• Is a "Family Nursing Process".
• Is a dynamic, systematic clinical reasoning process that emphasizes outcome of care (Pesut & Herman, 1999).
• Builds on traditional nursing process model, OPT emphasizes organizing care around the "keystone" issue that is challenging family health.
• By resolving the "keystone" family issue, a ripple effect will occur resulting in resolving many other problems.
• Nursing focus: collaborating with the family to achieve the most desirable outcome.

1. Family story.
2. Cue logic.
3. Framing.
4. Present state and desired outcome.
5. Interventions and decision making.
6. Clinical judgment.
7. Reflection.

The family story provides essential information about individual family members and the family as a whole. Getting the family (client) story represents the data collection process. Nurses collect data abaout the family via a variety of methods (e.g. interviewing the family client, chart review, process logs, phone logs, phone conversations with other professionals, previous visits with the family, school records).

OPT Step 1: Family Story "How To":

Set an Appointment with the Family

1. Remember that the assessment is reciprocal and the family will be making judgments about you when you call to make the appointment.
2. Introduce yourself and state the purpose for the contact.
3. Do not apologize for contacting the family. Be clear, direct, and specific about the need for an appointment.
4. Arrange a time that is convenient for the greatest possible number of family members.
5. Confirm the place, time, date, and directions.

OPT Step 1 - Family Story:

Deciding the Best Place to Meet

• Done before contacting the family.
• May be dictated by the type of agency for which the nurse works (i.e., home health would be conducted in the home, mental health agency may choose to have family meet in local clinic).
• There are advantages and disadvantages to meeting in the client's home.

OPT Step 1 - Family Story:

Advantages to Meeting the Client in the Home

• Makes it possible to view the everyday family environment.
• Family members are likely to feel more relaxed and thereby demonstrate typical family interactions.
• Emphasizes that the problem is the responsibility of the whole family and not one family member.
• May increase the probability of having more family members present.

OPT Step 1 - Family Story:

Disadvantages to Meeting in the Client's Home

• Their home may be the only sanctuary or safe place for the family or its members to be away from the scrutiny of others.
• Meeting with a family on their ground requires the nurse to be highly skilled in communication by setting limits and guiding the interaction.

BRIEFLY NOTED:

Too much disclosure during the early contacts between the family and nurse may scare the family away! SLOW the process down and take time to build trust.

• The nurse places the data into meaningful clusters of evidence. The clusters of evidence identify problems that are influencing the family's adaptation in the given circumstances.
• Nurses  make connections or see relationships between the sets or clusters of data to identify the "keystone" or foundation problem affecting the family.
• The "Keystone" issue is specifically stated as a family nursing diagnosis.

OPT Step 2 - Cue Logic:

The "Keystone" Issue

• The most important issue challenging the family health is called the "Keystone" issue.
• Often is provided by referral source.
• Nurse must view family with open approach because Keystone issue may have been misidentified by referral source.
• If Keystone issue is not accurately identified, family and nurse will collect data, design intervention and implement plans of care that do not meet the family's most pressing needs.
• The importance of identifying the correct Keystone Issue is central to making an accurate Family Nursing Diagnosis.

• The role of the nurse is to help the family understand the present state and determine the best possible outcome.
• In this step, nurses think about the family story through the "frame" of multiple theory-based approaches.
• By framing the problem from a theory, potential outcomes can be considered given the whole picture of the family client.

• Keystone issue is stated as the present (priority) problem that needs to be resolved.
• Outcome is stated in positive language.
• By placing "present state" side-by-side with "desired outcome", evaluation criteria become more clear (in OPT, called "testing"). 
• Evaluation criteria will be used by nurse to determine if the outcome is being achieved, partially achieved, or not achieved.

OPT Step 4 - Present State and Desired Outcome:

"Testing"

On the basis of the keystone issue, note the following:

• The present state of the health issue challengine the family is clearly identified.
• The nurse works with the family to determin a realistic outcome.
• The outcome depends on th ability of the famil to successfully adapt to the health issue.
• The family's strengths, the patterno ffamily response in similar past situations, and the path of the family health care problem are considered.

OPT Step 4 - Present State and Desired Outcome:

Outcomes

• Outcome is the opposite of the presenting problem and should be stated in positive language.
• Given information about the family, the nurse can predict course of events or pattern of change expected.
• Types of outcomes possible depend on the focus of the problem for the individual and the family as a whole.
• Outcome may be directed at the following:
• Preventing a potential problem.
• Minimizing the problem.
• Stabilizing the problem.
• Recognizing that the problem is deteriorating.

• Nurses must recognize that the family has the right to make its own health decisions.
• The role of the nurse is to:
• Offer guidance to the family.
• Provide information.
• Assist in the planning process.
• The nurse and the family work in a partnership to design and implement a plan of action based on the identified outcome.
• The nurse may assist the family by:
• Providing direct care that the family cannot provide.
• Removing barriers to needed services, thereby helping the family to function.
• Improving the capacity of the family to act on its own behalf and to assume responsibility.

