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Home > RNJ > 2009 > July/August > Promoting Family Integrity to Inspire Hope in Rehabilitation Patients: Strategies to Provide Evidence-Based Care (CE)

Promoting Family Integrity to Inspire Hope in Rehabilitation Patients: Strategies to Provide Evidence-Based Care (CE)
Donald D. Kautz, PhD RN CNRN CRRN-A Elizabeth Van Horn, PhD RN CCRN

The disability of one family member who requires inpatient rehabilitation care can negatively affect all family members and ultimately disrupt family integrity. The purpose of this article is to demonstrate how promoting family integrity also promotes hope when families are confronted with a newly disabled teen or adult. Current research findings indicate that rehabilitation nurses are in a key position to promote hope and family integrity by facilitating open communication between family members, fostering a tone of togetherness within and among families, and helping families resolve feelings of guilt and move toward forgiveness. These strategies are based on activities from the Nursing Interventions Classification (NIC) intervention “Family Integrity Promotion.” This article presents a review of research to support these NIC activities and offers practical suggestions so rehabilitation nurses can incorporate these strategies into their daily practice with patients and their family members.

Shane’s Story

Fifteen-year-old Shane sustained a C6-7 complete spinal cord injury after diving into a neighborhood pool. He has been in rehabilitation for 4 weeks after an uncomplicated 2-week acute-care hospitalization. His father, who is an emergency medical technician, witnessed the dive and rescued his son from the pool. He did not wait until a neck brace was applied before pulling him from the pool. After Shane was in rehabilitation, his father was overcome with grief and consumed by guilt, certain that he had caused his son’s paralysis. As a result of this fear, he has stayed away from the rehabilitation unit. During the course of Shane’s rehabilitation stay, his father and mother drifted apart and then separated. Shane’s mother became bitter and openly resented having to take Shane home; she refused to attend family conferences to learn how to care for him. Neither of his parents talked with the psychologist at the rehabilitation center, though they did call Shane’s primary nurse to check on his condition. Both parents expressed feelings of despair and admitted having a bleak outlook for Shane’s future and the family’s ability to stay together. Shane’s primary nurse was uncertain about how she could help the family, but thought that Shane’s return home would be compromised without some type of intervention. The nurse reasoned that if appropriate interventions were initiated, this family could allow itself to maintain hope for Shane’s situation and his life after discharge from the rehabilitation center.

In the preceding scenario, the nurse needed to implement strategies to help this father overcome his guilt and help the family communicate. Working with families is a key part of rehabilitation nursing. Rehabilitation nurses working in all settings teach families how to provide personal care, perform treatments, and prevent complications from disability. The rehabilitation team includes the family in setting goals and weekly conferences. These strategies help family members cope with the consequences of having a disabled family member and maintain hope for the future. Kautz (2008) and Smith and Kautz (2007) have described ways in which nurses can implement hope-inspiring strategies for patients in rehabilitation and on medical-surgical units. The purpose of this article is to demonstrate how promoting family integrity also promotes hope when confronted with a newly disabled teen or adult.

Miller (2000) defined hope as “an anticipation of a future that is good and is based upon…relationships with others…purpose and meaning in life, as well as a sense of ‘the possible’” (pp. 523–524). Miller identified nursing strategies that can promote hope; these strategies include sustaining relationships, expanding the client and family coping repertoire, enhancing a client’s control, devising and revising goals, and using a life-promoting interpersonal framework. Nurses also can promote hope by helping patients maintain control and sustain relationships with others. In this article, promoting hope is linked with promoting family integrity, which is defined as, “the promotion of family cohesion and unity” (Bulechek, Butcher, & Dochterman, 2008, p.345). The nursing interventions to promote family integrity that are presented here support and complement Miller’s strategies to promote hope. Some of the interventions have been studied previously and there is evidence of their effectiveness; others need further study.

According to the literature, the better a family copes with the emotional and physical demands of a disability or chronic illness, the better the outcome will be for the patient (Chelsa et al., 2003; Condon & McCarthy, 2006; Friedman, 2000; Hostler, 1999; Weihs, Fisher, & Baird, 2002). Some families need the rehabilitation team to help them anticipate or cope with feelings or reactions that they and the patient have experienced or will experience when they go home. Helping families cope will further encourage them to maintain hope in spite of the obstacles they now face. Some rehabilitation nurses believe that promoting family cohesion is best left to psychologists and social workers. Indeed, referring a family to therapy is one intervention nurses can suggest. There is evidence that even one or two family-focused sessions with a therapist that take place while a patient still is in inpatient rehabilitation makes a significant difference in how well the family does at home (Palmer, Glass, Palmer, Loo, & Wegener, 2004). Unfortunately, many families may not qualify for counseling, have access to it, or be able to afford counseling services.

