Family Health: A Pattern That Connects

Family health has taken on a new meaning in the post-September 11th world. The needs of families that have been ravaged by the loss of loved ones overshadow the enormity of the loss of innocence for all the families of the world. Yet against this new reality nurses must address the needs of families-one family at a time-as we view the "family as client." We acknowledge the embeddedness of families in communities on the one hand and the realities of individual members on the other as we use a zoom lens to move back and forth from family to individual, back to family, then to the larger community in a recursive process. Moreover, the nursing care of families not only depends on this flexible systemic focus, but also on the ability to subsume the reality of each individual while acknowledging the larger pattern of the whole, the community with its variations such as culture, race, religion, and the like. This talent is the unique hallmark of professional nursing practice.

In a variation of this flexible recursive process, Margaret Newman 1 explores the unification of nursing as an art and as a science. Referring to the "pattern that connects" she cites Wilber's notion of holarchy (rather than hierarchy), with each level being whole within itself but also a part of a larger whole. A holarchical progression of nursing knowledge has moved from emphasis on physical care to interpersonal process to an integrative approach to a unitary perspective. Each succeeding level transcends and includes the previous ones. So, having reached the unitary perspective, we do not discard the physical, interpersonal, and integrative knowledge. All are vital to the greater whole. 1 Thus, we could say that movement from an emphasis on the individual to family to an integrative local then to a global perspective represents another way of viewing the world family in a "pattern that connects."

The articles in this issue should be read from such a holarchical perspective, as they represent the physical, interpersonal, and the unitary perspectives.

Gavan's article, "Successful Aging Families-A Challenge for Nurses," examines the older adult family. With the numbers of these families consistently rising, she sounds an alarm about the paucity of research on successful aging families. She challenges nurses to explode the negative myths and stereotypes that restrict the life chances of older adults. Most damaging in this regard are older adults who accept these stereotypes as true and restrict their lives accordingly. Gavan regards myths having to do with senility, personality rigidity, loneliness, and children's abandonment of older parents as especially damaging. She cites ample research dispelling these myths and calls on nurses to become critically reflective in this regard. We must, she believes, separate normal aging characteristics from pathology. While the former are the result of inevitable, intrinsic, genetically determined processes, the latter are usually associated with extrinsic environmental factors including lifestyle, which are amenable to change and improvement. Finally, Gavan challenges nurses to take action to increase the numbers of nurses educated to care for our growing older population by supporting efforts to place the care of older adults on our local, state, and national health care agendas. She believes we also must work with our professional organizations to include courses focusing on the special care needs of older adults in our baccalaureate nursing programs.

In their article, "Creating Family: A Holistic Milieu at a Geriatric Adult Day Center," Sanfilippo and Forker describe a successful model for older adult care that elaborates and extends the positive philosophical approach described by Gavan. While acknowledging and attending to each older individual's physical needs, the authors stress the importance of a holistic approach that also considers the entire spectrum of psychosocial and spiritual needs. Such a holistic approach again, as Newman 1 indicates, includes knowledge of the physical perspective, yet transcends it as attention is focused on the pattern of the whole. Emphasis on transcendent values is enhanced by a view of this older group as a newly configured family that meets the needs of its members whose original families are either unwilling or unable to do so. Loss is an inevitable concomitant of aging-loss of family members, friends, and adult roles, in addition to physical limitations, can lead to feelings of isolation and sadness. Although these losses become a pattern of the whole, they can be transcended as human relationships are restored through new connections in the adult day care community family. Connections are enhanced through the use of healing modalities such as Tai Chi, spiritual discussion, imagery, aromatherapy, memory sharing, and music. As the authors note, "Together, clients accept responsibility for their life, move toward acceptance of the past, and move toward satisfaction with self." Several clinical examples ground these healing modalities in the lives of these older clients providing evidence of their effectiveness in improving the lives of these older adults.

