CHAPTER 3:

DEVELOPING THE FAMILY NURSING CARE PLAN

Araceli S. Maglaya

THE FAMILY NURSING CARE PLAN

Formulation of the nursing care plan is the next step in the application of the
nursing process after assessment, when the family nursing problems of each health
condition or health problem have been specified.

The family nursing care plan is a blueprint of the nursing care designed to
systematically enhance the family's capability to maintain wellness and or manage
health problems through explicitly formulated goals and objectives of care and
deliberately chosen set of interventions, resources and evaluation criteria, standa rds,
method/s and tools. As a written guide, the family nursing care plan is regularly
updated for modifications or changes based on family responses, realities, behavioral
processes and outcomes of care.

There are several reasons for planning nursing care. It is a systematic way to guide the
nurse on how to enhance the family's capability for health and health care resource
generation, allocation, and utilization to achieve specific desired outcomes of
prioritized health conditions/problems. Planning enhances the nurse's foresight for
teamwork and coordination of services to ensure adequacy and continuity of care.
Specifically in written form, the nursing care plan promotes systematic
communication among those involved in the health care effort, minimizing gaps and
duplication of services in settings where there is a frequent turnover of staff or when
several health workers are providing care to the same family. This is particularly true
in villages or areas used as field practicum sites for training in community health
work.

Steps in Developing a Family Nursing Care Plan

The assessment phase of the nursing process generates the health conditions
and corresponding family nursing problems which become the bases for the
development of the nursing care plan. Developing a family care plan involves many
steps. Generally the plan consists of the following: (1) Prioritized health condition/s
or problems; (2) Goals and objectives of nursing care; (3) Intervention plan; and, (4)
Evaluation plan.

The various steps in developing the family nursing care plan correspond with the
above components. Figure 3.1 shows a schematic presentation of the nursing care
planning process. It starts with a list of health conditions or problems prioritized
according to nature, modifiability, preventive potential and salience. The prioritized
health conditions or problems and their corresponding family nursing problems
become the bases for the next step which is the formulation of goals and objectives of
nursing care. The goals and objectives specify the expected health/clinical outcomes,
family response/s, behavior or competency outcomes.

The next step is selection of appropriate nursing interventions. It focuses on

alternatives and decision on appropriate intervention measures based on the specific
objectives formulated. The interventions specify the nursing actions to help the family
eliminate the barriers to the performance of health tasks or the underlying cause/s of
non-performance of expected health tasks. These interventions include family focused
alternatives or strategies to help members recognize/detect health problems or
opportunities to enhance wellness state or condition, monitor, eliminate, control and
manage health problems or sustain wellness condition/s. The method of nurse-family
contact and the resources needed are specified in this step to ensure that necessary
preparation is done to achieve the objectives of care in the most efficient way. The
last step is the development of the evaluation plan. It specifies the criteria/outcomes
and evaluation standards as explicit measures that determine achievement of
formulated objectives based on a required or desired level of performance or accepted
change in health condition or family reality. This close relationship between the
evaluation plan and the formulated goals and objectives explains the broken line
between the two boxes in Figure 3.1.

Prioritizing Health Conditions and Problems

Based on standards of community health nursing practice, the nurse handles a

caseload of clients in a specific municipality or cluster of villages. Given a caseload
of families, the nurse may realize that even for just one family, a number of health
conditions and family nursing problems can not be addressed all at the same time
within a specific period. Considering the situation, she can rank the identified health
conditions/problems into priorities. Bailon and Maglaya (1990) devised a tool called
Scale for Ranking Health Conditions and Problems According to Priorities (See Table
3.1). This tool aims to facilitate decision-making in determining which particular
health conditions and their corresponding family nursing problems can be addressed
by the nurse with the family as client-partner at appropriate points in time. There are
four criteria for determining priorities among health condition/s or problems. These
include:

1. Nature of the condition or problem presented - categorized into wellness

state/potential, health threat, health deficit and foreseeable crisis;

2. Modifiability of the condition or problem-refers to the probability of

success in enhancing the wellness state, improving the condition, minimizing,
alleviating or totally eradicating the problem through intervention;

3. Preventive Potential-refers to the nature and magnitude of future problems

that can be minimized or totally prevented if intervention is done on the
condition or problem under consideration;

4. Salience - refers to the family's perception and evaluation of the condition

or problem in terms of seriousness and urgency of attention needed or family
readiness.

