Friday, May 4, 2012

Community Health Nursing

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The family I decided to do my project on is the Johnson family. My sister-in-law at my niece’s birthday party introduced the Johnson to me. The Johnson family is the “nuclear dual career type.” A nuclear dual career family is “a basic family unit consisting of parents and their children,” (Davis, F. A. 17, p.11) in which both parents are working parents. The Johnson family migrated to Canada from Cape Verde, West Africa about fifteen years ago. The family consists of Michael Johnson (father), a 50 years old man who works as an order picker in a supply chain management company, a mother, Elizabeth, a 45 years old factory worker, Tracy, (eldest child) aged 1 attends university and works part time. Clement, (second child) aged 17 attends college, and Cathy,(third child) aged 1 is a junior high school student. My client family lives in a modest three bedroom rented apartment building in downtown Mississauga, Ontario. They are practicing Christians.

The family’s eldest child (Tracy) as stated above is 1 years old, thus putting my client family’s developmental stage in the “Teenage” stage. This family’s developmental tasks therefore, revolve around “balancing teenage freedom with responsibility and the establishing of post parental interests” (Dugas, 18, p.). Tracy currently works part time with the intention of saving money and moving in with her boy friend as soon as she has enough money saved up. She states “I feel I should not be a burden to my parents any more. I asked her why she feels this way, she replied, her parents have done enough for her and it is time for her to start her own family. Appendix (I) is the genogram I developed with my study family.

After my sister-in-law had introduced me to the Johnson family, I called them and we agreed to meet in their apartment on Saturday morning when the whole family will be home. When I got to their apartment they welcome me with a smile. I introduced myself as a second year nursing student from George Brown College. I told them I was doing a family project and that the assignment will require me making about 7 visits to their home by the time it is completed. I also explained to them that the purpose of my project is to promote and protect the family’s health, help pay proper attention and focus on any health issue or issues in the family by providing them guidance to an inclusive approach to solving them. I assured them that anything we discuss will be confidential and that only my professor will have access to whatever we discuss throughout the course of my assignment with them. I also assured them that I will only use their initials instead of their real names and that their address will not be used at all. After explaining to them what my project is about, I intentionally engaged them in a short but lively conversation about the socio-economic and political situation in both our native West African countries of Cape Verde and Nigeria respectively during which we shared some laugh and resentment for the corrupt political elites. They seem to have enjoyed the conversation. I sensed they fell more relaxed with me. Finally I asked the family if anyone has any concerns or questions. Nobody had any. So I thanked them for their time with me and they agreed to meet with me in their apartment the next Saturday.

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In my conversation with the family I employed different communication skills that enabled me to obtain as much information as possible from the family as they felt comfortable enough to willingly share it. I listened very carefully to the family when responding to my questions. I used paraphrasing, restatement, reflection, occasional touching and silence during our conversation. I also used open-ended questions like, “how does the socio-economic status of the family in Canada compare with their homeland’s? Question of this nature is open-ended. It is aimed at making the family feel at ease and increases their level of participation. “Such questions are designed to permit the client to express the problem or health need in his/her own words (Arnold and Boggs, 1, p.17).


(Dugas, 18, p.) defines family as “resource for everyday living, the ability of family members and a family as a whole to achieve stage specific development tasks”. I began the assessment of the family’s health and concerns by asking them to describe for me how they perceive their current state of health. Mr. and Mrs. Johnson (Michael and Elizabeth) seem to have similar perception of what being healthy is. They stated that being healthy entails being free of any bed-ridden illness and being able to perform a reasonable level of physical activities like walking, gardening, dancing and spiritually at peace with one’s self. Tracy (eldest child) described good health as being about staying physically fit and slim built through regular exercise. She also said good health is reflected in good skin with no sign of diseases and a stress free mental state. Clement and Cathy being younger than Tracy, understandably however, described good health as being able to participate in many sporting activities, partying occasionally, and not eating a lot of junk food. After they have all told me what their understanding of good health was, I asked them to grade the overall health of the family from poor, fair, fairly good, good to excellent. They scored their overall health as fairly good. They said their choice was based on the fact that with the exception of Tracy the family does not exercise at on regular basis. Also, Elizabeth suffers from hypertension. They admit they eat junk food during the week because the hardly find to cook.

