When considering nursing practice for families, there is a tendency to think of the family as a static entity, existing as it is when first encountered -- and as frequently described in this paper. But families are not static; they evolve as people change and age. For any nurse who is fortunate enough to provide services to a family over a period of years, the challenge is to ensure the focus of care is appropriate to the changing needs of family members (Edelman & Mandle, 2010). For example, delivering healthcare to a family during the period from 2000 through 2013 would require a practitioner to navigate some of the most extreme socioeconomic shifts experienced in several generations. The implications for healthcare are substantive when people loose significant percentage of their accumulated wealth, or when they lose their job, or when any number of variables that diminish the circumstances of a family.
Average U.S. Family
Around the time of World War II, socioeconomic forces were the catalyst for substantive social and culture changes in the lives of people living in the United States. One manifestation of this sea change was the structure and attributes of the nuclear family unit. The distance has grown very great between contemporary families and the Dick and Jane version of a nuclear family: a father, a mother, two (or 2.5 children to be exact for the time), a dog and a cat, and at least two grandparents living on a farm. Socioeconomic changes are perhaps most strongly manifested in terms of more social leniency coupled with the need and desire for more household income. One-parent families (often young single parents as roughly 80% of divorces involve people under 30 years of age), stepparents or blended families, and extended family members living together: these are the landscape of the modern family. In a majority of two-parent families, both parents work, often with childcare provided by grandparents or other family members or by childcare centers.
In the years between 2008-2012 (the most recent U.S. Census), approximately 65.5% of the population owned homes and 25.9% of the population lived in multiunit structures. The number of people living per household was 2.61. The per capita money income in 2012 was $28,051, while the median household income was $45,800 in 2010 (down 8% due to the fiscal crisis) and $53,046. The percentage of people living at or below the official level of poverty was 14.9% of the population. The average American family lost 40% of its wealth from 2007 to 2010, which basically pushed them back to 1992 levels.
U.S. Health Care Systems
Healthcare is provided to the citizenry through systems that are public and private, large and small, independent and collaborative -- many of these systems are federally funded or state funded with flow-through federal dollars.
The provision of health care in the United States primarily occurs in facilities that are privately owned and operated as businesses in the private sector. Non-profit enterprises operated roughly 62% of U.S. hospitals. Of hospital facilities located in the United Sates, approximately 20% are owned by the government, and roughly 18% are for-profit businesses. The United States government has enacted legislation over many decades to establish, build, and reform health care systems to serve the country's citizens. Indeed, approximately 60-65% of spending on healthcare and the associated provision of services occurs through federally funded and supported programs, such as: Children's Health Insurance Program, Medicaid, Medicare, Tricare, and the Veteran's Administration.
Public health systems have become more collaborative and therefore more complex, including public health agencies and other public sector agencies. Today, public health is delivered in schools, and through work with environmental protection agencies, land use organizations, Medicaid, and a full spectrum of private agencies that have the potential to impact community healthcare.
Public health is conducted through processes that are carried out by clinicians and practitioners who address community-wide or population-wide health issues. Nurses who work in public health contribute to the processes of identifying, prioritizing, and addressing health problems. Traditional outputs of public health include interventions, programs, policies, regulations, and services. In summary, "The processes of public health are those that identify and address health problems as well as the programs and services consistent with mandates and community priorities" (Bialek, 2009).
The U.S. Department of Health and Human Services has developed the Plan to Reduce Racial and Ethnic Health Disparities that outlines the objectives and actions of an initiative that will be undertaken to reduce healthcare disparities for people who are racially or ethnically diverse. The HHS Disparities Action Plan initiative is led by the Office of Minority Health, the agency charged with integrating the evidence-based practices at all HHS Department levels and into the communities where services are provided. A number of federal programs and initiatives form the foundation of the HHS Action Plan, including the Affordable Care Act, Healthy People 2020, the Let's Move initiative sponsored by First Lady Michelle Obama, and the President's National HIV / AIDS Strategy.
Barriers to Family Health and Wellbeing
Obstacles to healthcare barriers exist in every health care system. These barriers impact the ability of vulnerable patient populations to obtain the health care they need, or -- when compared to patient populations who are more advantaged -- that result in these vulnerable patients receiving inferior healthcare ("ASMAF"). A primary dynamic of these obstacles is that, "Barriers to care lead to disturbing racial, ethnic and geographic disparities in health status and clinical outcomes" (AMSA, 2013).
A wide range of circumstances can impact access to healthcare. The most common barriers to access are related to unemployment, inadequate benefits coverage, residing in rural areas, and being elderly or disabled. The convention for describing barriers to healthcare typically involves these categorical types of obstacles: Cultural, geographic, organizational, and socioeconomic -- and any combination thereof. Cultural barriers entail the beliefs that people hold and behaviors that people exhibit related to healthcare. Cultural barriers exist for patients, practitioners, and policymakers. Geographic barriers are the result of the distance between where people reside and medical facilities, or extant shortages of healthcare professionals in particular locations, such as rural areas or inner cities. Geographic barriers interact negatively with socioeconomic variables. Socioeconomic barriers are directly related to the ability of people to purchase health insurance, or to buy quality health coverage. Socioeconomic barriers also impact the ability of people to pay for out-of-pocket healthcare costs that are not covered by their insurance policy, assuming they have medical, dental, or vision insurance. Organizational barriers are manifested by issues like long wait times for appointments, inadequate public transportation to healthcare facilities, short or inconvenient hours of operation for the working poor, who often work two or more jobs and do not have child care. Although federal legislation has changed the physical context for people with disabilities, a lack of interpreters or absence of wheelchair accessibility can still create barriers to healthcare access. It is probably that a great many barriers are the result of a combination of these factors, a few of which can create a perfect storm for a vulnerable person in need of healthcare.
Nursing Care for Families
When the unit of analysis is at the country level, the United States does not fare well in comparison with many other developed countries (Davidson, 2013). But when the of analysis is an individual nurse or nurse practitioners, American patients benefit from some of the best-trained nurses available. There have been periods when registered nurses are in short supply in the U.S. And in other countries, which has resulted in recruitment efforts in other countries.
Family and public health nurses deliver evidence-based practice in community settings. Public health nurses function in the context of nurse-family partnerships that is relationship-based and relies on the development of trust between the nurse and the patients treated. Family and public health nurses provide intense support, training, and healthcare to first-time mothers who may be a risk, and strive to improve the health and development of children. Often, working with young, at-risk mothers is a specialty focus of community health nurses, who provide services during home visits and establish relationships that enable them to guide the young mother through the various stages of their pregnancy and the early years of mothering. In addition to healthcare, the nurse works to help patients deal with the emotional, physical, and social challenges of their pregnancy. This level of personalized nursing care contributes to measurable, enduring benefit in the lives of young mothers, their children and families, and their communities.
The structural, social, and economic changes that characterize family situations in the United States today have been catalysts for marked alterations in the provision of healthcare to families, in the work conducted by nurses, and particularly in the families. Although there has been movement backward toward traditional situations -- adult children living at home or older people living with their grown children -- the trend toward independent living by the subsets of extended family tends to continue on the same tack.…