• Nurses make clinical judgments.
• If the plan of action results in achievement of the identified outcome, the nurse may decide to continue with the plan of care, or may decide it is time to put plans in place for the termination of the nurse-family partnership.
• If outcome is not achieved or is only being partially achieved, it is critical that nurses step outside the situation or event to evaluate and reflect on the whole picture.
• If outcome is not achieved, nurse and family work together to determine the barriers.

OPT Step 6 - Clinical Judgment

Barriers

• Two known barriers:
• family apathy - may occur because:
• Of value differences between the nurse and the family.
• The family is overcome with a sense of hopelessness.
• The family views the problems as too overwhelming.
• Its members have a fear of failure.
• indecision - may be because the family:
• Cannot determine which course of action is better.
• Has an unexpressed fear or concern.
• Has a pattern of making decisions only when faced with a crisis.
• Nurse-related barriers:
• Imposing ideas
• Applying negative labels
• Overlooking family strengths
• Neglecting cultural or gender implications

OPT Step 6 - Clincial Judgment

Termination Plans

• Important part of clinical judgment is the decision to terminate the relationship between the nurse and the family.
• Consists of phasing out the nurse from family involvement.
• When built into the interventions, the family benefits from a smooth transition process.
• Family gets credit for the outcomes of the interventions they helped design.
• Should include a summative evaluation meeting in which nurse and family put a formal closure to relationship.
• Regardless of how termination comes about, it is an important aspect of working with families.
• If termination occurs suddenly, important for nurse to determine the forces bringing about the closure.
• Family may be initiating termination prematurely, which requires a renegotiating process.
• Insurance or agency requirements may be placing a financial constraint on the amount of time the nurse can work with family.

OPT Step 6 - Clinical Judgment

Strategies Often Used in Termination Plans

• Decreasing contact with the nurse.
• Extending invitations to the family for follow-up.
• Making referrals when appropriate.

• Nurses to engage in critical, creative, and concurrent reflection about the case.
• By stepping outside the action and viewing the whole picture, including the self, get a different perspective on the problem facing the family.
• Seeing the whole picture from outside the action increases the options for action.
• Three distinct parts to reflection:
• Reflect on the client outcome that is or is not being achieved.
• Reflect on and add the details of this case to the nurse's mental file (or library of knowledge)
• Engage in self-judgment.

• Is the cornerstone for family nursing interventions.
• Uses as systematic process to identify problem areas.
• Family strengths are emphasized as the building clocks for interventions.
• Interventions based on family-identified problems and strengths allows for equal family and provider commitment to solutions and ensures more successful interventions.

Family Nursing Assessment:

Friedman Family Assessment Model

• Draws heavily on the structure-function framework and on developmental and systems theory.
• Takes a broad approach to family assessment.
• Families viewed as a subsystem of society.
• Family is viewed as an open social system.
• Focus is on family's structure (organization) and functions (activities and purposes), and the family's relationship to other social systems.
• This assessment approach is important for family nurses because it enable them to asses the family system as a whole, as part of the whole of society, and as an interaction system.
• The approach was developed to provide guidelines for family nurses to gain an overall view of what is going on in the family. 
• Questions are extensive and it may not be possible to collect all data in one visit.
• Not all categories may be pertinent for every family.

Family Nursing Assessment:

Fiiedman Family Assessment Model - Guidelines

1. Identifying data.
2. Developmental family stage and history.
3. Environmental data.
4. Family structure, including communication, power structures, role structures, and family values.
5. Family functions, including affective, socialization, and health care.
6. Family coping.

Family Nursing Assessment

Friedman Family Assessment Model - Assumptions

1. The family is a social system with functional requirements.
2. A family is a small group possessing certain generic features common to all small groups.
3. The family as a social system accomplishes functions that serve the individual and society.
4. Individuals act in accordance with a set of internalized norms and values that are learned primarily in the family through socialization.

• Nursing is accountable to participating in the development of legislation and family policy.
• Government actions that have a direct or indirect effect on family are called family policy.
• All government actions affects the family in both negative and positive ways.
• The United State has no overall, official explicit family policy.
• An oft-cited argument for the lack of more explicit family policies is related to the financial burden that would occur if the definition of family was too broad.
• The Family Leave legislation is an example of a type of family policy that has been positive for families.

• Each family is an unexplored mystery, unique in the ways in which it meets the needs of its members and of society.
• Healthy and vital families are essential to the world's future because family members are affected by what their families have invested in them or have failed to provide for their growth and well-being.
• Families will continue to survive and serve as the basic social unit of society.

• Significant barriers:
• The narrow definition of family used by health care providers and social policymakers.
• The lack of consensus concerning what constitutes a healthy family.
• Until recently, most nurses had little exposure to family concepts during their undergraduate education and have continued to practice using the individual focus. Family nursing was viewed as "common sense" and not a theory-based nursing approach.
• Good comprehensive family assessment models, instruments, and strategies in nursing have been lacking.
• Nursing has strong historical ties with the medical model, which views families as structure and not central to individual health care.
• The traditional charting system in health care has been oriented to the individual.
• The medical and nursing diagnosis systems used in health care are disease centered, and diseases are focused on individuals.
• Insurance carriers have traditionally based coverage and reimbursement on the individual, not on the family unit.
• The hours during which health care systems provide services to families are at times of the day when family members cannot accompany one another.