) single career

b) dual career

Cohabiting couple unmarried couple living

together

Single-parent family- female or male headed as a

result of divorce, abandonment, separation, or

death.

Same sex persons living together as partners

Extended family - parents, grandparents and

children living together.

Empty nest families older couple living alone.

a) children are at college

b) children have a family of their ownSource: Adapted from Friedman, M.M. (1997)Family Nursing: Research, Theory & Practice


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Functions of Family

A family exists to meet the needs of its members. Regardless of its composition the

family performs essential functions, including:

Nurturing and nourishing the young.

Economic survival and support for family members.

Safety of family members from threats to survival, especially as concerns the

young, the old or disabled.

Transmission of cultural beliefs, traditions and values to the next generation.

Provision of care and support for family members in times of health and illness.

Providing a setting for love, companionship and intimate relationships.

In many societies, the family is part of the larger system of society, and supported by

social welfare and law enforcement agencies, religious institutions, schools and

health services in carrying out its functions.

Dysfunctional Family

The term dysfunctional is used to refer to families who may not be coping or

functioning well in society and who exhibit low self-esteem, both as individuals and

as a family group. Dysfunctional family communication patterns perpetuate low self-

esteem and are often characterised by 1) self-centeredness, 2) the need for total

agreement and/or 3) a lack of empathy.

In self-centred communication the individual focuses on his or her own needs to theneglect or denial of others needs, feelings or perspectives. It is often difficult to

negotiate with self-centred family members as they become hostile and defensive.

Communication based on the need for total agreement arises when marital partners

have low self-esteem and any differences are seen as a threat that can lead to

conflicts. Often tactics aimed at avoiding conflict or pleasing the other family

members are used to create a facade of agreement.

In the third example of dysfunctional relationships, characterised by lack of empathy,

family members cannot recognise the impact of their own behaviour on other family

members and are preoccupied with meeting their own needs. Communication tendsto be confusing, indirect, defensive and lacking honesty.

Assessing the communication patterns of families is a key tool in determining levels

of functioning.


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Current Trends Affecting Family Structure and Functions

Major demographic, social and economic forces impact family structure and

functions, in particular the role and status of women as family care providers. These

include:2

Ageing of the population.

Decline in birth rates and family size.

Widening gap between the rich and the poor.

Increasing access to education for women.

Delayed marriage.

Increasing rates of divorce and remarriage.

Increase in the number of single parent and stepparent families.

Changing and blurring of gender roles.

Growing womens employment outside the home.

Technological advances that reduce labour and provide more leisure

time.

Implications for nurses

Nurses with the knowledge, skills and understanding of the diverse family forms

can promote a healthy family by strengthening its structure and functions and

promoting positive family dynamics that favour health.

In caring for families, health care personnel must respect the unique nature of

each family. Negative stereotyping of some family structures, such as same sex

couples, may discourage those families from seeking health care support and

thus increase their risk for health problems. While some may decry the variations

in family forms as a decline in traditional family values, it is perhaps a sign that

the family is actually quite resilient in adapting to changing social conditions.


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CHAPTER TWO

How Nurses Provide

Family Care

Caring for families is a role intrinsic to nursing. The family setting provides an

opportunity to address the health needs of the family unit and its individual members.

Increasingly, a process of partnership, in which the family is actively engaged in its

health care, is replacing the traditional approach to health care, where physicians

and nurses are viewed as experts who decide what is good for the family and itsmembers. Families want to be involved, and informed consumers are demanding a

greater control of their care.

The extent of family involvement in health care can vary depending on the situation

or health problem. In situations involving minor acute problems, nurses generally

focus on the individual. However in chronic illness, serious acute problems, or

lifestyle issues, nurses must involve the entire family in providing care.

Key characteristics of family nursingNurses caring for families use basic principles to guide their interventions and to help

understand the complex, dynamic relationship between health of the family and

health of individual family members. These include:3

Family nursing is directed at family members who are healthy and ill.

The nurse recognises the relationship between individual and family health.

