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PubMed2001

The effect of families on the process of outpatient visits in family practice.

OBJECTIVES: Our goal was to describe how physician knowledge of patients' families affects the processes of patient care in family practices. STUDY DESIGN: Using a multimethod comparative case study design, detailed dictated field notes were recorded after direct observation of patient encounters and the office environment as part of the Prevention and Competing Demands in Primary Care Study. We identified domains of outpatient visits in which patients were accompanied by a family member or in which family-oriented content was discussed. POPULATION: Outpatient encounters with 1637 patients presenting in 18 family practices in the Midwest were analyzed using an editing style. OUTCOMES: We developed a typology for ways in which family context affects outpatient visits. RESULTS: Patients were accompanied during 35% of all outpatient visits, the vast majority of these visits involving children. Family history or a family member's problems were discussed during 35% of visits during which no family member was present. An analysis of these "family-oriented" visits resulted in a typology of 6 ways that family context informs and affects the outpatient visit: (1) using family social context to illuminate patient disease, illness, and health; (2) using family to discover the source of an illness; (3) discussing and managing the health and illness of family members; (4) family concern for patient's health; (5) using the family as a care resource and care collaborator; and, (6) giving family members unscheduled care. CONCLUSION: Family context is an important feature of family practice that influences the processes of patient care. Since family-oriented care is an essential feature of family practice, outcomes of this largely hidden part of care deserve further study.

Adult↗
PubMed1983

Plasma lipoproteins in familial combined hyperlipidemia and monogenic familial hypertriglyceridemia.

Plasma lipoprotein concentration, composition, and size were evaluated in two common familial forms of hypertriglyceridemia and compared with those in normal subjects. The very low density lipoproteins (VLDL) were triglyceride-enriched in familial hypertriglyceridemia (triglyceride/apoprotein B ratio: 25.7 +/- 8.9) as compared to normal (9.6 +/- 12.2, P < 0.001) or familial combined hyperlipidemia (9.7 +/- 3.3, P < 0.001). The diameter of VLDL was larger in familial hypertriglyceridemia (3.27 +/- 0.28 pm) than in familial combined hyperlipidemia (2.87 +/- 0.16 pm, P < 0.02). Although in familial hypertriglyceridemia VLDL tended to be larger, and in familial combined hyperlipidemia VLDL tended to be smaller than normal (3.08 +/- 0.48 pm), neither of these differences were significant. While VLDL was normally distributed in the control population, the size was skewed to larger particles in familial hypertriglyceridemia with fewer small particles (P < 0.05) and skewed to smaller particles in familial combined hyperlipidemia with fewer large particles (P < 0.05). VLDL was reciprocally related to low density lipoproteins (LDL) in familial combined hyperlipidemia (r = -0.80 to -0.87) suggesting that the concentrations of these individual lipoprotein groups were somehow interrelated. There was no significant relationship between these two lipoprotein classes in familial hypertriglyceridemia or in normals. In familial combined hyperlipidemia, the apoprotein A-I/A-II ratio was below normal (P < 0.01) suggestive of low HDL(2) levels. This change in apoprotein composition was independent of VLDL or LDL concentration. In familial hypertriglyceridemia, high density lipoprotein (HDL) cholesterol was reduced (33% below mean normal) and HDL triglyceride was increased (by 46%), while the concentration of apoA-I and apoA-II was normal. VLDL triglyceride was inversely related to HDL cholesterol in familial hypertriglyceridemia (r = -0.74, P < 0.005), but not in familial combined hyperlipidemia. The large, triglyceride-enriched VLDL observed in familial hypertriglyceridemia is compatible with the reported increase in VLDL triglyceride synthesis seen in this disorder. The increase in VLDL apoprotein B synthesis previously reported in familial combined hyperlipidemia was associated with VLDL of normal composition. The changes in HDL cholesterol in these two disorders might reflect exchange of triglyceride between VLDL and HDL or could be related to transfer of surface components during the catabolism of VLDL. The reciprocal relationship between various components of VLDL and LDL seen in familial combined hyperlipidemia, but not in familial hypertriglyceridemia or in normal subjects, might provide some insight into the pathological abnormalities in these disorders. The differences between these two common familial forms of hypertriglyceridemia provide further support that they are distinct entities.-Brunzell, J. D., J. J. Albers, A. Chait, S. M. Grundy, E. Groszek, and G. B. McDonald. Plasma lipoproteins in familial combined hyperlipidemia and monogenic familial hypertriglyceridemia.

