INTERNATIONAL NURSES DAY 2002

NURSES ALWAYS THERE FOR YOU: CARING FOR FAMILIES

Information and Action Tool Kit

All rights, including translation into other languages, reserved. No part of this publication may be reproduced in print, by photostatic means or in any other manner, or stored in a retrieval system, or transmitted in any form without the express written permission of the International Council of Nurses. Short excerpts (under 300 words) may be reproduced without authorisation, on condition that the source is indicated. ----------------------------------------------------------------------------------------Copyright 2002 by ICN - International Council of Nurses, 3, place Jean-Marteau, CH-1201 Geneva (Switzerland) ISBN: 95005-42-2

CARING FOR FAMILIES Table of Contents

Message from ICN Introduction Chapter one Defining Family Chapter two How Nurses Provide Family Care Chapter three Caring for Poor, Displaced and Refugee Families Chapter four Family-Friendly Policies and Services Influencing public policy Family-friendly activities Sample press release Media backgrounder Sample survey ICN Position Statements: Participation of Nurses in Health Services Decision Making and Policy Development Nurses and Primary Health Care Health Services for Migrants, Refugees and Displaced Persons Annex 1

1 3 5 9 19 23 31 33 35 37 39

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43 45

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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 family health, the ICN has selected Nurses Always There for You: Caring for Families as the theme for International Nurses Day (IND), 12 May 2002. ICN has done considerable work in this area. The Caring for Families document builds on this previous work, which includes several products. In 1994 ICN published the Healthy Families for Healthy Nations kit as part of the years IND celebrations. The inaugural Virginia Henderson Fellowship in 1999 focused on the family nurse and most recently, ICN published The Family Nurse, a monograph outlining key issues, 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 are the places where nurses practice. However, the family, in one way or another, is always a principal target for nursing care. This years IND theme of Nurses Always There For You: Caring for Families aims 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 that nurses can be powerful advocates in determining the best public policy for family health. As part of your IND activities, we encourage your association to share your knowledge and experience in caring for families with policy makers, the public and other health professions with a view to encouraging family friendly policies in health care delivery. We look forward to hearing about your subsequent successes.
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The health of the family has never been more important in shaping a strong and vibrant society. As nurses help individuals and families to make healthy choices, cope with illness and chronic disability, manage stress and work with them in their homes, schools and workplaces, they are helping to ensure the strength of the most fundamental building block of society. Sincerely,

Christine Hancock President

Judith A. Oulton Chief Executive Officer

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 Families presents 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

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 individual family members, so as to promote health, prevent illness, and provide cure, care and rehabilitation services. Nurses work with families: To reduce the factors that damage health To enhance good health and well being To strengthen self-care and coping skills

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 legal relationships.. 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.

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 throwaway kids. 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 Nuclear family one parent, living in the same household. a) first marriage families b) blended or step-parent families Nuclear family husband, wife and children living together. a) first marriage families b) blended or stepparent families Nuclear family husband and wife living alone; childless or no children living at home. a) single career b) dual career Single-parent family- female or male headed as a result of divorce, abandonment, separation, or death. 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 own
Source: Adapted from Friedman, M.M. (1997) Family Nursing: Research, Theory & Practice

Common non-traditional family forms Unmarried parent and child living alone, usually mother and child

Unmarried couple and child living together usually a common law marriage

Cohabiting couple unmarried couple living together

Same sex persons living together as partners

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 selfesteem 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 the neglect 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 tends to be confusing, indirect, defensive and lacking honesty. Assessing the communication patterns of families is a key tool in determining levels of functioning.

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.

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 its members. 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 nursing

Nurses 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.

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 home environment so that the disabled can improve mobility and engage in selfcare. 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:

Identifying the health concern or problem Evaluating to see if desired outcomes have been achieved

Collecting and analysing data

Establishing goals and desired outcomes

Implementing strategies and interventions to improve health

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. 2. 3. 4. The Family Assessment and Intervention Model (FAIM) The Friedman Family Assessment Model The Calgary Family Assessment Model (CFAM) and the Calgary Family Intervention Models (CFIM) 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 encompassing assessment, education, and assistance. This includes mobilising resources from other professional and service providers in the health and community sectors.

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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 and intervention, 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 the family 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 and functioning.