When caring for individual members in health and illness the nurse also

attends to the family.

Family care is concerned with the overall experience of the family in terms

of its past, present and future. Family nursing takes into account the bigger picture of the familys

community and cultural context.


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Family nursing considers the relationships among family members and

recognises that individuals and the family group do not always achieve

maximum health simultaneously.

The nurse tries to increase family interactions between the nurse and family

and between family members. The nurse recognises that the person in a family who has the most

symptoms may change over time and the focus of nursing actions will

require change.

Family nurses must work to define priority health issues with the family.

The Nine-Star Family Nurse: multi-skilled with diverse roles

Nurses working with families play multiple roles, depending on the family needs and

the settings for care, which can include the home, health care facilities, temporary

refugee shelters or the streets. In an effort to capture the full range of the nurses

work with families, we will refer to the key roles in terms of the nine-star nurse. The

roles of the nine-star family nurse include:

Health educator: Teaching families formally or informally about health and

illness and acting as the main provider of health information.

Care provider and supervisor: Providing direct care and supervising care

given by others, including family members and nursing assistants.

Family advocate: Working to support families and speaking up on issues

such as safety and access to services. Case finder and epidemiologist: Tracking disease and playing a key role in

disease surveillance and control.

Researcher: Identifying practice problems and seeking answers and

solutions through scientific investigation alone or in collaboration.

Manager and coordinator: Managing, collaborating and liasing with family

members, health and social services and others to improve access to care.

Counsellor: Playing a therapeutic role in helping to cope with problems and

to identify resources.

Consultant: Serving as consultant to families and agencies to identify and

facilitate access to resources.

Environmental modifier: Working to modify, for example, the homeenvironment so that the disabled can improve mobility and engage in self-

care.

The nine-star family nurse uses a number of these roles to identify health risks, a

health problem or a need, and to address the situation working singly or in

partnership with families, other health professionals and community groups.


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Identifying and Meeting Family Health Needs

Nurses use a systematic assessment to profile family structure and functions and

determine family health needs. The individual and family should be involved as key

partners in all the following steps:

Family Assessment and Intervention Models

Many approaches can be used to collect information on families for assessment

purposes. Some models developed by family nurses are:

1. The Family Assessment and Intervention Model (FAIM)

2. The Friedman Family Assessment Model

3. The Calgary Family Assessment Model (CFAM) and the Calgary Family

Intervention Models (CFIM)

4. WHO/EURO Family Health Nursing Model

(These models are explained in greater detail in Annex 1)

At present, consistency in language and the theoretical foundations of family nursing

are variable. However, the available models reflect certain common views of family

nursing practice.

1. Practice has a holistic perspective of care, locating the individual seeking support

and/or care within the family unit, or takes the whole family as the focus of care.

2. Practice recognises that family structure, strengths, weaknesses and dynamics

can enhance or diminish optimum health potential or illness-care, and, therefore,

influence family nursing assessment and intervention modes.

3. Practice promotes the meaningful involvement of family members in

assessment, decision-making and planning as a well as care.

4. Practice mobilises a range of resources and services encompassingassessment, education, and assistance. This includes mobilising resources from

other professional and service providers in the health and community sectors.

Collecting andanalysing data

Identifying the healthconcern or problem

Establishing goals anddesired outcomes

Implementing strategies andinterventions to improve health

Evaluating to seeif desired outcomeshave been achieved


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Accordingly, we can look at the following approaches to family nursing:

Viewing the family as context

Though the nurse may focus on the individual in terms of assessment andintervention, the family is seen as context or secondary focus. The family can be a

stressor or a resource to the individual and the nurse may involve the family to

varying degrees depending on the situation.

The nurse may assess the family as part of the individuals social support system. In

some instances this data may not be used in developing a care plan, where in others

it is incorporated into a care plan for the individual and the family is actively involved

in care. For example in providing care for a child, the child is viewed within the

context of the family, which is the primary provider of care. As continuity of care

depends on the family, nurses identify family strengths and weaknesses and aim to

improve family effectiveness in care.