Adult↗
PubMed2006

Clinician statements and family satisfaction with family conferences in the intensive care unit.

OBJECTIVES: The quality of family-clinician communication in the intensive care unit is often inadequate, but little is known about specific clinician communication behaviors that might improve family satisfaction. In this exploratory analysis, we hypothesized that clinicians' communication behaviors providing emotional support to families during intensive care unit conferences would be associated with increased family satisfaction. DESIGN: We audiotaped 51 intensive care unit family conferences in which withholding or withdrawing life support was discussed or bad news was delivered. Emotional support techniques used by clinicians during each conference were identified and coded using grounded theory. SETTING: Four Seattle hospitals. SUBJECTS: Family members of critically ill patients. INTERVENTIONS: Questionnaires rating satisfaction with communication were completed by 169 family members. MEASUREMENTS AND MAIN RESULTS: Linear regression with generalized estimating equation methods was used to analyze the association between the frequency of clinicians' emotionally supportive statements and family satisfaction. Increasing frequency of three types of clinicians' statements during family conferences was associated with increased family satisfaction: a) assurances that the patient will not be abandoned before death (p=.015); b) assurances that the patient will be comfortable and will not suffer (p=.029); and c) support for family's decisions about end- of-life care, including support for family's decision to withdraw or not to withdraw life-support (p=.005). CONCLUSIONS: Most family members participating in this study were quite satisfied with the communication in the family conferences. Specific clinician communication behaviors are associated with increased family satisfaction during family conferences among family members who are willing to have a family conference recorded. Our results suggest that clinicians in the intensive care unit may improve the experiences of families of critically ill patients by providing explicit support for decisions made by a family with regard to end-of-life care and by assuring families continuity of high-quality care with particular attention to the patient's comfort.

Adult↗
PubMed2004

Concept development of family resilience: a study of Korean families with a chronically ill child.

AIMS: To clarify and delineate the concept of family resilience in the context of the chronic illness of a child. This study also investigated the concept of family resilience in relation to family functioning in order to compare and contrast family resilience and family functioning. DESIGN AND METHOD: Three phases of the hybrid model of concept development were applied: theoretical, fieldwork and final analytical. In the theoretical phase, a working definition of family resilience was developed by a literature review. The fieldwork phase comprised in-depth interviews with 11 parents with a chronically ill child, in the paediatric oncology unit of a university hospital in South Korea. The qualitative data obtained from the interviews were analysed to find attributes of family resilience. The final analytical phase compared and interpreted the findings from the theoretical and fieldwork phases in order to clarify and refine the concept of resilience. RESULTS: The definition of family resilience was of an enduring force that leads a family to change its functioning dynamics in order to solve problems encountered. Twenty-one conceptual attributes of family resilience emerging from this study were differentiated into four dimensions: (i) intrinsic family characteristics, (ii) family member orientation related to family characteristics, (iii) responsiveness to stress and (iv) external orientation. CONCLUSIONS: Family resilience is an enduring force that leads a family to change its dynamics of functioning in order to solve problems associated with stresses encountered. This conceptualization led to the development of a model of family coping that incorporates both family resilience and family functioning, as the property and as the process of change, respectively. RELEVANCE TO CLINICAL PRACTICE: In order to build a family that functions better under stress, it is necessary for nurses to focus more attention on family resilience, especially in terms of the development of intervention strategies to strengthen family resilience.

Adaptation, Psychological↗
PubMed2003

Family-nurse co-construction of meaning: a central phenomenon of family caring.