Other nursing strategies can help families maintain integrity; these include providing the family with information about family visitation, establishing trusting relationships, family privacy, caring for all family members, listening to family members, and causes of illness. Nurses also can monitor family relationships and counsel family members on additional effective coping skills. Rehabilitation nurses can refer to Van Horn and Kautz (2007; 2008) to examine the level of evidence for each of these activities. In this article, three additional strategies will be examined: facilitating open communication, promoting a tone of togetherness, and relieving guilt. All of the strategies mentioned here are based on “activities” from the Nursing Interventions Classification (NIC) intervention “Family Integrity Promotion” (Bulechek et al., 2008) and can be implemented while providing daily nursing care. Implementing these activities as a cluster will not only help with family function, but also may lead to promoting hope for the moment.

Facilitate Open Communication Among Family Members

The first intervention is to facilitate open communication among family members. Past events, which may include unemployment, substance abuse, criminal activities, or volatile relationships, may preclude some family members from communicating openly. A new disability intensifies family relationships and forces problem solving and communication within a family. By broaching these topics in a nonthreatening way, nurses can facilitate open communication and problem solving between family members. Nurses can openly acknowledge that these discussions are difficult while talking about the issues that can help families devise and revise goals. A nurse can say something like, “One of our goals in rehab is for the disabled person to be able to live independently and continue to work. Talking about this can be tough. Many families avoid these topics to keep from insulting each other. Yet we know that when honest, nonhurtful communication occurs in a family, the rehab outcome may be better. Setting goals for work and leisure may help to guide therapy here in the rehabilitation hospital. I’d like to talk now with you about work and leisure goals.” In this statement, the nurse sets the stage for discussing these topics, offers support in dealing with these issues, and provides hope for the future.

The evidence is clear that open communication with families facilitates the rehabilitation process for both family members and patients. In a study by Duhamel and Talbot (2004), family members determined that these nursing interventions were among the most useful: interventive questioning, providing educational information, and exploring the illness experience with the family. In Hostler’s (1999) evaluation of a pediatric family-centered rehabilitation program, communication between families also facilitated communication within families. Modeling positive communication in one family may influence another family’s ability to communicate. Peer family support and family support groups in rehabilitation settings also increase communication, reduce parental burden, improve parents’ ability to care for disabled children, and affect the transition home and back to work for disabled patients (Aitken et al., 2005).

One aspect of communication that may be overlooked is helping families relieve stress with humor. Humor has been found to increase families’ ability to grieve and maintain hope (Kylma & Juvakka, 2006). Chinery (2007) and Christie and Moore (2005) found that humor encouraged relaxation, promoted general wellness, and fostered positive and hopeful attitudes. Nurses can encourage families to share in joke telling and watch favorite TV shows or videos to foster laughter. Diamond (2005) argues that if family members can find the humor in their circumstances, the family can survive.

Two celebrities with disability have written eloquently about how humor gave them and their families hope. In Nothing Is Impossible, Christopher Reeve (2002) wrote that humor was especially helpful in defusing anger, which can be a barrier to communication. Humor may be effective in encouraging families to talk about sensitive topics. In My Stroke of Luck, Kirk Douglas (2002) recounted time and again how his family used humor to maintain family togetherness. As nurses, we can model the healthy use of humor and assign family members to bring a new joke with them every day.

Facilitate a Tone of Togetherness Within/Among the Family

A growing body of evidence supports the view that being together as a family not only promotes family integrity and function, but also benefits the growth of individual family members. The studies also provide a framework nurses can use when working with families to facilitate togetherness. For example, Baumann, Caroll, Damgaard, Millar, and Welch (2001), through their work on human becoming theory, discovered emergent meaning for families who communicated and remained open to the possibility of the present and future. By sharing time with each other spontaneously, families honored cherished memories and developed a new vision of the future. In their research on women family caregivers, Salin and Astedt-Kurki (2007) discovered that a sense of togetherness within a family was an important theme among family members of frail older adults. Reviewing research on the families of patients with head injury, O’Neill and Carter (1998) found that promoting involvement of family and friends and facilitating communication with relatives were integral components of rehabilitation. These authors concluded that encouraging a family to express their feelings to one another is a key part of coming to terms with a new disability so that a family can effectively contribute to the patient’s rehabilitation. In a study of families with children with special needs, Segal (1999) found that families had idealized images of togetherness and good relationships. Even though these idealized images were not actualized, parents continued to work toward being together, sharing, and taking advantage of opportunities for learning.