Family as sum of its members

The family can also be seen as the accumulation or sum of the individual family

members. Care is provided for family members as individuals, rather than focusing

on the family as the unit of care. Each individual member is seen as a unit with little

emphasis on the interrelationships with the family.

Caring for families at this level is based on the assumption that if each members

health is addressed, the health needs of the family will be met. However, viewing thefamily as merely a sum of its members challenges holistic care in terms of family

impact on the individual and individual impact on the family. Increasingly nursing care

is focusing care on the family as a whole, rather than on some of its members.

Working with family subsystem as client

In this type of family nursing practice, family subsystems are the focus of assessment

and care. Examples of family subsystems include parent-child relationships, husband

and wife marital relationships and care-giving issues within the family. The

assessment of family dynamics and relationships can provide insights into family

health and illuminate opportunities for nursing intervention to strengthen coping andfunctioning.


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Focusing on the family as client

In this case the nurse focuses on the entire family as the primary unit for assessment

and care. The family is in the forefront and the family members in the background or

the context. The emphasis is on interaction of family members.

What do Nurses Offer to Family Care?

Family nursing involves a continuum of care across the life span: health promotion,

disease prevention, care, cure and rehabilitation services. This continuum of care

represents the nursing capacity to improve family health.

A highlight of some of key nursing contributions and roles in family care include:

1. Promoting health

Although much of health care today focuses on illness and its treatment, nursing has

aligned itself well with the recent trends and public demands for wellness and health

promotion. With the primary health care movement nurses have been in the forefront

of promoting family functioning and healthy family lifestyles. This includes

encouraging families to take responsibility for their own health by providing relevant

health information, and working with families to explore choices and make informed

decisions.

The presence of nurses in primary health care settings including schools, workplaces

and homes, allows nurses to be proactive in identifying populations at risk, screening

and early detection, providing counselling and therapeutic services, liasing with

relevant family health services, and targeting vulnerable groups4.

Nursing actions that focus on health promotion and disease or injury prevention aim

to achieve mutually supportive outcomes. For example, teaching individuals and

families strategies to prevent abusive and violent behaviour improves communication

among family members, promotes family harmony, safety and their mental health. As

well it prevents stress and injury associated with violence.

In order to support families in health promotion, nurses use the steps of the nursing

process: assessment, planning, implementation and evaluation. During assessment

nurses examine family processes such as interaction, development, coping, and

functioning, with a view to identifying family strengths as well as stressors and

barriers to health. Through assessment the nurse identifies areas for nursing

intervention.


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Areas where nurses can support families in their health promoting activities include:

Family and individual dietary and nutrition patterns.

Family safety practices in the home and outside the home.

Disease risk reduction and health behaviour patterns.

Family and individual recreation and exercise. Coping with family events such as births, illness, deaths, retirement, separation

and divorce.

Family interactions and social support.

Smoking cessation.

While nurses are the main primary health care providers to families in addressing

many of these issues, partnerships with other professional groups, referrals to other

resources, and involving other sectors such as social services, employment centres,

and others are crucial.

2. Prevention and early detection of disease

One of the main goals in family health is prevention of disease and disability. Nurses

are well placed to apply the different levels of prevention in a broad spectrum of

health and illness. Nurses work with families at three levels of prevention:

Primary prevention: The nurse implements specific preventive measures in order

to keep people free of disease or injury. Examples include child immunisation,

smoking prevention, and exercise and fitness programmes.

Secondary prevention: Nurses identify problems, treat and/or refer for timely

action. Examples include screening and follow up of people with hypertension ordiabetes to prevent complications; screening for osteoporosis after a fracture.

Tertiary prevention: This refers to the prevention of complications of disease,

minimising disability and maximizing functioning through rehabilitation. Examples

include teaching diabetics about diet and foot care, and teaching motion

exercises to patients recovering from injuries.

Prevention of disease through early detection, diagnosis and treatment is important.