The purpose of the study was to understand and interpret caring in the family health experience by exploring the interactional phenomenon of family-nurse co-construction of meaning in the paediatric intensive care unit (PICU). A hermeneutic phenomenological method within a framework of existentialism and symbolic interactionism was used in the investigation. The convenience sample for this study was four family-nurse dyads, that is four families of critically ill children (all with positive outcomes) and the four nurses assigned to their care who were participating in a larger study. Data were derived from semi-structured interviews regarding significant interactions throughout the child's illness and subsequent significant interactions of families with other nurses and nurses with other families. Trustworthiness of the study was addressed through the criteria of credibility, dependability, transferability and confirmability. Co-construction of meaning in the family health experience was found to have two dimensions: interdependent and independent. Both families and nurses described being like family as an essential component of the interdependent experience. Independent dimensions for families were journeying through troubled waters of learning the meaning of the illness event and sensing family comfort through the nurse's care. Independent dimensions described by nurses were journeying through troubled waters of learning to care for families and living with another's fear. The family-nurse interaction, the relational connection and the evolution of meanings that families and nurses construct, was affirmed as the major vehicle in the co-construction experience. Family caring is influenced by the existential meaning constructing, process-oriented, interactional nature of the family health experience. Caring in the family health experience is enhanced through actions the nurse performs on behalf of, and with, the family while understanding the family's unique situation. Caring enacted by nurses in participation with families holds abundant potential for enhancing the family health experience and honor the ethic of caring as central to nursing.

Adult↗
PubMed2004

[Family resiliency factors for the adaptation of family who have a congenital heart disease].

PURPOSE: The purpose of this study was to explore the relationships of family strain, perceived social support, family hardiness, and family adaptation and identify the family resiliency factors for the adaptation of families who have a child with congenital heart disease. METHOD: The sample consisted of 90 families who had a child diagnosed with congenital heart disease and completed surgical treatment. Data was collected from parents using a questionnaire. RESULTS: Results from path analyses revealed that family strain had a direct effect on both perceived social support and family hardiness, and an indirect effect on family adaptation. Also, the findings revealed that perceived social support had a direct effect on both family hardiness and family adaptation, and family hardiness had a direct effect on family adaptation. Thus, these results indicated that perceived social support and family hardiness had a mediating effect on family strain. CONCLUSION: Findings provide the evidence for the theoretical and empirical significance of perceived social support and family hardiness as family resiliency factors for family adaptation. Clinical implications of these findings might be discussed in terms of family-centered nursing interventions for the families who have a child with congenital heart disease based on an understanding of family resiliency for adaptation.

Adaptation, Psychological↗
PubMed1991

[Types of families, living conditions, functioning of family systems and social maladjustment during latency and adolescence in underprivileged milieus].

Available data on the impact of certain types of families is lacking, and the results are often misleading with respect to maladjustment. Following a description of variations in delinquent activity and behaviour problems according to family type, the authors analyse the difficulties in the operation of family systems. Comparisons of six family types apply to data from 763 boys aged 10, 319 female and 426 male adolescents, aged 14 and 15: intact families, father-based and mother-based single-parent families, father-based and mother-based reconstituted families and substitute families. The article's data show that in the late eighties, nearly 40 per cent of children and adolescents living in low-income districts in Montreal belonged to disunited families. In addition, the data confirm a classic observation: in comparison with intact families, disunited families are underprivileged in relation to living conditions, deficient in relation to psychosocial functioning, and propitious to behaviour problems and delinquent activity. In addition, it has been established that certain disunited family types represent a considerable risk factor. The damaging effect of family structure increases in the following order: intact families, mother-based single-parent families, mother-based reconstituted families, substitute families, father-based reconstituted families and father-based single-parent families. Finally, certain intervention methods are suggested to help prevent behaviour and family problems.

Adolescent↗
PubMed2003

Family intervention in schizophrenia--impact on family burden and attitude.