The experienced nurse practitioner can determine priorities among health conditions
or problems utilizing her judgment on all these four criteria without necessarily going
through the process of scoring. The arithmetic computations utilized in the scale can,
however, guide the students or new practitioners who still need to gain the skill in
deciding which factors have more weight over others. The computations help
systematize priority setting by determining a specific score for each problem on the
list. The nurse considers several factors in order to be objective in the decision-
making process when setting priorities.

Prioritize the Health Conditions and Develop the Evaluation Plan Specify:
Problems based on: • Criteria, Standards, Outcomes
• Nature of Condition or Problem Based on Objectives of Care
• Modifiability • Methods/Tools
• Preventive Potential
• Salience

Define Goals and Objectives of Care Develop the Intervention Plan

Formulate:
• Expected Outcomes: • Decide on:
• Conditions which sustain
wellness state • Measures to help family
• Conditions to be eliminate:
observed to show problem
is prevented, controlled, • barriers to performance
resolved or eliminated. • of health tasks
Client response/s or
behavior • underlying cause/s of
non-performance of health
• Specific, Measurable Client- tasks
centered Statements/
Competencies • Family-centered alternatives to
recognize/ detect, monitor, control
or manage health condition or
problems

• Determine Methods of Nurse-Family

Contact

• Specify Resources Needed

Fig 3.1 Steps In Developing the Family Nursing Care Plan

Factors Affecting Priority-Setting

Considering the first criterion nature of the condition or problem presented the biggest
weight is given to wellness state or potential because of the premium on client's
efforts or desire to sustain/maintain high level wellness. The same weight is assigned
to a health deficit because of its sense of clinical urgency which may require
immediate intervention. Foreseeable crisis is given the least weight because culture
linked variables/ factors usually provide our families with adequate support to cope
with developmental or situational crisis.

The nurse considers the availability of the following factors in determining the
modifiability of a health condition or problem:

1. Current knowledge, technology and interventions to enhance the wellness

state or manage the problem
2. Resources of the family - physical, financial and manpower
3. Resources of the nurse - knowledge, skills and time
4. Resources of the community facilities and community organization or
support

To decide on an appropriate score for the preventive potential of a health condition or

problem, the following factors are considered:

1. Gravity or severity of the problem - refers to the progress of the disease/

problem indicating extent of damage on the patient/family; also indicates
prognosis, reversibility or modifiability of the problem. In general, the more
severe or advanced the problem is, the lower is the preventive potential of the
problem.

2. Duration of the problem - refers to the length of time the problem has been
existing. Generally speaking, duration of the problem has a direct relationship
to gravity; the nature of the problem is a variable that may, however, alter this
relationship. Because of this relationship to gravity of the problem, duration
has also a direct relationship to preventive potential.

3. Current Management refers to the presence and appropriateness of

intervention measures instituted to enhance the wellness state or remedy the
problem. The institution of appropriate intervention increases the condition's
preventive potential.

4. Exposure of any vulnerable or high-risk group preventivepotential of a

condition or problem.
 TABLE 3.1 SCALE RANKING HEALTH CONDITIONS AND PROBLEMS
ACCORDING TO PRIORITIES

Criteria Weight
1. Nature of the condition 1
or problem presented
Scale**
wellness state 3
health deficit 3
health threat 2
forseeable crisis 1

2. Modifiability of the 2
condition or problem
Scale**
easily modifiable 2
partially modifiable 1
not modifiable 0

3. Preventive potential 1
Scale**
high 3
low 2
moderate 1

4. Salience
Scale** 1
a condition or 2
problem, needing
immediate
attention
a condition or 1
problem not
needing immediate
attention
not perceived as a 0
problem or
condition needing
change
Scoring:
1) Decide on a score for each of the criteria.
2) Divide the score by the highest possible score and multiply by the weight:
(Score/Highest Score) x Weight
3) Sum up the scores for all the criteria. The highest score is 5, equivalent to
the total weight.
Developed by Salvacion G. Bailon and Aracell S. Maglaya. For details see article:
"Tools and Guidelines for Nursing at the Family Level. The Anphi Papers,
22(1):13,1977. Updated by A.S. Maglaya in 2003
** Figures (0,1,2,3) for the weights and scale values are arbitrary deta more by
convenience in computation.
Effective health management/health maintenance pattern and desire for or
engagement in healthy lifestyle activities increase the preventive potential of a
wellness state of condition
To determine the score for salience, the nurse evaluates the family's perception of the
condition or problem. As a general rule the family's concerns, felt needs and/or
readiness increase the score on salience.