The family’s past experience with health issues principally borders on Elizabeth’s ( mother) stress level and weight problem. Elizabeth is slightly overweight and has hypertension. According to her she might have inherited it from her father since she was about 40 years of age. Elizabeth had a crisis late last year, at friend’s Christmas party. She stated, “I think I had a little too much to drink that day and that must have caused blood pressure to rise”. She stated she came home from the party that evening and complained about a pounding headache and took Tylenol. About hours later, the headache worsened and her temperature rose. Michael (father) stated, him and the eldest child Tracy had to rush her to emergency unit of the local hospital. The triage nurse checked her B.P. among other routine checks. Elizabeth’s BP was 10/108 which was above her normal BP of 150/100. She was then sent for further tests to ensure there has not been any damage to her organs. I asked? “what did your family find helpful from the doctors and nurses at the hospital? (Open-ended question). They all almost simultaneously replied, “yes, they were very helpful and supportive.” “They advised us to ensure that Elizabeth stays away from alcoholic drinks.” Michael added that they were given name of community resource centers where Elizabeth can learn how to manage her hypertension and lose weight. Through the support group the family stated, they learn alternatives to the salty spicy food they were used to in their native Cape Verde so that she can lower her salt intake and consequently her BP. Elizabeth was also counseled on the need to cut down the number of hours she spends at her job. She admitted this as being the most difficult of all the preventive measures she was counseled on as she has to help support the family’s financial needs among other needs.

As a CHN I believe the Johnson family health issues are mainly stress, hypertension and Elizabeth’s weight problem. Getting the family’s current stress level and the mother’s in particular to a level such as will not develop into another health crisis is a major concern. Increased weight and stress could elevate the mother’s BP. Also increase in the family overall stress level could affect the family’s harmonious relationship due to lack of communication and attention from the parents and the eldest child, Tracy. Related to Elizabeth’s (mother), hypertension, the family is concerned about her not eating breakfast and lunch regularly at home because of the long hours she spends at her job. The family fears this might result in her consuming food with high salt and fat content, which will obviously not help her weight gain and hypertension.


The goals I helped the family set to address their health issues are

1). The family will collectively improve their knowledge of stress management and hypertension prevention and treatment and also weight reduction through nutrition and exercise in 5-weeks at a local community resource center that I will recommend to them in addition to the one they have been attending during the mother’s last crisis with hypertension.

). The family will be introduced to “Canadian Food Guide” for 6 weeks. This will show them appropriate servings of nutritious food even with their busy schedule and keep them healthy without weight gain problems especially for the mother.

). To reduce her stress, Elizabeth (mother) will be advised to walk to work at least one stop from her current drop off location. She will be advised to the same on her return trip at the end of the day’s work. Our target will be for the mother to lose between -lbs a week or 10-15lbs by the end of 5-weeks.

4). I will introduce the family in general and the mother in particular to stress relieving African American gospel music to relax them in stressful situations.

5). The family will be advised to avoid alcoholic drinks for Elizabeth sake in order to prevent her BP from rising thereby triggering hypertension.

I stressed to the family that I believe these goals are achievable if they dedicate their time and effort and I will be available to offer my assistance whenever it is needed. On this note I gave them my cell phone to lend weight to my desire to assist them meet our set goals.

The health problem identified by the Johnson family as a major concern to them is Elizabeth’s (mother) hypertension and weight problem. The family and I discussed in greater details the steps involved in developing an achievable health plan. The planning stage is one of the most important in the nursing process. As stated in the text, “the purpose of health planning may center on improved crisis management or health promotion,”(Logon, 186, p.50). With my knowledge and skill, I educated the family on the need and importance of achieving set goals regarding their health issues. The family was encouraged to use services of Canadian Heart and Stroke Foundation whose programs and services I am confident will be of great help to the Johnson. I explained to the family the programs of the organization that are relevant to their health problem. I told them the organization would provide them with pamphlets, videos on hypertension, high blood pressure weight management exercises among many other resource materials that may helpful to their situation. The organization will also provide the Johnson with support groups that will provide them the necessary moral support and encouragement. Most importantly, the family through the support group will be able to meet with others copying with the same heath problems as they are. The agency’s nutrition and exercise programs will help Elizabeth a lot in losing weight and stress to some extent. The other members of the family will also learn how to eat nutritionally balanced diet and reduce stress from the nutritional and exercise programs of the agency. I emphasized to the family the need to be motivated in order to achieve our goals. The family said they will use the services of the agency and promised to go there at a time and date to be determined by them to suit their schedule. I gave them the address, phone number of the agency and the name of the person to contact.