As the population ages and the prevalence of chronic disease increases, tertiary

prevention is becoming equally important in minimising the physical or mental

disabilities that threaten activities of daily living (ADLs) or instrumental activities of

daily living (IADLs).

3. Caring for family members in their own home

As care shifts from the hospital to the home, family nurses provide skilled nursing

care and help families to cope with illness or injury. As well nurses help families

develop self-care skills. And where recovery is unlikely nurses care for patients,

providing the conditions for a peaceful and dignified death. Family nursing services in

the home can include:


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Diagnosis and treatment of minor conditions and referrals if needed.

Management of acute or chronic illness.

Monitoring changes in health status.

Teaching family members about the illness and medications.

Training family members in self care skills. Rehabilitation services.

Palliative care

4. Cost effectiveness of nursing in family care

Health care reforms worldwide have particularly highlighted rising health care

expenditure, giving rise to a focus on cost effectiveness and cost containment. The

proper training and cost effective utilisation of health care providers has been one

approach to streamline costs. This has given attention to improving the utilisation of

nurses to maximise access to health care.

The literature suggests that good outcomes can be achieved in effectiveness, cost-

containment and patient satisfaction by using the expertise of nurses. Examples

include:

A study by the American Nurses Association showed that certified nurse

midwives provide care that results in shorter hospital stay, fewer premature

deliveries, and babies who are as healthy as those delivered by physicians5.

In Alberta, Canada, public health nurses who are employees of the local boards

of health routinely provide infant and pre-school immunisation. In Ontario, thesesame immunisations are provided by physicians. The outcome of immunisations

shows that Alberta and Ontario have the same success in prevention diphtheria,

tetanus and polio, but the cost is much less in Alberta. 6

In a study of 1,815 patients who requested and got a same day appointment,

nurses received a total score of 78.6 % while general practitioners had a score of

76.4%. The results suggest that a same day appointment service led by nurses is

acceptable to most patients and nurses offered clinically effective services. 7


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Caring for Families: Some International Vignettes

Family Nursing in Slovenia

Since 1996, each district has had a primary community nurse who is thefirst line, and constant contact for people wherever they live and work.Using a life cycle approach, twenty-four hour care is provided to familiesfrom birth to death. The nurse takes on many roles, including care provider,decision maker, communicator, community leader and manager of servicesfor the clients, patients, families and the local community. The goal is toprovide all families with a registered nurse that will work with them from birthto death.

(Source:8)

Family Health Nurses in Botswana

In Botswana, where the family nurse practitioner (FNP) has beenrecognised for twenty years, the approach adopted is a combination of ageneralist who provides care for families and a nurse who cares for thepatient suffering from illness. Family nursing practice is defined within theprinciples of primary health care and is concerned with health maintenance,health promotion and curative care for family members of all ages,throughout the life cycle. Care, which includes curative services as well ascounselling, most often takes place in outpatient facilities in consultationwith one or more family members. Family assessment focuses on the family

as a socio cultural unit affected significantly by social changes in thecountry.

(Source: Standards of Family Nurses Practice: NursesAssociation of Botswana, 2001)

* * *

A Nurse and a Family in America: The Smith Family

I work in a paediatric clinic providing health care services to a variety ofclients. One day I noted that the next patients on my schedule were twolittle boys ages 4 and 5, who had had just been placed in a new fosterhome. The state requires a physical exam on all children within a week ofbeing placed in a foster home. I encountered two little boys who wereliterally climbing the walls. They could not sit still for even a few seconds.It didnt take me long to feel exasperated with these two children. l lookedin utter amazement at the foster parents, wondering how long anyonecould tolerate these two boys in their house.


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The foster parents were two men, Ted and Ray. They were a gay couplewho had been referred to me by a friend of theirs. They were in a stablelong-term relationship. They wanted children and knew that the only waythey could become parents was to become foster parents . They wereboth employed in good jobs and were willing to make any sacrificesnecessary to become parents.