Scoring
After the score for each criterion has been decided on, the number is divided
by the highest possible score in the scale. The quotient is multiplied by the weight
indicated for the criterion being considered. Then the sum of the scores for all the
criteria is taken. The highest score is five (5), equivalent of the total weight. The nurse
considers as priority those conditions and problems with total scores nearer five (5).
Thus, the higher the score of a given condition or problem the more likely it is taken
as a priority. With the available scores, the nurse then ranks health conditions and
problems accordingly.

Formulation of Goals and Objectives of Care

A goal is a broad desired outcome toward which behavior is directed. An
example of statement of goal in family health nursing practice is:

After nursing intervention the family will be able to take care of the disabled
child competently

A cardinal principle in goal setting states that goals must be set jointly with the
family. This ensures the family's commitment to their realization. Basic to the
establishment of mutually acceptable goals is the family's recognition and acceptance
of existing health needs and problems. The nurse must ascertain the family's
knowledge and acceptance of the problem as well as the desire to take actions to
resolve them. This is done during the assessment phase.

Barriers to joint goal setting between the nurse and the family include the following:

1. Failure on the part of the family to perceive the existence of the problem. In
many instances the problem is seen only by the nurse while the family is
perfectly satisfied with the existing situation. An example of this is the threat
posed by improper waste disposal. Many families especially in the rural areas,
have no sanitary toilet facilities. But to some families this is no problem at all
since there is the wide open field, the bush or the river which can serve the
same purpose.

2. The family may realize the existence of a health condition or problem but is
too busy at the moment with other concerns and preoccupations. For example,
a mother may perceive the need for immunization for the children but her
household chores take precedence over other concerns.

3. Sometimes the family perceives the existence of a problem but does not see
it as serious enough to warrant attention. The common cold is a condition that
is all too often taken for granted. The same is true with intestinal parasitism
which is commonly regarded as a normal condition in childhood.
 4. The family may perceive the presence of the problem and the need to take
action. It may, however, refuse to face and do something about the situation.
Freeman (1957, pp. 126-128) offers the following reasons for this kind of
behavior.
a. Fear of consequence(s) of taking action For example, diagnosis of a
disease condition may mean expense or social stigma for the family.
b. Respect for tradition/cultural beliefs, values - In Philippine culture,
elders play a part in decision making. Behavior which are not
sanctioned by the old folks in the family are not likely to be adopted. A
couple, for instance, may not accept the goal of limiting family size to
just three children if their parents do not approve of contraceptive
practice
c. Failure to perceive the benefits of action proposed -This could be a
function of a client's previous experience with health workers and their
services. Going to a health center, for example, is an advice frequently
given by nurses. When this does not yield beneficial results from the
point of view of the family, it will be ignored the next time it is
offered.
d. Failure to relate the proposed action to the family's goals - Families
differ in their prioritizing of goals. Economic and social goals.
generally occupy a higher position than health goals in families'
ranking of their concerns and preoccupations. When proposed actions
to improve health are not related to family's goals (e.g. economic
stability), they are not likely to be accepted.

5. A big barrier to collaborative goal setting between the nurse and the family
is failure to develop a working relationship. Nothing will be accomplished, as
a matter of fact, in a nurse's work with families unless the family sees the
nurse as someone who is genuinely concerned with its welfare. The elements
of mutual respect, trust and confidence are crucial to the success of the nurse-
family partnership towards better health.

Goals set by the nurse and the family should be realistic or attainable. They should be
set at reasonable levels. Too high goals and their consequent failure frustrate both the
family and the nurse.

A clear definition of the problem situation and an accurate assessment of available

resources facilitate the setting of realistic goals. Both of these are functions of the
depth and breath of the assessment process.

Goals, like objectives, are best stated in terms of client outcomes, whether at the
individual, family or community levels. Objectives, in contrast to goals, refer to more
specific statements of the desired results or outcomes of care. They specify the criteria
by which the degree of effectiveness of care is to be measured. Goals tell where the
family is going; objectives are the milestones to reach the destination.

Objectives stated as outcomes of care in family health nursing practice specify

physical, psychosocial states or family behavior (or competencies). Examples are
given below:
 1. After nursing intervention, the malnourished preschool members of the
family will increase their weights by at least one pound per month.
2. After nursing intervention, the family will be able to:
a. Feed the mentally retarded child according to prescribed quantity
and quality of food.
b. Teach the mentally retarded child simple skills related to the
activities of daily living.
c. Apply measures taught to prevent infection in the mentally retarded
member.

The more specific the objectives, the easier is the evaluation of their attainment.
Specifically stated objectives define the criteria for evaluation.