The relationship I developed with the family is based on mutual respect, trust, empathy, openness, understanding and care for their well being. During the introductory phase of the project I told the family I will mot use their real names. Only their initials will be used and that my professor is the only person I will share their information with. With this in place, they were assured of confidentiality of their information and consequently I gained their trust. They felt at ease sharing their personal information and health problems with me. On my part I maintained confidentiality at all times as promised. During the working phase, they were allowed to make suggestions rather me instructing them on what to do. I empowered them by allowing them to make their own with me decisions with me providing where necessary.

During the working phase, I used such therapeutic communication skill as (listening response) by listening, nodding, and even clapping when the family made suggestions. I also maintained eye contact to show my attentiveness to on-going discussions between us. When Elizabeth, (mother) stated she would not find it easy to eat food cooked without salt and low fat in order to avoid future episode of hypertension, I replied, “I do understand your feelings, since most of your native African food you like to eat are salty and spicy. However, your motivation and enthusiasm are necessary for our goals to be achieved,”(acknowledgement). During the termination phase, of nurse-client interviews hints are given to client that the interview is about to end. This is done to alert the family to ask any important questions they might be thinking of postponing, and has the tendency to make the client more focused as opposed their wondering away if they were not hinted. This type of communication skill prepared me to urge the family to ask any other questions they had before we before we departed.

The article I selected in discussing the current social trend affecting the Johnson is titled “Management of Family and Workplace Stress Experienced by Women of Colour from Various Cultural Backgrounds.” By Basanti Majumbar, PhD, and Shelinci Ladak, BA. The article dealt with the study of how women of colour, immigrants and refugees face a major problem of stress and concerns. The illustrated how women from the target group cope with such challenges as barriers of language, different environment, discrimination and lack of support. The above stated factors were measured and compared with the focus group. The article stated identified the sources /causes of the stresses and management strategies the target group considered important to the study subject. The study, according to the article, found that women form the target group identified four areas of stress, namely, headache (68%), anger (5%), fatigue (5%)and insomnia (8%). The results of the study also showed women experience in different ways .For example, the amount of hours they work per week and the schedules. It also showed women experience stress because of their multiple as mother, worker and wife. The researchers also found that women manage their stress through prayers; listening to music, hot bath, medication and exercise. Another significant finding the article pointed out is “women of ethnic minorities experience psychological adaptation due to cultural conflict as they to resettlement conditions, occupational and financial difficulties, loss of status and reduced social support.” Also the study found that women in the focus group ranked stress management strategies in of effectiveness as follows prayer (64%), listening to music (55%), hot bath (4%), exercise and reading (41%)and positive affirmation (40%). The findings in the above stated article, relate very closely to the Johnson family. It illustrates the problems the family is currently facing. Worth mentioning here is the fact women studied in the article stated that working long hours (between 65-80hours) a week to make ends meet and this contributes significantly to their stress sources. I find that their situation mirrors that of Elizabeth (mother), because she stated she works over 50 hours a week to assist her husband in providing for their family’s financial needs. This shows why the Johnson have stress and relies heavily on fast food for dinner most of the time. Elizabeth confessed ordering pizza for her family for dinner because she is often too tired by the time she gets home from her job. My study family like some immigrant families also faces diminished status. For example Michael was a successful businessman in his native country but he has not been able to raise enough capital to start any business since arriving in Canada. He does factory work to support his family. This has been a major source of stress for sometime. Also, I believe my study family’s stressful situation will be significantly reduced and eventually be eliminated because as practicing Christians they believe in the power of prayers when faced with difficulty. This was demonstrated when the led by Michael, the father, the children prayed for Elizabeth their mother in her hospital bed during a hypertension episode. They confessed that was very helpful in coping well with that stressful period in their family life.

As a CHN, I am able to help make positive changes in individuals, families and community at large by collaborating with other health care professionals on the need for health promotion. For example, as a CHN I have helped my study family identify the major health issues of concern to them. I was through professional skill able to suggest routes of action required by guiding them to the sources of beneficial community resources available to them but which they do not know anything about. Also by suggesting to them support group sessions they are able to find out that they are alone in their problem and as such helps remove any sense of despair.