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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 or diabetes 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, costcontainment 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, these same 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 the first line, and constant contact for people wherever they live and work. Using a life cycle approach, twenty-four hour care is provided to families from birth to death. The nurse takes on many roles, including care provider, decision maker, communicator, community leader and manager of services for the clients, patients, families and the local community. The goal is to provide all families with a registered nurse that will work with them from birth to death.
(Source: )
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Family Health Nurses in Botswana In Botswana, where the family nurse practitioner (FNP) has been recognised for twenty years, the approach adopted is a combination of a generalist who provides care for families and a nurse who cares for the patient suffering from illness. Family nursing practice is defined within the principles 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 as counselling, most often takes place in outpatient facilities in consultation with one or more family members. Family assessment focuses on the family as a socio cultural unit affected significantly by social changes in the country.
(Source: Standards of Family Nurses Practice: Nurses Association of Botswana, 2001)

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A Nurse and a Family in America: The Smith Family I work in a paediatric clinic providing health care services to a variety of clients. One day I noted that the next patients on my schedule were two little boys ages 4 and 5, who had had just been placed in a new foster home. The state requires a physical exam on all children within a week of being placed in a foster home. I encountered two little boys who were literally 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 looked in utter amazement at the foster parents, wondering how long anyone could tolerate these two boys in their house.

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The foster parents were two men, Ted and Ray. They were a gay couple who had been referred to me by a friend of theirs. They were in a stable long-term relationship. They wanted children and knew that the only way they could become parents was to become foster parents . They were both employed in good jobs and were willing to make any sacrifices necessary to become parents. I was sceptical. I spent a great deal of time talking to Ted and Ray about how many obstacles they would be facing. Having an instant family could spell disaster to even a 'normal,' stable relationship with 'normal' children. These men faced what appeared to be insurmountable odds. The two little boys 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 in amazement while these two boys were transformed from difficult, unruly children, to well-behaved, loving boys. I found myself considering asking Ted and Ray if they would give parenting classes for some of my other patients because they were the best parents I had in my practice. Recently I looked on my schedule and found I had a walk-in appointment with the boys. They had brought me the pictures from the courthouse, immediately after their adoption. Ray and Ted had changed the last names of the boys at the time of the adoption. The boys proudly informed me that they were now the 'Smith family.' I was touched beyond words that they wanted me to share this important moment with them. It is not very often that you can be present at the birth of a new and special family.
Renee McLeod, MSN, RN Excerpted 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 family breakdown 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.

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Working with Migrants, Refugees and Displaced People

The family as the basic unit of society is often the greatest casualty of war and natural disasters. Worldwide families are witnessing changes caused by armed conflict, political upheaval, economic hardships, and natural disasters that challenge family 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 women and 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 access to 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 create family-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:

Special interest groups

Political ideology

Public opinion

Public Policy

Equity and solidarity

Media

Some determinants of healthy public policy

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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 on ones 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 such services 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 be obtained 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 resources for 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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References
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International Council of Nurses (ICN) International Classification for Nursing Practice. Beta. Page. 62. 2 Friedman, M.M. (1998), family Nursing: Research, Theory, & Practice. Fourth Edition. Pp.11-16. Stamford: Appleton & Lange. 3 Gilliss, C (1989), Family Research in Nursing. In C.L. Gilliss, B.L. Highley, B.M. Roberts, & I.M. Martinon (eds.), Towards a science of family nursing (pp.37-63). Menlo Park, CA: Addison Wesley. 4 WHO, Europe (2001), Second Ministerial Conference on Nursing and midwifery in Europe. Report of a WHO Conference, Munich, Germany, 15-17 June 2000. p. 11. 5 Brown s. and Gimes, D (1992), A Meta.-Analysis of Process of Care, Clinical outcomes and Costeffectiveness of Nursing in Primary Care Roles, Nurse-Practitioner and Nurse-Midwives. Washington, DC; American Nurses Association. 6 Canadian Nurses Associations initiative of Cost-Effective Nursing Alternatives. Cited in the Value of Nursing in a Changing World, ICN. 1996. 7 British Medical Journal 2000: 320: 1038-1048 8 Gec, T. (2000, March). Personal communication about the community nursing unit in Slovenia. 9 United Nations Development Programme, (2000), Human Development Report 2000. New York: Oxford university Press. 10 United Nations High Commissioner for Refugees (UNHCR) web site at: www.unhcr.ch 11 World Health Organization (1997), Nursing practice around the world. Geneva:WHO. 12 ICN (2001), Guidelines on Shaping Effective Health Policy. Geneva: ICN.

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