Person and Family-centered care

Family and kinship: evolution from traditional ties to diverse connections

• In 1970, Firth and Firth defined family and kinship as a set of ties socially recognized to exist between persons because of their genealogical connection, relationships created by marriage and/or procreation of children.
• By 2023, families are still seen as kin-related groups, but kinship now includes many connection types: adoption, surrogacy, friendship, cohabitation, and fostering.
• Other family types mentioned: single parent, dual career, single, dual, extended, blended, and binocular (note: transcript uses binocular; later sections describe blended/binuclear as well).
• The nurse’s role: care for a person while considering their family roles or influence on the person’s health and care.

Communities and cultures; diversity and inclusion in nursing practice

• Communities and cultures include LGBTQIA plus persons, language minorities, religious communities, and persons with disabilities.
• Differences in social and ethnic backgrounds, gender, and social orientation reflect a community’s diversity.
• Nurses should use inclusive language and advocate for policies that allow all persons to feel included in their health care process.
• Nurses should find individual ways to care for those with disabilities to respect autonomy while providing needed assistance.
• Core idea: care of families within culturally diverse contexts.

Cultural competence and culturally responsive care

• Culturally competent care is the lifelong process of applying evidence-based nursing in alignment with patients’ cultural values, beliefs, and practices to improve outcomes.
• Cultural responsive care is the process of determining proper care by understanding, respecting, and integrating a person’s cultural beliefs into health care; essential for trusting nurse–patient relationships.
• When people are valued for all aspects of identity, background, and experiences, they feel safe and understood; cultural responsive care is required for trust-building.
• Nurses must be intentional in learning about other cultures and belief systems.

Influence of family structure on care and society

• Family structure encompasses: who is considered family, birth order, number of parents in the household, whether a parent is single by choice or circumstance, nuclear vs extended families, and the family’s origin.
• Family structure helps determine individuals’ societal roles.

Dysfunctional vs functional families; ethical and legal considerations

• Dysfunctional families may lead to mental health issues, trauma, abuse, abandonment, or neglect.
• Functional families support well-being, help individuals adapt to change, and balance individual and family needs.
• Legal and ethical issues related to family members include stepparent rights and responsibilities.
• In the United States, stepparents have limited legal rights and responsibilities.

Legal authority and stepfamilies

• Legal decision-making authority generally belongs to the two biological parents.
• Stepparents can assist their spouse but cannot make major decisions (school, medical care, religion, etc.) without biological parent consent.
• If a stepparent and biological parent divorce, some states may grant visitation rights to the stepparent.
• Paperwork such as a signed consent to treat letter can exist, notarized and signed by both biological parents and legal guardians.
• A stepparent can pursue adult adoption of the child if the other biological parent agrees to terminate parental rights.
• Court requirements for stepparent adoption commonly include: being married to the biological parent for at least one year and living with the child for at least six months.

Dual career families

• A dual career family is defined as a household in which both parents work.
• A 2015–2017 survey found that dual career families with children under six years old had an income of 53{,}873, higher than that of single career families.
• In dual career households, health insurance is usually available and affordable compared with households without employment.
• Challenges include time management and role conflict due to competing professional and family responsibilities; women in dual career couples often experience more stress due to continuing domestic task and childcare burdens.
• When interviewing families, the nurse should gather information on how family roles are assumed by each partner.

Single career families

• A single career family is a household where one parent works and the other stays at home.
• Historically, the stay-at-home parent was commonly a woman; currently, about rac{1}{5} of stay-at-home parents in the United States are fathers.
• Benefits of single-career households: when a parent is available for child care, outside childcare costs are reduced and more income is retained in the home.
• Potential downside: when the stay-at-home parent returns to work, employment options may be limited due to gaps in work history.

Single parent families

• Single parent families consist of children living with one parent.
• In the United States, nearly 24{,}000{,}000 children live in a single-parent home, with about 14{,}500{,}000 living in a mother-only household.
• Annie E. Casey Foundation data: nearly 30 ext{%} of single-parent families live in poverty compared with about 6 ext{%} of married couples.
• Children in single-parent situations face higher risks of physical, mental, and behavioral problems due to poverty.
• Benefits of single-parent households include potential for parents to focus more on children, and, in cases of divorce from violent partners, reduced stress from escaping violence.
• In healthcare settings, nurses should confirm the presenting parent is the legal guardian before sharing health information; documentation should reflect guardian status.

Extended family

• An extended family includes grandparents, aunts, uncles, and cousins.
• In some cultures, nuclear and extended families live in the same house; some families share one residence to save money, while others house grandparents due to health needs.
• When a patient has extended family present, nurses should ask whether the patient wants extended family included in the care plan before discussing private health information.