As a CHN, I have all along made the family understand that the success of our implementation plan lies principally in their own motivation and enthusiasm. My job is essentially to use my professional skills to encourage them achieve the goals we set in our plan. The Canadian Heart and Stroke Foundation programs were effective and helpful in assisting the Johnson regarding Elizabeth’s high BP that may lead to a hypertension episode. The agency’s stress management and group therapy sessions recommended to Elizabeth is helping her reduce her stress. She (Elizabeth) stated that, “meeting people with similar problems as mine during group sessions has been a big motivation for me and has as a result encouraged me to work harder on my problems. She also stated, she was given a recipe for low salt and fat food that she now cooks and enjoy. By accompanying their parents, the children to therapy sessions the whole family especially the children exercise regularly now. During the working phase Tracy (eldest child) had said her perception of good health meant staying slim and fit with occasional exercise. Thanks to the agency’s resource materials she now follows the Canadian Food Guide religiously to avoid unwanted excess weight gain. She however, confessed she takes her younger siblings out once in while to enjoy their favourite French fries.

CFAM (Calgary Family Assessment Model) “is an integrated conceptual framework that combines concept from nursing and family therapy to provide a clear systematic model for assessment.” (Dugas, 18, p.8). The CFAM was helpful and effective during the planning and assessment phases of my work with the family. For example, the structural assessment and functional assessment helped in the development of the family’s genogram and ecomap respectively, with active participation from them. The genogram provided in single glance a pictorial view of the family’s internal structure and the relationship between them. The ecomap on the other hand focused on the family’s external structure with emphasis in this case on how the family is connected to the world around it locally, i.e. schools, church, friends, community services e.t.c. In short CFAM, helped me view the family as a unit whose components parts have some effect on the other as opposed to treating it the members as just individuals.


I met the Johnson family in their apartment on September 8, 00 at 1100am. I introduced myself as a second year nursing student at George Brown College. I told them that I would be spending the next 5-6 weeks with them. I explained to them that the purpose of my project is to use my professional skills as a CHN to help assist and empower them in identifying health issues of concern to the family. I clarified to them that I was not there to make diagnoses of any health problem, but rather to provide researched information on health issues they want addressed that will eventual improve the family’s overall wellness using proven therapeutic communication skills. I also informed them that only their initials would be used in my report. Neither their names nor address would be used to ensure confidentiality of all information they would provide me throughout the project. We designed the family’s genogram and agreed on the date and time for the next.


On Saturday, October 5th. 00, I arrived at the Johnson apartment at 1 noon as agreed on in the previous meeting. With all members of the family present, we discussed in a very relaxed mood topics like the family’s hobbies, spirituality, and community resource center in their locality, the parents’ jobs, the children’s school and extra curricula activities. This information helped me in drawing the family’s ecomap. I asked what the family perceives as good health and what they consider a health issue at the moment. Elizabeth raised her concerns about her high BP and weight problem. I also asked, “how does the family cope with Elizabeth’s issues and how has it affected the family’s overall health?” They replied, “we take her to the hospital when it develops into crisis. Michael (the father) added, “ This, coupled with long ours at my job is very stressful.” Before this meeting ended we set date for next meeting.


On October 1th. 00 at 115pm I met the Johnson in their apartment. I was 15 minutes late. On arrival I met the family sitting around their dinning table waiting for me. They said they were a bit worried and wondered if I was going to show up that day because I have been prior today’s meeting. I greeted them, apologized for my lateness and I explained that my car disappointed. We joked about my old car. Fortunately, this set the tone for a very relaxed mood for the continuation of the working phase of the project. I asked them how they would to improve their current state of health. I encouraged them to express freely their opinions as there are no right or wrong answers to my questions, (i.e. I would not be judgmental). We proceeded to discuss the family’s goals and implementation strategies to the problems they have identified, emphasizing to them that the latter has to clear, simple and achievable. Having discussed and explained to them sources of community resources on the health issues identified they showed motivation and enthusiasm to free the family of its stressful situation. They thanked me and we set the date for the next meeting.