BACKGROUND: This study focuses on the effect of psycho-educative family therapy on the self-assessed burden in families in which one member has suffered from relapse of schizophrenia or a schizoaffective syndrome. The impact on the family's self-assessed attitude towards continuing to take care of the patient was also evaluated. Burden and attitude were assessed continuously during a period that contained no further relapse episodes. METHODS: Included were 31 families in which one family member suffered from schizophrenia or a schizoaffective syndrome. Of these, 14 families underwent a psycho-educative intervention programme called BFT (Behavioural Family Therapy). The remaining 17 families, i. e. the contrast group, received conventional family support. The intervention was initiated within 24 h after the patient/family member was admitted to a psychiatric ward due to relapse of the psychotic disorder. The intervention continued until the patient was discharged from hospital. Falloon's Distress Scale and Attitude Scale were used in the families' self-assessments of burden and attitude towards continuing to take care of the patient, respectively. The self-assessments were performed on three occasions: 1) on the day of admission to the ward, or the day after; 2) 4-5 weeks after admission; and 3) on the day of discharge, or the day after. Medication doses were registered upon admission and at the time of discharge. Finally, the rates of re-occurring relapses within 1 year after discharge from hospital were determined, i. e. 1 year after the completion of the family treatment programme. The BFT families had access to the therapist for questions after the programme had been completed, when needed. The patients and families in the contrast group had access to physicians and therapists in the outpatient care. RESULTS: The self-assessed family burden was significantly lower for the BFT families at the time of discharge, compared to the contrast group, and the self-assessed attitude towards continuing to take care of the patient was significantly more positive for the BFT families at the time of discharge, compared to the contrast families. One patient in the BFT group relapsed within 1 year, whereas 13 patients relapsed in the contrast group. The dosages of neuroleptics were significantly lower on discharge than on admission for the patients in the BFT group. CONCLUSIONS: The results suggest that BFT, when provided to schizophrenic patients and their families during a hospitalisation period caused by a psychotic relapse, reduces the feeling of burden in these families. Likewise, the families' attitude towards continuing to take care of the patients was influenced in a positive way.

Adult↗
PubMed1975

Dietary survey of low-income, rural families in Iowa and North Carolina. II. Family distribution of dietary adequacy.

Distribution patterns of Iowa and North Carolina families for dietary adequacy at various income levels were compared according to: (a) two family dietary standards, based on the 1968 Recommended Dietary Allowance and the Ten-State Nutrition Survey dietary standards, and (b) two income standards, family income and per capita income. A 24-hr. recall method was used to collect the dietary data. Nutrients studied included: protein, calcium, iron, vitamin A, ascorbic acid, thiamin, and riboflavin. Clear differences emerged in family distribution patterns by the two dietary standards and by the two income standards. Comparison of family distribution patterns for dietary intake by the two standards showed that percentages of families with poor nutrient intakes were lower by Ten-State evaluation than for the recommended allowance evaluation, except for protein and iron. For example, the percentage of families with poor calcium intakes, by Ten-State criteria, was approximately half that measured by the recommended allowances. While, according to the latter, calcium was the most limiting nutrient in many family diets, vitamin A was most limiting by Ten-State evaluation. The proportions of families with poor ascorbic acid, thiamin, and riboflavin intakes were also lower by Ten-State standards. While the iron adequacy remained approximately the same by both dietary standards, the percentage of families with poor protein intakes was higher by the Ten-State criteria. A higher percentage of families at each income level had fair and good diets by Ten-State comparison. Family distribution patterns for intakes of individual nutrients at various family income levels demonstrated a positive relationship between nutritional intake and income. Proportions of families with poor nutrient intakes according to per capita income tended to increase with the income level. For both income standards, the percentages of families with good and fair diets in the total family sample gradually increased with income. Percentages of Iowa families with fair and good diets at various income levels were, in general, higher than those of North Carolina families. The lowest and the highest percentages of families with poor diets of two population groups were higher for per capita income distribution than for family income distribution.

Adolescent↗
PubMed1989

Who is the family doctor? Relating primary care to family care.