I was sceptical. I spent a great deal of time talking to Ted and Ray abouthow many obstacles they would be facing. Having an instant family couldspell disaster to even a 'normal,' stable relationship with 'normal' children.These men faced what appeared to be insurmountable odds. The two littleboys were going to be very difficult to live with. I doubted they could do it,but I told them I would be there for them no matter what.

The next 2 years brought them to my office many times. I watched inamazement while these two boys were transformed from difficult, unruly

children, to well-behaved, loving boys. I found myself considering askingTed and Ray if they would give parenting classes for some of my otherpatients because they were the best parents I had in my practice.

Recently I looked on my schedule and found I had a walk-in appointmentwith the boys. They had brought me the pictures from the courthouse,immediately after their adoption. Ray and Ted had changed the lastnames of the boys at the time of the adoption. The boys proudly informedme that they were now the 'Smith family.'

I was touched beyond words that they wanted me to share this importantmoment with them. It is not very often that you can be present at the birth

of a new and special family.

Renee McLeod, MSN, RNExcerpted from the book Touched By a Nurse,

By Jim Kane and Carmen Germaine Warner, Lippincott 1999.


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CHAPTER THREE

Caring for Poor, Displaced and

Refugee Families

Families in Poverty and Other Difficult Situations

It is estimated that 1.4 billion people live in poverty worldwide and this is increasing9.

Poverty and other social and economic upheavals tear families apart resulting in

migration, homelessness and other adverse health effects. Nurses often come

across people where the family as a basic support system does not exist or has

failed, and the entire family finds itself without shelter. In many societies,

unemployment, poverty and violence in the family are the main causes of familybreakdown and marginalisation.

Homelessness is a growing problem in many countries, especially in large cities

where the displaced often live in the most degrading environment. Many homeless

people and especially street children are literally sleeping on the streets with grave

health and social consequences. Homelessness puts people at increased physical

and psychosocial stress. The lack of family networks and other strong ties can

increase vulnerability to deprivation, illness, injury and disability. Street children are

particularly at risk of violence, homicide and rape.

As poverty and homelessness have direct impact on individual and family health,

measures to address these ills are of direct concern to nurses. Early action may be

the most important way to keep a family intact and healthy. As with families in other

situations, involving poor and homeless families in identifying their problems and

needs remains a cardinal principle in their care. Nursing actions to address health

needs of poor and homeless families include:

Identifying the health status and health needs of vulnerable populations.

Collaboration with community groups and sectors for income generation, and

income security, e.g. to increase access for family and child allowances,

disability benefits, unemployment insurance, etc. Increasing access to health services for the poor.

Lobbying governments against child labour and exploitation.

Lobbying for vocational training and job placement of young people.

Working to increase access to sheltered housing and food security for older

persons.


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Providing support for families who care for people with chronic disease or

those caring for children orphaned by HIV/AIDS.

Providing information on community resources and facilities, e.g. shelters,

half-houses, health centres for the poor.

* * * * * * * * * * * * *

Working with Migrants, Refugees and Displaced People

The family as the basic unit of society is often the greatest casualty of war andnatural disasters. Worldwide families are witnessing changes caused by armed

conflict, political upheaval, economic hardships, and natural disasters that challengefamily stability and continuity. One outcome of these can be uprooting and migration.

Uprooted families seeking refuge in other countries, or being displaced

internally, are a too familiar scene in newscasts. Displaced persons are

frequently placed in camps as an emergency measure to provide relief,

shelter and meet nutritional needs. Camp life imposes many hardships such

as restrictions to work or to travel, and refugees face increased risk of abuse.

They often suffer a sense of isolation in their new environment.

The United Nations High Commission for Refugees (UNHCR) reports that womenand children constitute more than three quarters of the 21.7 million refugees and

displaced people worldwide10. They often suffer from malnutrition, respiratory illness,

diarrhea, parasitic diseases and sexually transmitted diseases. In addition, many

refugees have suffered torture and other abuses in their home country. This

contributes to their feelings of fear, anxiety and the development of mental health

problems. Inadequate health facilities and poor sanitation are often the norm in

refugee camps. Women and young girls are particularly vulnerable and are often

subjected to sexual harassment, rape, and physical attacks.