Journal 4

I met the family in their apartment at 100pm on Sunday October 0th. 00. All members of the family were present. With the openness, respect, and mutual trust that we have established in the course of last three meetings we began this meeting by summarizing the goals and implementation strategies spelt out in our previous meetings. The family told me they had started implementing some of the goals outlined in our last meeting. Michael (father) was quick to announce that the family has agreed to ban alcoholic drinks and salty food in their household for good of all. Michael also added that he had arranged for the family to attend their first support group session at the local Canadian Heart and Stroke Foundation office on October 1th. 00. I was delighted to see the family very motivated and felt that my professional skill of empowering client was successful. We scheduled the next and final meeting Saturday, October 6th 00 at 100pm.

Journal 5

I met the family for the last time on October 6th 00 at 100pm. in their apartment. I reminded that the meeting was the last we would hold for the project. We then went over all the goals set to address the family’s health issues and the corresponding implementation strategies we developed to achieve them. To further motivate the family not to rest on their oars, I congratulated them for the efforts they have made thus far in achieving some of the set goals. They expressed their appreciation for the help and guidance I provided them. Elizabeth (mother) was particularly delighted for the fact she now able to do some much for herself and her family in such short time through the knowledge she acquired in the last 4 weeks. She stated, “ I couldn’t have done this without your support and encouragement. Thank you my daughter.” I was happy that through this project I was able to help the family to address the health problem of stress and hypertension and improve the family’s health. I reminded that this meeting was the last, and thanked them for their time.

I used both verbal and non-verbal communication such as nodding, laughing and smiling during my conversation with the family. I listened attentively to them and did not ask too many questions to prevent of feeling of being under interrogation. I also asked the family both open-ended and close-ended questions. For example, I asked, “what did the family find helpful from the doctors and nurses at the hospital?” (Open-ended). I also used listening response therapeutic communication method like leaning forward to signify paying attention and interest in the subject, occasionally nodding and saying such words as “go on”, “oh really”, and “mm”.

Journal #1

I went to the Johnson family apartment on 8th September at 1100am. According to (Arnold and Boggs, 1, p.17), “communication starts with building rapport in the beginning of a relationship or interview thereby establishing a trusting environment in which the client will feel comfortable sharing information”. Therefore, in order to promote a relaxed atmosphere for day’s meeting, I decided that everyone tell a story about any experience we have been involved in. I began by sharing my personal funny experience with my study family and I noticed they laughed loudly and freely. As a result I was successful in getting everybody to loosen up. After my story Elizabeth, (the mother) asked to tell hers and we all almost simultaneously said yes to her request. They all had something to share and while they were sharing their stories, I was nodding, clapping and laughing (non verbal communication) thereby expressing my interest and understanding in the story being told (understanding). We then proceeded to the development of the Johnson family’s genogram by asking questions like “I need some information about your family, like age, occupation and hobbies” (information seeking). The communication skill I employed enabled me to obtain as much information as possible from the Johnson family as they willingly shared it, thus making the genogram development part of my project very successful. I also listened very carefully to my study family during their response to my questions. I avoided giving advice immediately when there was need for it. Furthermore, I used paraphrasing, restatement, reflection occasional touching and silence during our discussions. My meeting went well as there was a surge in the relaxing mood in the family in which the meeting took place. Finally, I reassured my study family of the confidentiality of all that we discussed by re-emphasizing that only their initials not their proper names will be used in the report. I asked my study family to think about their state of health individually and as a family as well as any issues of concern to them for the purpose of our next meeting. I then thanked them for their time and they said they looked forward to meeting me next Saturday for the next phase of my assignment.

Journal #

On Saturday afternoon, October 5th, I arrived at Johnson’ family home at about 115 p.m., 15 minutes later than scheduled. I met the family seated around the dining table patiently waiting for my arrival. I apologized for arriving late and explained to them that my babysitter disappointed and that I had to hurriedly make alternative arrangement. They sympathized with my situation and enquired if my children would be all right. After we had settled down and hoping to build on the rapport we established during my previous visit, I asked if any has an answer or answers to what I had asked the family to think during my previous visit, i.e. the family’s view of it’s state of health and any other health issues of concern. Surprisingly, everyone was ready to say something which was an indication of a comfortable nurse-family relationship had developed between my study family and me. That was exciting to see happen! Mr. and Mrs. Johnson

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