Nurses can help families maintain togetherness by guiding them to engage in activities together during the rehabilitation stay and after the patient returns home. Four of the Nursing Outcome Classifications (NOC) indicators for the NOC outcome “Family Integrity” include “prepares and eats meals together, participates in leisure-time activities together, participates in family rituals, and participates in family traditions” (Moorhead, Johnson, Maas, & Swanson, 2008, p. 353). Encourage families to bring food to the rehabilitation unit, especially traditional homemade dishes or take-out meals the family has eaten together in the past. The nurse can suggest the family eat together in a conference room or cafeteria. Hostler (1999) found that families’ bringing in food was a key indicator of family-centered rehabilitation for children with head injuries. These activities include more than just eating; having traditional meals together may evoke powerful memories of family togetherness and help families envision a new future that transcends the disability. This may be a good starting point at which families can come to terms with the disability. Helping families reminisce about favorite times in the past may help them envision how they will be able to participate in family rituals and traditions in the future despite the new disability. Nurses can facilitate reminiscence by asking family members to bring in pictures, favorite movies, or DVDs of favorite television shows. It is important for both the nurse and family to remember that idealized images of their family’s togetherness need not be actualized (Segal, 1999). Finally, when nurses spontaneously spend time with patients and families, they are promoting togetherness within the families and opening themselves to a new vision of their future as rehabilitation nurses. We need to remind both families and ourselves of Baumann and colleagues’ (2001) conclusion that moments of serendipitous togetherness can enhance a positive view of the future and promote hope.

Directing the family to solve problems together also may increase togetherness. A family of a patient with brain injury said, “We have had the best day today. We went and got our son a new pair of tennis shoes. We aren’t from this big, confusing city. We found the store, drove there on our own, picked out the right-size shoes, and brought them back. This is one of the first times we have been able to do something worthwhile for our son since his injury.”

Help Families Forgive and Resolve Feelings of Guilt

The NIC activity under “Family Integrity Promotion” related to guilt is “assist family to resolve unrealistic feelings of guilt” (Bulechek et al., 2008, p. 345). There are two additional NICs: “Guilt Work Facilitation” and “Forgiveness Facilitation.” Resolving guilt and facilitating forgiveness are conceptually linked; therefore, the activities the nurse can implement are combined here.

Feelings of guilt and shame can be overwhelming for the family of a newly disabled patient, as depicted in Shane’s story. Family members may feel they should have intervened if a disability was due to alcohol or drug abuse. Families of patients with diabetes and heart disease who experienced a stroke may feel guilty because they did not help the patient with exercise, weight loss, and smoking cessation. Families of those who became disabled in an automobile crash or another type of injury may have had a fight in the hours before the event and believe they were the cause of the disability. Families may feel guilty that they did not spend more time together before the disability. It has been said, “Guilt is the gift that keeps on giving.” Rehabilitation nurses likely have seen feelings of guilt and shame tear families apart. Situations involving guilt often are complex and most likely require a variety of tailored intervention strategies. Ingersoll-Dayton, Campbell, and Ha (2009) conducted a quasiexperimental study to test the effectiveness of a group forgiveness intervention with older adults, ages 57–82. The group intervention consisted of 8 weekly sessions of journal writing, minilectures, and group discussion. Participants reported improvements in physical health, forgiveness, and depression. Research to support the effectiveness of these strategies with rehabilitation patients and their families is needed.

Recine, Werner, and Recine (2009) offer four evidence-based forgiveness approaches that nurses can use with individuals, families, and communities. The interventional approaches include 1) providing persuasive information by focusing on the benefits to health and the heart for forgiving, 2) helping individuals to vicariously experience forgiveness through structured faith practices, 3) helping with awareness of and coping with physiologic information and the reduction of negative symptoms associated with anger, guilt, and blame through mindfulness-based stress reduction, and 4) helping individuals complete concrete acts of forgiveness. The authors provide recommendations for individualizing these interventions as well as methods for overcoming barriers to implementing health promotion through forgiveness.