Because nurses are among the front-line health care providers, they are in a good

position to deal with the immediate and long-term health needs of displaced families.

The health problems that nurses may confront in this context include mental illness,

malnutrition, and communicable diseases such as tuberculosis. In addition, nurses

need to deal with cultural barriers and lack of information about available resources

and how to access them. There are many ways that nurses work with refugee

families to promote health, including:

Identifying the health and nursing needs of displaced persons.

Helping with emergency assistance and resettlement programmes,

with focus on vulnerable groups, e.g. children, older persons and the

disabled.


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Planning for the provision and the evaluation of health services

provided to displaced persons.

Linkages with other services such as sanitation, water supply and

feeding centres.

Collaborating with human rights groups and NGOs to increase accessto care, including lobbying governments to provide adequate health

services.

Assessing for signs of torture or other mistreatment.

Promoting adherence to drug therapy, appointments for checkups,

immunisation, etc.

Providing information on available health and social services and how

to access them.

Providing care through outreach services in camps and other settings.

Unprecedented numbers of people have become migrants, refugees or displaced

persons in recent decades. On 1 January 2001, there were 21.7 million refugees in

the world that is, one out of every 280 people on the planet. Another 30 m are

classified as internally displaced persons.

These populations often poor health status may be aggravated by deprivation,

physical hardship and stress. The lack of resources in the country of first

asylum/resettlement may compound the problem.

Nurses, as citizens of their countries, patient advocates and care providers, can

make a great contribution to resolve the health problems of displaced and refugee

families and help them adjust to a new way of life.


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CHAPTER FOUR

Creating Family-Friendly

Policies and Services

Influencing Family-Friendly Public Policy

Influencing public policy is a nursing role and increasingly an expectation of the

public. Nurses have demonstrated leadership in forming baby friendly and mother

friendly hospitals, where services and environments are tailored to client needs,

instead of the other way around. A similar focus and leadership is needed to createfamily-friendly health services.

Health policy includes the directives that promote the public welfare through a

specific type of action. They are shaped by politics and reflect societal values, beliefs

and attitudes. Policy decisions can vary from institutional policies such as workplace

safety, to organisational policies such as banning smoking within NNA premises.

In influencing public policy nurses need to understand the different factors that

influence policy:

Some determinants of healthy public policy

Political

ideology

Special interest

groups

Publicopinion

MediaEquity andsolidarity

PublicPolicy


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This means that nurses must understand and work with diverse interest groups and

networks. Recent health care reform has led to changes in health policy that affect

the provision of services. For example user fees are levied to recover some of the

cost in health care, but this may be a barrier to access for low-income families.

Nurses must be the balancing force so that essential health care is not dependent onones ability to pay.

A WHO review showed that nursing faces a number of challenges that hamper its

contribution to health care policy11: lack of authority and power at all levels to change

practice, exclusion of nurses from policy making, and non-representational of nurses

in decision-making committees during resource allocation, human resources planning

and other issues. However nurses have vital skills that make them effective resource

in shaping healthy public policy.

Nurses are concerned with healthy public policy to ensure that all sectors and

services take up health in their agenda. For example while health is the function of

the ministry of health, other sectors such as agriculture, employment, public safety,

water supply and housing equally contribute to health. It is important that nurses

become key advocates of healthy public policy in a holistic way. Healthy public

policy, whether at the family or community level, facilitates healthy choices by

removing barriers and constraints. Health promotion and disease prevention are

enhanced by healthy public policy.

Nurses individually or through their national nurses associations can contribute to

health policy through:12

Lobbying to include nurses on key policy boards and committees.

Positioning the association as an expert resource through clear, written

policy position statements.

Being informed of health and public issues, proposals and

developments.

Developing appropriate strategies for different policy issues and

processes.

Forming strategic alliances with other organisations.

