- Intervention

 Nursing interventions involve most of the ADD HEALTH steps in the nursing process (see Nursing Process). They address physical interventions ordered by the physician as well as nursing actions to decrease anxiety and optimize systemic congruence of patient and family.

IMPORTANT:  In cases where time is short or families are not available, the process described below can be modified.  Most importantly, the nurse thinks the situation through and uses creativity and patient feed-back if possible to arrive at interventions. 

For the systematic and detailed planning and intervention process, the situation at the time of the assessment is compared with the situation before the illness in order to draw conclusions about the optimal future health status of the patient/family and to set goals accordingly.

Step 1: Assess Health Patterns

Based on the assessment data (on patient and family), the nurse draws conclusions about the health status before the illness and at the present. The nurse draws simplified models based on the assessment data pertaining to each process dimension. The illustration below refers to a before-after situation. It should be drawn for both the patient system and the family system since the two can differ significantly. 



Assuming the models above refer to the family, the first (before) shows a reasonably healthy family that is well organized (SM = System Maintenance), has strong togetherness (C = Coherence), has reasonable flexibility to make changes (I = Individuation) and has some experience with making major adjustments (SC = System Change). After the illness, all dimensions have suffered. The family organization has been disrupted; roles have changed (SM is smaller); there are interpersonal struggles and insecurities that have affected togetherness (C is small); family members are near crisis, feel lost, and can no longer learn or find solutions (I is hardly existing); the family had to make changes but much of these forced changes have not been satisfactorily integrated in the family operation or accepted as being permanent (SC is small).

Step 2: Describe the Systemic Diagrams

The nurse needs to arrive at a clear goal to work toward. Only the family can help set this goal. It is therefore of great importance to explain to the family, how the assessment of health and needs has been made. To explain the model, simpler terms can be used. Experience shows that families respond very positively to such teaching. The nurse shows the above diagrams to the family (or the patient), and finds out from the family members whether they agree with the diagrams. They can then describe how they see their family operate in the four dimensions. The same is done also for the patient as an individual system.

After the family outlines what they do to maintain their family, how they work together, what they have learned and what changes they will have to make, they will define together with the nurse where the problems are that prevent them from being healthy as a family or individuals. 

Step 3: Determine the Need for Change

Nurse and family draw the ideal family/individual diagrams together. What should SM, C, I, SC look like? The family ultimately determines what their ideal system should look like. 

Based on this discussion and the diagram, nurse and family agree on a focal dimension (the one that needs most reinforcement). The family will decide what they will change in this dimension and set this change as their goal. This process should be repeated for the individual patient. (Working on a focal dimension simplifies the process; growth in one dimension will stimulate the overall growth process and will be noticed throughout the system).

Example:  After Mother had a stroke, family members decide to keep her at home. They need to reformulate System Maintenance (focal dimension). One daughter decides to move in with Mom temporarily, other members share responsibility for shopping, keeping up the garden, rides to doctor's office, bringing in food and giving the caregiver occasional respite. Sharing in the responsibilities also strengthens togetherness (C); teaches each member additional skills (I), and the new operation will result in system change (SC) that eventually becomes maintenance of the larger family.  The nurse draws the diagram for the "Ideal Family" with a large SM quadrant, and larger C, I, and SM, similar to the diagram before the stroke (see picture above).

The use of the ASF-E is an additional way to determine a focal dimension. Its use is additional only and does not replace a detailed assessment of the situation. (See Evaluation for details)

Step 4: Highlight Existing strengths

To implement the plan (see above example), the family needs encouragement that is best achieved through exploring capabilities and experiences and putting them to work. If the family has shown strength in previous difficult situations, they can draw from these. Clients and nurse explore possible family actions focusing on the positive to give the members courage and motivation.

Step 5: Encourage the Use of Systemic Resources

While the action plan is being formulated, the nurse explores with the family what help they need to be successful. Do they need financial assistance, medical equipment, a pastor's visits, neighbors' help, etc.? Of the essence is the well-being of all family members involved. They should not be overwhelmed with work and responsibility. 

Step 6: Assist in the Discovery of New Strategies

The above process may occur in one long session with the family or in several sessions. As the family members become more open with the nurse, they will voice hesitations, conflicts, and problems. These should be discussed in depth to avoid failure in the future. New ways of handling certain difficulties can be suggested by the nurse, but often, the family members themselves will have ideas that can be worked out together. Depending on the complexity of the situation, this process may be concise or lengthy. 

Step 7: Lead the Health Process

As the nurse, you work as a consultant, not a teacher. The family is the expert of their own situation, not you. You do not impose your own ideas and opinions but listen to those of the family/patient. You may present certain solutions as questions  (e.g. would this approach work for you?) You can tell the family of some previous experiences of yours that worked and let the family evaluate. Importantly, however, make sure the family thinks the solutions are their ideas.  Be patient and don't expect sudden change. Families need repeated and honest praise for their effort (Step 9: Honor all Efforts)