Many families receive care as intact family units. To determine which specialists provide this family care, a subset of families (N = 447) enrolled in the Rand Health Insurance Experiment were examined. Among families designating a single primary care physician, family physicians and general practitioners provided 65.9% to 89.7% of their family care. Internists provided 20.0% and 27.3% of family care for younger and older couples, respectively. The remaining specialties, including pediatrics and obstetrics-gynecology, each provided less than 5% of family care; these small proportions of family care may reflect the specialists' self-imposed limits in primary care roles. As family members matured, families used fewer pediatricians and obstetrician-gynecologists for primary care and concurrently increased their use of family physicians or general practitioners. Care for intact families is provided predominantly by family physicians or general practitioners, although in families without children, internists also play an important role. Self-defined limits in primary care roles by physicians in various specialties and the changing use of specialties during the family life cycle largely determined which specialties provided family care.

Adolescent↗
PubMed2005

Family functioning in school-age children with cystic fibrosis: an observational assessment of family interactions in the mealtime environment.

OBJECTIVE: To examine, using direct observation methodology, differences in family functioning at mealtime between families of school-age children with cystic fibrosis (CF) and families of school-age children without a chronic illness. METHOD: Family functioning was rated using the McMaster Mealtime Interaction Coding System (MICS) during a videotaped dinner among 28 families of children with CF and 27 families of non-ill, age-matched peers. Families were rated on overall family functioning and on six dimensions of the MICS: task accomplishment, communication, affect management, interpersonal involvement, behavior control, and role allocation. RESULTS: Ratings for families of a child with CF were significantly lower than they were for comparison families on overall family functioning and on four of the six MICS dimensions: communication, affect management, interpersonal involvement, and behavioral control. Moreover, a significantly greater percentage of families of children with CF were rated in the unhealthy range on overall family functioning and on five of six MICS dimensions. There was no relationship between family functioning and child weight status for children with CF. CONCLUSIONS: The current study suggests that for families of school-age children with CF, the family system is negatively affected during mealtime. Dietary interventions need to address family-centered, as well as child-centered, interventions to help families manage challenges presented during the family meal.

Child↗
PubMed2003

The family in the family medicine literature.

BACKGROUND: The degree to which the family medicine literature articulates unique family practice approaches and perspectives that are distinct from other primary care specialties has not been well studied. To determine how often a family practice perspective is included in clinical articles in the family medicine literature, we performed a family medicine journal review. METHODS: We reviewed 173 original research articles, review articles, and case reports from four family medicine journals from the year 2000: American Family Physician, Journal of Family Practice, Journal of the American Board of Family Practice, and Archives of Family Medicine. Each article was scored by independent reviewers as to whether the article discussed family aspects of care or family context. RESULTS: A total of 9.3% of clinical articles discussed family aspects of care; an additional 17.3% made some limited mention of the family or social context. Female first authors were 2.5 times more likely to have demonstrated a family practice perspective. Articles published in the American Family Physician and review articles were most likely to discuss family medicine perspectives, but these differences were not statistically significant. CONCLUSIONS: Unique family medicine approaches and perspectives are not discussed commonly in clinical articles in the family medicine literature.

Bibliometrics↗
PubMed1998

The family in family practice: is it a reality?

BACKGROUND: The purpose of this study was to describe, from multiple perspectives, the extent to which community family physicians focus on the family. METHODS: In a cross-sectional study, research nurses directly observed consecutive patient visits for 2 days in the offices of 138 community family physicians. Data were collected on 4454 outpatient visits using direct observation, patient and physician questionnaires, and medical record review. Descriptive statistics were calculated, and a factor analysis was used to identify subsets of correlated family focus descriptors. RESULTS: On average, 10% of the time intervals during patient visits was devoted to addressing family issues. Other family members were present during 32% of visits, and another family member's problems were discussed in 18% of visits. Seventy percent of patients reported that other family members see the same doctor. A family history was obtained during 51% of visits by new patients and 22% of visits by established patients. Genograms were present on 11% of charts and family folders were seldom used. The presence or absence of a family history of breast or colon cancer was noted in 40% of charts. A factor analysis identified two different physician styles: family history as a context for care of an individual patient, and the family as the unit of care. The latter approach correlated with the patient's assessment that the doctor knew their families. CONCLUSIONS: Family physicians show a high degree of emphasis on the family, and exhibit two different styles of family focus in community practice. The effects of these different approaches to family care on patient outcomes is an important area for future research.