Blended or binuclear families

• A blended or binuclear family consists of parents and children who are not biologically related to the other parent.
• Typically formed after death or divorce, but can occur when individuals have never married.
• According to the Step Family Foundation, more than 50 ext{%} of US families are remarried and recoupled.
• Challenges for blended families: children may struggle adjusting to new parents and siblings; stepparents may feel the stepchild is trying to replace their other parent.
• Stress can arise for both parents and children; nurses should be aware of potential family stress when caring for a person.

Care of LGBTIA plus persons and families

• The biggest barrier to culturally competent health care for LGBTIA plus individuals is healthcare providers’ lack of knowledge.
• Providers may be confused about pronouns, terminology, gender-affirming care, and guidelines specific to transgender and gender-conforming persons.
• Table 2.1 (from the source) lists current LGBTQIA plus terminology (definitions provided below).
• Key terms:
  • Transgender: umbrella term for a person whose gender identity and expression may differ from birth-assigned gender.
  • LGBTQIA plus: lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and other identities.
  • Bisexual: attracted to people with male and female gender identities.
  • Cisgender: gender identity matches sex assigned at birth.
  • Gender affirmation: aligning gender expression, social perception, and physical appearance with gender identity.
  • Gender expression: how a person communicates gender identity through behavior and/or appearance.
  • Gender identity: internal sense of one’s gender (female, male, both, neither, or another identity).
  • Gender nonconforming: does not fit traditional expectations of masculinity/femininity; includes gender fluid, gender expansive, genderqueer.
  • Queer: sexual orientation not straight or gender identity not cisgender.
  • Sexual orientation: emotional, romantic, or sexual attraction to others.
  • Transfeminine: assigned male at birth, identifying as trans nonbinary.
  • Transgender man: male gender identity, assigned female at birth.
  • Transgender woman: female gender identity, assigned male at birth.
  • Transmasculine: assigned female at birth, identifying as trans nonbinary.
• Historical trauma: cumulative trauma associated with a specific cultural, racial, marginalized, or ethnic group; useful for nurses to examine LGBTQIA plus experiences in US healthcare historically and presently.
• Discrimination and bias: LGBTQIA plus patients may arrive with experiences of discrimination; survey data from 2018:
  • 8\% reported clinician refused to see them due to perceived sexual orientation.
  • 7\% reported clinician refused to recognize a child of a same-sex partner.
  • 9\% reported clinicians used harsh or abusive language.
  • 7\% reported unwanted physical contact (fondling, sexual assault, or rape).
• Language and inclusive care: affirmative and inclusive language and gender-affirming interventions can improve outcomes and create safer spaces.
• Gender-affirming language: essential for mental health and trust; intake forms, pronoun questions, gender identity questions, and self-introductions with pronouns help.
• Safe health care spaces: environments should be inclusive; EHRs should support gender-affirming or gender-neutral terms; check-in logs should include more than male/female options and inclusive relationship statuses.
• Advocacy: nurses can promote safe spaces, private disclosure areas for gender identity, sexual orientation, sex assigned at birth, and pronouns; independent patient-accessible electronic records (tablets) for disclosure.
• Diversity in materials: offices should feature LGBTQIA plus-friendly images and materials reflecting diverse families.
• Guidelines: 2014 Gay and Lesbian Medical Association guidelines for creating safer spaces; cues include rainbow flags, unisex bathrooms, LGBTQIA minus symbols; posters of diverse same-sex couples and transgender people; posters from HIV/AIDS organizations; brochures on LGBTQIA health topics (breast cancer, safe sex, hormone therapy, mental health, STIs, testing/treatment); nondiscrimination statements.
• EHR charting and discrimination: most EHRs do not accommodate diverse gender identities, chosen names, or pronouns; example: transgender man delivering birth but wristband gender cannot be changed; misidentification can cause PTSD, depression, and anxiety.
• Policy and awareness: fewer than 50\% of US healthcare facilities have policies ensuring welcoming interactions with transgender persons (as per Human Rights Campaign); nurses advocate for LGBTQIA plus-friendly care in safe environments (e.g., maternal health units).
• Family planning for LGBTQIA plus families: all people with a uterus should be offered full reproductive care (preconception, pregnancy, contraception, abortion); fertility preservation services are often lacking in facilities serving LGBTQIA plus patients.
• Transgender-specific abortion access: Jones et al. study estimates between 462 and 530 transgender people obtaining abortions primarily at facilities that did not provide transgender-specific health care.
• LGBTQIA plus family formation: many LGBTQIA plus people raise children via adoption, surrogacy, pregnancy through artificial insemination; unplanned pregnancies occur due to consensual sex or sexual assault; data indicate higher rates of sexual assault among LGBTQIA plus people; SANE and ED staff must be culturally competent.

