This paper serves to stimulate debate on the ways in which nurses can engage with families in effective and constructive ways. In some ways, it articulates what many nurses will have been aware of throughout their practice, that families are important, whether to patients, or in their own right. We may all remember times when a family was an important element of the care we gave. We may have found family members essential providers of care, with key insights and information, or we may have found family members difficult or divided. Moreover, we may all recall conversations with patients where the importance of family was a central feature. We may have been aware that some of our patient's sense of self was intimately tied up with their family – they saw themselves primarily as a mother or a husband, for example. On the other hand, they may have felt that their family had stopped them from developing an identity – obligations and tensions had prevented them from moving beyond family roles and relationships.
Much of this has been explored in research. Nolan et al. (1996), for example, have talked about the way in which family care has become an increasingly important aspect of care, and Reed et al. (2004) have talked about the importance of family to older people. If services become more restricted or less available, for example, the family may be the main providers of care. In these contexts, nurses must take the family into account when planning and delivering care.
In some ways, however, this goes against the emphasis, at least in Western culture, on individualism. The growth of the idea of the individual as the focus of care has a powerful history in nursing. It began with an awareness of the problems of care which was carried out indiscriminately as a routine set of general tasks, and where nursing could be either given to those who did not need it, or not given to those who did, because the routine rather than need dictated practice. This led to a focus on developing ways of distinguishing individual needs, through assessment and care planning, and the developments of frameworks for doing this – nursing models (Reed 1992). As nurses, then, we have a strong tradition of thinking about patients as individuals with specific needs, goals and rights. Different patients need different care and have different goals, which we strive to integrate with our practice, under a universal set of human rights to dignity, autonomy and privacy.
The move towards individualized nursing care, however, may have had some unintended consequences. While we may be able to think through individual needs better, to focus on the individual in isolation runs the risk of leading to decontextualized and disconnected care, as boundaries around individuals are defined more tightly. If we draw these boundaries too narrowly, we can exclude the social and familial context of the patient. As the paper by Li indicates, families are very much involved in care and have a range of needs themselves. Ignoring the family to focus on the individual patient, then, can neglect an important dimension of a patients’ life, fail to recognize the needs of families, and may lead to inappropriate and ineffective care.
Li's paper is based on a small sample of family carers and staff, and did not aim to cover the whole range of family concerns. The paper cannot, therefore, be taken as a definitive account of family responses to the care needs of an older person, even less of other patients. We need to be careful, then, that we do not under-estimate the complexity and diversity of family relationships. We may all have come across families that were not concerned about or supportive of each other, or families where there were huge arguments or differences about what should happen, or what course of action should be taken. We should not assume, then, that all families are the same. In addition, we should not use a too literal definition of ‘family’ which includes only those with legal or biological connections to the patient. As societies change, families do too, and we need to find a way of incorporating different forms of family into our definition. This may include families based on co-habitation, without formal marital status, second families and step-families, to name but a few of the possible variations. It may also include friends and colleagues as well, under the heading of ‘significant others’.
The process of responding to families, then, is a complex one. Even if we are happy with the definition we use, we will still need to be aware of the dynamics of relationships in families, which lead to patterns of interaction. These dynamics have been explored in some depth, in the field of family (or systemic) therapy, so they are understood in many ways (Dallos & Draper 2000). The challenge for nursing, then, is to adapt and develop this knowledge for a range of different nursing contexts. Some of this has begun in the mental health field (see, for example, Reed 1999), but the lessons learned here need to be extended across all nursing contexts. If we are to follow the direction of Li, then, we need to think carefully about how we might need to develop the nursing perspective from individuals to the family and social system in which they live.