The next section on letter writing proclaims the value of this strategy, again to reinforce positive alternative solutions to problems. There might be a need for the nurse to come to closure with a patient and have the opportunity to reinforce gains that have been made as well as to point out work that is yet to be done. Letters provide such an option and are more "enduring," less "ephemeral." Letters also can be useful to inform, to encourage, to coach, and to comfort. Finally, the last section on storytelling stresses the notion of making stories available to broader audiences for their healing potential. Healing through the use of narratives holds unlimited possibilities for positive outcomes and can be used by all nurses wherever they practice. In this way narratives can be seen as a strategy that truly connects.

Tuyn's article, "Metaphors, Letters, and Stories: Narrative Strategies for Family Healing," explores narrative strategies for family healing. The use of metaphors, letters, and stories is assessed for their ability to help individuals and families recover from disappointment and loss. Citing White and Epston's approach, she connects the use of narrative strategies with a philosophy of "respect for human beings/systems as dynamically unfolding entities whose lives are always evolving and remain deeply integrated with one another's." Tuyn demonstrates an easy movement across individual and family stories connecting them to ownership by the larger community and society as well. The "pattern that connects" in narratives can be used to structure stories that either liberate or defeat. O'Hanlon's seven elements of narrative therapy are elaborated, the use of which leads to the goal of creating new, more life-affirming stories, as well as new audiences for these stories that support and reinforce a positive point of view. Problems must be externalized, distinguishing the person from the problem that, Tuyn believes, helps people express their wholeness. Here, metaphors can be helpful. Throughout the article there is liberal use of narrative examples from the author's experience that offer a practical application of theoretical ideas, making the use of these strategies very accessible to all nurses as they work with individuals and families in a variety of settings.

"Jamaican Families," is the result of Miner's family research involving successive yearly trips to Jamaica accompanied by small groups of baccalaureate nursing students. With a wide-angle focus, the author considers the meaning of the Jamaican family in terms of structure and function. She argues family patterns are an adaptive response to the context of Jamaican culture and not, as is commonly believed, the reason for the marginalization of these people. Rather, marginalization is related to pervasive poverty, years of oppression, colonialism, and punitive economic policies. Miner further elaborates Jamaican family patterns as an adaptive response in terms of affective function (to meet each family member's needs), the socialization of children, reproduction, economic survival, and health care. For example, matrifocality is an adaptive response in that it provides women with flexibility, power, and control within their own households and guarantees that they have the principal role in the socialization of their children. In complementary fashion, fathers do not necessarily maintain a constant presence in the household and have minimal overall expectations for fatherhood, but are counted on for economic maintenance and child discipline. Extensive kinship networks involving child shifting and foster care support all family members, again functioning as adaptive responses to the exigencies of daily life in this poor, developing country. This descriptive study challenges old beliefs about Jamaican families as it challenges stereotypes that portray a negative view of this and similar cultures in the developing nations of the world.

Newman's 1 injunction to nurses is that they absorb and carry forward knowledge from the various realms of their learning, never leaving behind what they have learned, but rather moving easily from one realm to another as they apply their knowledge and skill to the care of families. This approach eschews a focus on parts, but rather views the pattern of the whole-whole individuals, whole families, whole communities. Each level transcends, yet includes, the previous level.

The last article in this series, "Adolescent Girls, Single-Parent Fathers, and Menarche," shifts the zoom lens to focus on adolescent girls and their fathers. Kalman studied the ramifications of adolescent girls living with their fathers at the time of menarche. She was interested in determining how these young women perceived their menarcheal experiences living with their fathers as primary caregivers. Her findings suggest that, although the participants felt they had a close relationship with their fathers, menarche was embarrassing and, as a rule, their fathers lacked credibility regarding menstrual issues. Moreover, these adolescents felt an emotional and physical distancing from their fathers.

As more and more adolescents live with their fathers, Kalman suggests that nurses become more involved in encouraging support for these young women from other sources such as mothers (if available, sisters, grandmothers, and the like). Nurses also need to be aware that the fathers in these situations need information and guidance in helping their daughters negotiate this often-frightening life transition.

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