Speaking out publicly through strategic use of the media. Developing unified positions with other nursing organisations.

Educating and involving the membership in policy issues and strategies.

Ensuring nurses representing the association are well prepared and

articulate.

Preparing younger nurses with potential for leadership.

Maintaining constructive relationships with influential people.


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Creating Family Friendly Services

Health facilities and services that are not in accord with the expectations and cultural

values of the community tend not to be properly utilised. People tend to bypass suchservices and seek care elsewhere. Family friendly policies encompass a range of

decisions by policy makers that affect families directly or indirectly. Policies that affect

access to housing, health services, income, education, social services or

employment can be broadly defined as family policy. The aim of family friendly policy

should be to enhance the well-being of the family and its individual members. Some

indicators of family well-being include: satisfaction with care, meeting the needs of

families, reducing the stress of families, providing additional resources and matching

resources to the needs of families.

Examples of barriers to family-friendly health facilities include:

Service hours that do not suit working parents.

Inadequate range and variety of services.

Providing different services on different days. For example, antenatal services

may be provided on selected days and immunisation may not be available

during those days, thus requiring extra trips to health facilities.

Health personnel that do not respect cultural and community beliefs and

values.

Requiring the family to make heavy expenditures in terms of travel, waiting

time, services available, or finances, etc.

Lack of referrals from primary care to higher levels of care. Discrimination and unfairness in access services.

Rude and uncaring attitude that dehumanises families.

Lack of respect for privacy and confidentiality of people.

Analysing how health and social welfare policies affect the work of family nurses is

essential. Nurses can then lobby for policies that enhance the well being of family

members and the family unit. Examples of family friendly policy areas include:

Increasing access to health care.

Reducing the burden of out-of pocket payments for care.

Aligning service hours to suit the working life of the community.

Providing services that match expressed needs of families.

Providing culturally appropriate services.

Providing services for informal caregivers.


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It is important to recognise how policies in health care financing and delivery

influence family health and functioning is important. A general starting point is to

analyse how health and social welfare policies are affecting families. In order to

understand the family issues and concerns, an assessment is needed to determine

policy, gaps, changes or the need to lobby for a new one. Useful data can beobtained by:

Identifying the economic and social status of family members, including their

educational level, sources and amount of income.

Determining if the family can meet basic needs.

Determining the familys dependence on medical and social assistance, e.g.

free health care.

Finding out what health services the family uses and if they can afford it.

Exploring other sources of health care with family.

Determining family acceptance of and satisfaction with services.

A broad understanding of the family situation will help nurses identify family

resources and family needs and thereby determine the policies and programmes

affecting families. Strategies can then be developed to increase family access to

services by influencing policy.


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Concluding Remarks

Caring for families is an exciting and rewarding aspect of nursing. Nurses are the key

resource in caring for the family, the basic structure of society. Nursings long

tradition in family care is well aligned with recent trends towards health promotion,

disease prevention and self care issues that involve the family. Nurses are the main

care providers to families including the vulnerable and marginalised groups such as

immigrants, refugees, street children and the elderly.

Using a systematic approach of assessment, diagnosis, implementation and

evaluation, nurses play a key role in health promotion, disease prevention, care and

rehabilitation. They also enhance family integrity and functioning. Nurses experience

of working with diverse families and their understating of health services are vital

elements in creating family friendly services. Nurses need to be more politically

active to provide information and testimony to bring about needed changes in health

delivery systems that benefit families. Nurses can influence policy through their

national nurses associations as well as through their individual efforts.

Their multi-skilled roles and closeness to people makes nurses essential resourcesfor family health. Whether in health facilities, or community settings and homes,

nurses reach out to people with a continuum of care that covers the entire lifespan. It

is important that every family has access to a nurse to whom they could turn in times

of health and illness. The nurse is well positioned to be the primary care provider

and act as a gate-keeper and entry point to other relevant health services. The full

potential of the nursing workforce must be fully mobilised to create healthy families in

a healthy world.


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