Objectives vary according to the time span required for their realization. Short term or
immediate objectives are formulated for problem situations which require immediate
attention, and results can be observed in a relatively short period of time. They are
accomplished with few nurse-family contacts and with the use of relatively less
resources. Long-term or ultimate objectives, on the other hand, require several nurse-
family encounters and an investment of more resources. The nature of outcomes
sought require time to demonstrate. Such is the nature of behavior change which is
often the object of nursing intervention. Medium-term or intermediate objectives are
those which are not immediately achieved and are required to attain the long-term
ones.

As with goals, objectives should be realistic and attainable considering the resources
of the nurse, the family and the community. In addition, they should be measurable.
Specific statements of objectives facilitate the evaluation of their attainment.
Objectives and evaluation are directly related. When objectives are stated in terms of
observable fact and/or behavior, the criteria for evaluation become inherent and
evident.
Example:
Nursing goal -The family will manage malaria as a disease and threat in an endemic
area.
Short-term/immediate objective- The sick member/s will take the drugs
accurately as to dose, frequency, duration and drug combination. All members
will use self-protection measures at night till early morning when biting time.
of the mosquito vector is expected.

Medium-term/intermediate objective - All members will have regular

medical check-up and laboratory confirmation (i.e., blood smear) to monitor
presence of malaria.

Long-term objective- All members will carry out mosquito vector control
measures.

DEVELOPING THE INTERVENTION PLAN

The next step in developing the family nursing care plan is formulating the
intervention plan. This involves selection of appropriate nursing interventions based
on the formulated goals and objectives. In selecting the nursing interventions, the
nurse decides on appropriate nursing actions among a set of alternatives, specifying
the most effective or efficient method of nurse-family contact and the resources
needed. Some examples of methods of nurse-family contact include the home visit,
clinic conference, visit in the work place, school visit, telephone call, group approach
(like health classes), and use of the mail (e.g. letter/s, electronic mail). The resources
which include material (e.g., supplies, equipment, teaching aids/kits, visual materials,
handouts, charts, etc.) or human (e.g., other health team members, development
workers, community leaders) must be specified in the plan to ensure that necessary
preparation, coordination and collaboration are done before the implementation phase
to maximize efficiency.

The following general directions for nursing interventions can guide selection of
appropriate nursing interventions:
1. Analyze with the Family the Current Situation and Determine Choices and
Possibilities based on a Lived Experience of Meanings and Concerns.
2. Develop/Enhance Family's Competencies as Thinker, Doer and Feeler
3. Focus on Interventions to Help Perform the Health Tasks
4. Catalyze Behavior Change through Motivation and Support.

Analyze Realities and Possibilities based on Family's Lived Experience

of Meaning and Concerns

Family life and nursing practice are both phenomenological unified realities of
experiencing the self interacting with others in specific situations that are affected by
meanings, concerns, emotions, past experiences and anticipated future (Benner and
Wrubel 1989). The appropriateness of the nursing intervention is, therefore,
dependent upon the lived meaning of the experiences of family members with each
other and with the nurse, given the current situation and possibilities in health and
illness realities. Because family health nursing practice is a phenomenological
experience for the family and the nurse, the family becomes an active participant in
the application of the nursing process. The family and the nurse are participants in an
active, mutual, dynamic interchange of realities, concerns and resources. Both need to
analyze and understand the current health/illness situation as the family experiences it.
To ensure appropriateness of nursing intervention, the nurse needs to explore with the
family the possibilities and choices presented by the current situation given the
meanings, concerns, social relations, and resources.

Through the participatory approach the nurse can select experiential learning
strategies to help the family understand its behavior in terms of dynamics, realities,
vulnerabilities and possibilities. Through the "Look-Think-Act" cyclical process, the
family can be encouraged to analyze antecedents or factors contributing to or
producing specific health problems. Based on the analysis, the nurse can catalyze
learning processes such that the family can learn to deconstruct mindsets or current
beliefs and be guided on how to re-order patterns and relationships for fresh insights
and workable options to modify and improve family dynamics and realities.

Develop/Enhance Cognition, Volition and Emotion

To determine the appropriateness of nursing intervention, the nurse is given a
choice of possibilities that helps her and the family gain a clearer understanding of the
self as a thinker, a doer and a feeler. The choice contributes to a process of self-
understanding of the family as a system and of each individual member (Allanach
1988, pp. 78-79).