Cross-Sectional Studies↗
PubMed2004

Family functioning in adolescent anorexia nervosa: a comparison of family members' perceptions.

Abnormal patterns of family functioning have often been reported in anorexia nervosa. Moreover, members of families with an adult with eating disorders have different family functioning perspectives. This study investigated whether differences in family members' perspectives, similar to the ones found in families of adults with eating disorders, can be found in families of adolescents with anorexia nervosa. Perceived family functioning, measured with the Family Assessment Device, was compared between 49 control and 34 clinical families, and across family members. Differences were found between the two groups on a number of aspects of family functioning, with the clinical families showing most disturbances. There was a general agreement across family members in their perceptions of family functioning, with one notable exception. Clinical daughters disagreed with both their parents about the family level of communication, whereas control daughters disagreed only with their fathers. Disagreements between clinical adolescents and their mothers about the family communication style appear to be important in anorexia nervosa in this age group, although it is not possible to reach conclusions about the direction of causality. These findings support the use of family-oriented therapies that aim to identify and work with difficulties in communication within the family.

Adolescent↗
PubMed2002

Comparisons between cancer survivors and family members on meaning of the illness and family quality of life.

PURPOSE/OBJECTIVES: To explore the meaning of the illness to the family and family quality of life (QOL) for survivors and family members and to describe similarities and differences between survivors' and family members' meaning of the illness and family QOL. RESEARCH APPROACH: Descriptive, qualitative. SETTING: Homes of survivors and family members in an urban metropolitan area in the midwestern United States. PARTICIPANTS: A sample of 123 Caucasian and African American cancer survivors, one to six years after treatment had ended, and their family members (N = 246). Four cancer diagnoses (i.e., breast, colon, prostate, and uterine) were represented. METHODOLOGIC APPROACH: Two open-ended questions derived from a family model of survivorship. Content analysis was used to analyze the responses. MAIN RESEARCH VARIABLES: Meaning of the illness and family QOL. FINDINGS: The positive dimensions of survivorship in meaning of the illness and family QOL were seen for patients and family members, although long-term stressors also were reported. More similarities than differences in meaning and QOL were noted between survivors and family members. CONCLUSIONS: Patients' and family members' perspectives of the meaning of the illness and family QOL are important to assess during survivorship to address both individual- and family-level perspectives in cancer care. IMPLICATIONS FOR NURSING: Nurses should offer opportunities for patients and family members to search for positive meaning in the cancer illness, develop strategies to handle stressors that are present during survivorship, and enhance family strengths and resources to promote family QOL.

Adaptation, Psychological↗
PubMed1999

Family member as a hospital patient: sentiments and functioning of the family.

The aim of this pilot study was to find out how families experience the hospitalization of one family member and to chart the participation of the family in the treatment of the hospitalized family member. A questionnaire was used to gather data for the study and the three open-ended questions in the questionnaire were interpreted using content analysis. The study population (n = 70) was the family members of patients in the neurological wards of Tampere University Hospital. The study demonstrated a variety of negative sentiments in the families, such as worry, fear, shock, anxiety and depression at the hospitalization of their family member. The families also expressed neutral and positive sentiments, such as approval, relief and faith in the help given. Nearly 80% of the families' statements dealt with emotional responses. Changes in the everyday life of the family caused by the hospitalization of a family member were also reported, with most changes affecting the immediate family. Hospital visits gave a rhythm to family life. There were changes in the sharing of housework and taking care of affairs, as well as in relationships within the family. Family members spoke of their loneliness, fear and longing. External changes in family life were present in 13% of statements. Helping the patient in hospital involved functions like participation in nursing care, taking the patient to the cafeteria and rehabilitation. Only 20% of statements dealt with emotional support for the patient. Future research could broaden the perspective to include the views of patients, nurses and doctors on the reality of family nursing.

Activities of Daily Living↗