“Guilt Work Facilitation” and “Forgiveness Facilitation” can help to resolve guilt. Nurses can help patients and families identify their feelings of guilt and possible irrational beliefs and help them see that guilt is a universal reaction to catastrophic or disabling illness and injury (Bulechek et al., 2008). Nurses also can facilitate forgiveness by helping families “let go” of an issue or explore anger, bitterness, and resentment—all while employing the strategies of presence and empathy. Nurses can help families use spiritual practices such as prayer, healing touch, and visualization of healing. Some families may need an objective party to assist in resolving feelings of guilt and anger (Bulechek et al., p. 377). Additional resources for families to help them with feelings of guilt may include ministers, pastoral counselors, or other spiritual leaders who can help them maintain their faith. An evidence-based guideline for nurses to use in meeting clients’ spiritual needs has been developed by Delgato (2007). Other guidelines for nurses to use in providing spiritual care have been developed for working with older adults (Gaskamp, Sutter, Meraviglia, Adams, & Titler, 2006) and in critical care (Smith, 2006) and palliative care (Byrne, 2007) settings. These guidelines also can be adapted for rehabilitation settings.

A simple intervention to help family members begin to resolve feelings of guilt and shame is to encourage them to either ask for forgiveness, or, if this is impossible or inappropriate, to forgive themselves. Teach family members to say to themselves the thing that they did or failed to do, admit that these actions were wrong, and then either ask for forgiveness or say “I did wrong, and I forgive myself.” Encourage family members to do this every time feelings of guilt or shame enter their mind. They soon may find they are free of the burden. This intervention also can help an individual forgive another. The person will say, “These people treated me wrong or made these mistakes, and I forgive them.” This intervention is one of many that should be tested by nurses in clinical trials to determine its effectiveness in rehabilitation settings.

In a review of the forgiveness literature and the implications for nursing practice, Festa and Tuck (2000) noted a lack of tools to measure the intrapsychic or interpersonal dimensions of forgiveness. They also observed that the focus of nursing care often is in the context of the family, and likewise the focus in forgiveness may need to be on siblings, marital dyads, parent-child dyads, or multigenerational family members. In the example of Shane, the father needed to forgive himself, the mother needed to forgive the father, and both parents needed to forgive Shane. Festa and Tuck also note that the optimal time line for forgiveness is unknown. Consequently, it is likely that nurses will be able to help some—but not all—families.

Promoting Family Integrity also Promotes Hope for the Moment

This article demonstrates that nurses can promote family integrity while providing routine nursing care. The NIC activities, facilitating open communication between family members, facilitating a tone of togetherness within and among family members, and helping families to resolve feelings of guilt may increase a family’s sense of togetherness and integrity and the likelihood of a positive rehabilitation outcome for the patient. Equally important, these interventions will help promote hope, especially for the moment.

A nurse may hear a family member say, “All I am trying to do is get through today.” This statement points to the need to focus on the moment. We all need to take time to smell the coffee, appreciate the smell and beauty of flowers, or feel the sun on our faces. When walking into a patient’s room, a nurse can comment on the fact that the family is all there, for this moment in time. The nurse can stop and smell the flowers that someone has brought, read a get-well card, or comment on the television show family members are watching. A nurse simply may say, “I see you all are here; that gives me hope.”

Unfortunately, the moment at which a nurse walks into a room may be filled with pain and fear that one’s problems are not solvable. In a chapter on using literature therapeutically with patients, Hobus (2000) retold a Zen parable that is both comforting and disturbing, yet also encourages people to appreciate the moment and to enjoy what they have in spite of the insurmountable obstacles in their lives. “The parable tells about a man who drops over a cliff while trying to escape a tiger and clings tightly to a vine. But there is another tiger below him, snapping and snarling. All he can do then is with his free hand pluck a strawberry on that same vine and eat it, and enjoy its sweetness” (p. 456). Hobus recommends that families read favorite books together, write poems and journals together, and gain empowerment through readings from the Bible and words and music of hymns to increase feelings of love, hope, and self-worth.

No matter how dysfunctional, poorly coping, angry, or ridden with guilt family members may be, patients have only one family. Some problems are unsolvable. For some patients, being with family may be like being with two snarling and snapping tigers—one above, and one below—as they cling to a vine. But nurses may be able to help patients and families recognize that amid the chaos, there is a strawberry that can be enjoyed. Right here, right now. And in that moment, there is hope.

Acknowledgments

The authors gratefully acknowledge the editorial assistance of Ms. Elizabeth Tornquist and the technical assistance of Ms. Brandy Conrad, MSN RN, and Ms. Dawn Wyrick in the preparation of this manuscript.

About the Authors

Donald D. Kautz, PhD RN CNRN CRRN-A, is an assistant professor of nursing at the University of North Carolina–Greensboro School of Nursing, Adult Health Department, Greensboro, NC. Address correspondence to him at ddkautz@uncg.edu.

Elizabeth Van Horn, PhD RN CCRN, is an assistant professor of nursing at the University of North Carolina at Greensboro, in Greensboro, NC.

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