Nursing interventions that enhance or maximize the competencies of the family as

thinker include making information/data or knowledge readily available and
accessible for ease of and confidence in understanding current situations in health and
illness. Decision-making on appropriate actions to take are, likewise, enhanced.
Developing and maximizing the skills and communication competencies of the family
as doer enhance confidence in carrying out the needed interventions to initiate and
sustain change for health promotion and maintenance, and accurate disease/problem
management. As feeler, the family needs to develop or strengthen its affective
competencies in order to appropriately acknowledge and understand emotions
generated by family life or health and illness situations (e.g., fear, anger, anxiety,
jealousy, guilt).

By doing so such emotions can be transformed into growth-promoting choices and

actions. When the family realizes that acknowledging feelings and allowing them to
guide understanding of the situation and the self, the experience can attain the greatest
freedom in moving into new possibilities. Benner and Wrubel (1989) succinctly
explain:

By acknowledging the dwelling in the occasions and meanings of our feelings we can
gain the skill to rehearse and return to positive feelings such as joy, pride, comfort and
contentment... By remembering and reexperiencing positive feelings on new
occasions, we are sometimes enabled to change our context or circumstances to ones
that foster those feelings, see new possibilities for action in the unchanged
circumstances, or simply experience pleasure and see things in a rosier light. This
positive ability may provide a respite and offer perspective during a time of negative
feelings such as fear or anxiety. This respite may be what one needs to face and
understand the source of the negative feelings (pp. 170-171).

Focus on Interventions to Help the Family Perform the Health Tasks

The nurse needs to focus her choice of interventions on helping the family
minimize or eliminate the possible reasons for or causes of the family's inability to do
the health tasks:

1. Help the Family Recognize the Problem. Examples of nursing interventions to

enhance the family's ability to recognize its health needs and problems include: (a)
increasing the family's knowledge on the nature, magnitude and cause of the problem;
(b) helping the family see the implications of the situation, or the consequences of the
condition; (c) relating health needs to the goals of the family (both health and non
health related goals); (d) encouraging positive or wholesome emotional attitude
toward the problem by affirming the family's capabilities/ qualities/resources and
providing information on available options.

2. Guide the Family on How to Decide on Appropriate Health Actions to Take.

This can be done through: (a) identifying or exploring with the family the courses of
action available and the resources needed for each; (b) discussing the consequences of
each course of action available; and, (c) analyzing with the family the consequences
of inaction.

3. Develop the Family's Ability and Commitment to Provide Nursing Care to its
Members. The nurse can increase the family's confidence in providing nursing care to
its sick, disabled and dependent member through demonstration and practice sessions
on treatments or techniques utilizing readily available, low-cost and equipment and
other resources.

Contracting is creative intervention that can maximize opportunities to develop the

ability and commitment of the family to provide nursing care to its members by
focusing on assisting the members to act effectively on their own behalf (Clemen-
Stone and others 2002, p.281). It is an intervention whereby the nurse creates a
situation in order that the client learns to achieve a specific health-related behavior
through a sequentially arranged explicit steps and conditions or elements jointly
identified by both parties. This intervention uses reinforcement contracts on a variety
of health-related behavior requiring complex behavioral changes such as adherence to
diet, medication and other treatment regimens to maintain desirable laboratory values,
lose weight, and control blood pressure (Steckel 1980, p. 1597). Such complex
behavioral changes require the performance of explicit steps (intermediate behaviors)
and each step requires reinforcement if the terminal new behavior is to be learned and
maintained. Contracting provides a systematic method of increasing desirable client
behavior through the use of the principle of positive reinforcement. Using this
principle the nurse and the client mutually agree on favorable reinforcing experiences
or consequences as rewards when the client performs the desired behavior.

In order to make this intervention effective, the necessary elements of the desired
behavior must be made explicit and must be written in the form of an agreement. To
make the behavior consciously reinforced it must be observable and measurable. The
contract specifies the terminal, intermediate behaviors and the reinforcers as rewards
for the client in return for performing the behaviors. The client and the nurse jointly
identify the terminal behavior and the component intermediate behaviors. Steckel
used contracting as intervention in her researches on patient adherence to health care
prescriptions. She recommends that the contract be written, dated, signed by all
parties concerned and a copy is given to each one. Furthermore, she specifies in her
contract the method for monitoring the behavior through recording. See Box 3.1 for a
sample family-nurse contract.