Challenges in caring for diverse families

• Clear and effective communication is essential; language barriers can hinder quality care.
• Provide language-appropriate resources: CLAS guidelines (Culturally and Linguistically Appropriate Services).
• Linguistic competencies (AHRQ definition): readily available, culturally appropriate oral and written language services through bilingual/bicultural staff, trained medical interpreters, and qualified translators.
• All educational materials, instructions, and consent forms should be offered in the patient’s preferred language.
• When caring for non-English-speaking patients with limited English proficiency, seek trained medical interpreters.
• The Joint Commission requires interpreters to be trained; some states allow bilingual providers to substitute for interpreters; do not rely on family members as interpreters due to confidentiality and accuracy concerns.
• Interpreters may be on-site or via video/telephone.
• Coordinate patient conversations with other health care team members while being mindful of cultural implications about topics and decisions.
• Whenever possible, obtain an interpreter of the same gender to prevent embarrassment in sensitive matters.
• Guidelines for medical interpreters:
  • Allow extra time for interviews or conversations.
  • Meet with the interpreter beforehand to provide background.
  • Document the interpreter’s name in the progress note.
  • Address the patient directly; do not direct questions to the interpreter.
  • Speak in first person (I).
  • Avoid idioms, abbreviations, slang, and jargon.
  • Use short paragraphs or sentences.
  • Ask only one question at a time.
  • Allow sufficient time for interpretation before moving on.
  • Have the patient repeat instructions to verify understanding.

Disability and pregnancy; accessibility and patient-centered care

• Cultural competence applies to those with physical and intellectual disabilities.
• For pregnant or living persons with disabilities, collaborate with the patient to create a care plan that respects their needs and uniqueness.
• Statistics: among US women aged 18$-$39, approximately 4.7\% experience hearing loss.
• Deaf patients: use American Sign Language interpreters to discuss health history and labor/delivery expectations.
• Visually impaired: provide tours of the labor and delivery unit to help familiarity with surroundings; staff should introduce themselves verbally (name tags may not be read);
• Safety: warn patients before touching; announce yourself when entering and leaving the room.
• Accessibility: written information should be available in braille or audio formats.
• Newborn care: describe newborn’s facial expressions and behaviors in response to interventions to assist with care.
• Physical disabilities: care tailored to individual needs; hospitals/clinics should have wheelchair access (accessible bathrooms, wide doors), adjustable exam tables; assistive devices as needed (e.g., bedside commode, shower chair).
• Birth support: assist the birthing person into the most comfortable position.

Culture, beliefs, spirituality, and religion in health care

• Culture: set of norms, attitudes, and beliefs passed across generations; affects illness beliefs, treatments, communication with providers, and care decisions.
• Culture influences: how people think about health/illness, how receptive they are to treatment recommendations, and when/how they receive care.
• Spirituality vs religion:
  • Spirituality: personal sense of peace and meaning in life.
  • Religion: organized belief system practiced by a group; healers may also be religious leaders.
• Religious beliefs can affect medical decisions (e.g., Jehovah’s Witnesses refusing blood transfusions) and dietary practices (vegetarianism in Hinduism, Jainism, Buddhism).
• A thorough cultural assessment should include religion and spirituality as part of care planning.

Cultural context: adolescent parenthood and global perspectives

• Adolescent motherhood in Western cultures versus other cultures.
• US birth data (National Vital Statistics Reports): US teen birth rate in 2020 was 15.4 births per 1{,}000 females aged 15–19; this rate was down by 8\% from 2019 and down 75\% from 1991.
• Factors associated with teen pregnancy in the US include: teen mother status, lower education, lack of family connection, living in communities with higher substance misuse, violence, and hunger, race/ethnicity (more common among Black and Hispanic populations), less access to family planning information/services, and greater distrust due to mistreatment by the medical community.
• In other countries (example: Ghana), about 20\% of girls become pregnant before age 18; adolescent pregnancy is associated with health risks and social/economic hardships for youths, families, and society.
• Globally, an estimated 21{,}000{,}000 adolescent girls become pregnant annually and about 12{,}000{,}000$$ give birth before age 16.
• Ghana-specific factors include: lack of contraception knowledge/access; sexuality is a taboo subject; sex education often limited to abstinence messages; child marriage is prevalent.
• US adolescent pregnancies are associated with higher incidences of violence in marriage, reduced education and employment opportunities, social stigma, and rejection by family/community.

Ethical, practical, and real-world implications

• Importance of inclusive language, patient autonomy, and respect for diverse family structures in all nursing interactions.
• Need for ongoing education on LGBTQIA+ health care needs and terminologies to reduce barriers to care.
• Ensuring accurate documentation of guardianship, consent, and parental rights in changing family configurations.
• Addressing structural issues like access to interpreters, affordable care, and disability accommodations to improve equity in health outcomes.
• Recognizing societal and cultural factors that influence health behaviors, pregnancy risks, and family dynamics in both local and global contexts.