4. Enhance the Capability of the Family to Provide a Home Environment

Conducive to Health Maintenance and Personal Development. The family can be
taught specific competencies to ensure such a home environment through
environmental modification, manipulation or management to minimize or eliminate
health threats or risks or to install facilities for nursing care. The family can learn to
construct or modify needed facilities in the home such as a commode for a disabled or
aged member who can not use the family's toilet because of distance. Environmental
conditions conducive to breeding and habitation of vectors of diseases (such as
mosquitoes) can, likewise, be improved by the family if it has the necessary
competencies to carry out vector control measures. For example, the nurse can teach
specific techniques or procedures like clearing stream banks of overhanging
vegetation and debris to expose them to sunlight and speed up water flow to eliminate
breeding sites of Anopheles flavirostris, the primary mosquito vector of Malaria.
Another example is the need to change water in flower vases at least every two days
or not to allow water to remain stagnant in artificial containers (like old tires or
discarded cans) in order to eliminate breeding places of Aedes egypti, mosquito
vector of Dengue and Dengue Hemorrhagic Fever.

To minimize or eliminate psycho-social threats or risks in the home environment, the

nurse can work closely with the family to improve its communication patterns, role
assumptions, relationships and interaction patterns.

5. Facilitate the Family's Capability to Utilize Community Resources for Health

Care. Another major intervention involves maximum use of available resources
through coordination, collaboration and team work provided by an effective referral
system. Easy access to available health and socio-economic resources starts with
maintaining an updated file that lists such resources, their addresses or telephone
numbers and specific services offered.

A sample format of the file or index of community resources is shown below:

Name of Office and E-mail Type of Client Requirements/

Agencyand Address/ and Specific Procedures for
Person to Contact Telephone Number Services/Schedule Referral

A two-way referral system can facilitate mobilization of resources for families. The
nurse or the agency establishing such a system can have previous arrangements or
agreements on the referral procedures and services with the agencies or resources
involved.

A sample two-way referral form is shown in Figure 3.2. The nurse of the referring
agency accomplishes the first half of the form providing the necessary information or
case summary and specifying the reasons for referral or the services requested. She
can let the family bring the form to the agency where referral is made. She can advice
the family that after the necessary consultation is done with the agency where referral
is made, the family can bring back the second half of the form with information on
services done, findings and recommendations. Other alternatives are possible, such as
a messengerial service that brings the forms from one agency to the other. The nurse
can also do the necessary communication with the personnel of the agency where
referral is made for follow-up and coordination.

An effective two-way referral system ensures monitoring of the case, problem or

situation, follow-up of required interventions, case or services and evaluation of the
clients' status or family's problem/situation.
 (Letterhead of Referring Agency specifying Name, Address and Telephone
Number)

Name of Agency to Which Referral is Made:

Address: Date:

Name of Patient/Family Head:

Age:
Sex: Civil Status: Occupation:

Address:

Case Summary:

Reason for Referral/Services Requested:

___________________________
Signature of Referring Personnel
and Designation
______________________________________________
(Cut here and send back to)

Name of Referring Agency:

Address:

Date:

Name of Patient/Family Head:

Age: Sex:

Services Done/Findings/Recommendations:

______________________
Signature and Designation

(See back page for instructions)

Fig. 3.2. Sample Two-way Referral Form

 (back page)

Two-Way Referral Form

Objective:

Set-up a referral system that facilitates access to services and Information by client/
family and agencies.

Instructions:

1. The personnel of the referring agency (e.g., barangay station; R.H.U.) fills
up the first half of the form providing pertinent data as indicated (i.e., case
summary and reason for referral or services requested.

2. The client/family brings the referral form to the agency where referral is
made to avail of the services needed.

3. The personnel of the agency to which referral is made fills up the second
half of the form, specifying the services rendered/findings and
recommendations, and sends back the form to the referring agency through the
client/family.

4. The client/family brings back to the referring agency (e.g., barangay station;
R.H.U.) the duly accomplished second half of the form for decision, action or
information. The form is filed with the client's record.
Catalyze Behavior Change Through Motivation and Support.

To bring about self-directed change, people must learn to learn from their
experiences, According to Chin and Benner (1976, p.37), frequently people have
learned to defend against the potential lessons of experience when these threaten
existing equilibria, whether in the person or in the social system. In order to help
people lower their defenses and allow themselves to experience the needed change, it
is necessary to have a learning environment that nurtures the change. The change
agent can help the client put to maximum use valid knowledge through concern for:
(1) human needs or the "use-value of a given piece of knowledge; (2) security, trust,
self-esteem, self-identity, group esteem and group identity; (3) accurate and
appropriate preparation and transmission of messages. To catalyze the change
process, support is needed so that an otherwise insecure, threatened or anxious client
who is faced with the stresses of an unfamiliar reality can experience stability or feel
some sense of self-trust or confidence to sustain actions and complete the behavior
change.

In family health nursing practice, the family as a system needs to achieve optimum
reality-orientation in its adaptation to changing internal and external environment This
is done by developing and institutionalizing its own problem-solving structures and
processes through performance of the family health tasks. To catalyze the behavior
change towards problem-solving competencies, a theory of family health nursing
intervention was developed by Maglaya (1988). Motivation and support are
components of this intervention. Motivation as conceptualized in the intervention
theory is any experience or information that leads the family to desire and agree to
undergo the behavior change or proposed measure and take the initial action to bring
about the change (p.18). Support as an intervention is any experience or information
that maintains, restores or enhances the capabilities or resources of the family to
sustain these actions and complete the change process. The intervention leads the
family to feel "secured" or "in control of the situation" in the face of uncertainties,
stresses, blocks or barriers to the solution of the health condition or problem or threats
to self-esteem and affection or danger to life (p.19). To illustrate, a young mother with
a severely malnourished nine-month old baby suffering from diarrhea can be so
overwhelmed with her child's condition that she rejects any advice to do oral
rehydration and continue feeding the child. Experience taught the mother that such
actions lead to vomiting and more frequent bouts of diarrhea. Through motivation and
support, the nurse can help the young mother understand the cyclical relationship of
diarrhea and malnutrition and the causes of diarrhea when giving oral feeding. She
can develop the mother's competencies to administer oral rehydration slowly through
the cup, spoon or dropper. She can demonstrate to the mother how to prepare and give
easily digested rice gruel mixed with protein concentrates, made from powdered
beans, sun-dried or toasted-dry small fish or shrimps (see Chapter 14). During the
initial experiences of the mother in carrying out such measures to manage diarrhea,
the nurse's physical and psychological availability or accessibility are sources of
support especially during experiences of fear, doubt and helplessness. When the nurse
can not be physically present, the young mother can be made to feel that the nurse's
help is readily available through the clinic visit, telephone or written note.

In an evidence-based intervention research on family empowerment for malaria

prevention and control in a rural barangay (village) in Abra Province, motivation
support intervention consisted of four major components (Maglaya et al, 1999). The
first component included visioning or goal-setting activities which helped families
clarify or specify the reasons for the needed behavior change. The second component
consisted of planning sessions which focused on developing family competencies to
specify the objectives and strategies to achieve expected goals (i.e., what can be done
to achieve the specific behavior changes and how these can be carried out). The third
component consisting of implementation or practice sessions centered on providing
the families guided experiences or opportunities to carry out or practice the
competencies/ skills learned. The last component focused on evaluation activities
which developed the families' capabilities to specify "What happened?", "What were
missing?" and, "What to do next?" Research findings showed that these four
components of the motivation-support intervention significantly improved the
families' competencies on early casefinding, prompt/appropriate treatment, use of
self-protection measures and environmental manipulation to eliminate the breeding
and resting sites of the mosquito-vector of malaria.

Fleury's model of wellness motivation was adapted using the motivation-support

intervention. Families were guided thru the behavior change process: from
constructing the intention to initiate/sustain the change to translating the intention into
actions, and lastly to integrate the actions/change into existing lifestyle. Appendix E
specifies the nursing interventions to facilitate the families' movement through each
stage. Chapter 18 describes in detail the family empowerment process and outcomes
based on an intervention research on malaria control done in Danglas, Abra Province
from 1997 to 1999.

Criteria for Selecting the Type of Nurse-Family Contact

Effectivity, efficiency, and appropriateness are major criteria for selecting the
type of family-nurse contact. While the home visit is expensive in terms of time,
effort, and logistics for the nurse, it is an effective and appropriate type of family-
nurse contact if the objectives and outcomes of care require accurate appraisal of
family relationships, home and environment, and family competencies (i.e. the best
opportunity to observe actual care given by family members).

The clinic or office conference is less expensive for the nurse and provides the
opportunity to use equipment that cannot be taken to the home. In some cases, the
other team members in the clinic may be consulted or called upon to provide
additional service. The clinic or office conference also emphasizes to the family the
importance of empowerment and assuming responsibility for self-help.

The telephone conference may be effective, efficient and appropriate if the objectives
and outcomes of care require immediate access to data, given problems on distance or
travel time. Such data include monitoring of health status or progress during the acute
phase of an illness state, change in schedule of visit or family decision, and updates
on outcomes or responses to care or treatment.

The written communication is another less time-consuming option for the nurse in
instances when there are many priority families needing follow-up on top of problems
of distance and travel time. If the family is motivated and independent enough such
that the nurse can use the advantage of placing responsibility for action on the family,
sending a letter, note (as reminder, follow-up on medication/treatment or update on
progress or referral) and learning materials are appropriate, effective and efficient
options. A school visit or conference provides an opportunity to work with the family
and school authorities on how to determine the degree of vulnerability of and work
out interventions to help children and adolescents on specific health risks, hazards or
adjustment problems. An industrial plant or job site visit is done when the nurse and
the family need to make an accurate assessment of health risks or hazards, and work
with employer or supervisor on what can be done to improve on provisions for health
and safety of workers.

DEVELOPING THE EVALUATION PLAN

The evaluation plan specifies how the nurse will determine changes in health status,
condition or situation and achievement of the outcomes of care specified in the
objectives of the family nursing care plan. The plan includes evaluation criteria
indicators, standards, methods and tools/evaluation data sources. As the nurses
systematic guide to facilitate improvement in client's health status, home and
environment condition or situation, behavior or role/task performance, the evaluation
plan specifies the criteria as objective, measurable and flexible indicators to determine
achievement of expected performance, behavior, circumstances or clinical status (ICN
1989). An evaluation standard refers to the desired or acceptable condition, clinical
status or level of performance corresponding to an evaluation criterion or indicator
against which actual condition, clinical status or performance is compared.

The evaluation plan also includes evaluation methods and tools and/or evaluation data
sources. Examples of evaluation methods include direct observation, interview, oral
or written tests, record review, health/physical examination (e.g. vital signs and
anthropometric measurement-taking, IPPA, etc.). Note that these are similar methods
used during the assessment phase. It must be remembered that because the cyclical
nature of the nursing process, evaluation ushers in the assessment phase at the next
level of application of the nursing process. Evaluation tools include performance
evaluation checklist, rating scale, interview guide, food recall form, food frequency
and food record form as examples. Instruments such as weighing scale, thermometer,
blood pressure apparatus, tape measure and glucometer are examples of evaluation
tools too. Evaluation data sources are records and reports which document the data
results generated from specific methods and tools to determine achievement of
expected outcomes based on the goals/objectives specified in the family health
nursing care plan. See Table 3.2 for a sample evaluation plan.

DOCUMENTATION

The family care plan is a written guide of the nurse and family to ensure a systematic
approach to planned behavior change. Appendices C2 and C3 include The Family
Service and Progress Record (FSPR) and the instructions on the Use of the Family
Service and Progress Record. Together with Appendix C1 (Charting Nursing Care,
Progress Notes and Client Responses/Outcomes), these tools are examples of how to
set up a record keeping system which provides direction for planning, implementation
and evaluation of client care. Accurate record keeping is an important responsibility
of the community health nurse. It provides evidence for professional accountability
and quality care.

OUTCOMES
Goal: Improve the
nutritional status of the two-
year old family member
Objectives:
The family will be able to:
1. Provide adequate
care to the two-year
old member
TABLE 3.2 SAMPLE EVALUATION PLAN
EVALUATION/
INDICATORS
Weight (as nutritional status
criterion)
Performance
Criteria/Indicators:
1.a Identify inadequacies in
specific nutrients generated
from the baseline dietary
intake of the child
1.b Prepare meals based on
cycle menu plan
EVALUATION EVALUATION
STANDARDS Method Tools/Data Source
Increase of at least 1 kilogram Weight Weighing scale, Early
in sic weeks Monitoring Childhood Care and
Development Card for 0-6
years
Correct identification of Dietary history Food recall form or food
inadequacies in intake of taking frequency record
specific macronutrients,
vitamins and minerals critical
to growth, bone development
and strong immune system.
Accurate application of Daily Record Review Menu plan
Nutrition Guide Pyramid for
Filipino children 1-6 years.
Preparation of meals guided Observation Performance evaluation
by principles such as nutrient checklist
preservation, increased variety
and appealing to taste.
 1.c. Feed the child based on Child's daily food intake based Record Review Estimated food record
agreed upon quality and on recommended energy and Observation and performance evaluation
quantity of food. nutrient intake for age group Interview checklist

1.d. Carry out strategies/ Appropriate and effective Interview and Performance evaluation
measures to address child's measures based on child's age Observation checklist
eating idiosyncrasies and and nature/magnitude of
problems eating/feeding problems

2. Utilize community 2.a. Bring the child to the Clinic follow-up at least once Record Review Early Childhood Care and
resources for care health center/clinic for during the month Development Card for 0-6
regular early childhood years old
growth monitoring and care.