37.1 Family Concepts

Definition of Family

Many variations exist in the definition of family. These include legal, cultural, social, and personal definitions of family. What constitutes a family is a prime area of debate for legal and health-related purposes. Family is often defined in terms of structure, with each family member filling a specific role (like father, mother, or child). On the other hand, family may be defined in terms of how members relate to one another. A family is a socially recognized group, usually joined by blood, marriage, cohabitation, or adoption, that forms an emotional connection and serves as an economic unit of society. Sociologists identify different types of families based on how one enters into them. A family of orientation refers to the family into which a person is born. A family of procreation describes one that is formed with the intention of bearing children. These distinctions have cultural significance related to issues of lineage.

In a social or cultural context, families may also be defined as groups where participants view themselves as family members and act accordingly. In other words, families are groups in which people come together to form a strong primary group connection and maintain emotional ties to one another over a long period. Such families may include groups of close friends or teammates. Another perspective views families as groups that perform vital roles for society—internally (for the family itself) and externally (for society as a whole). Families provide for one another’s physical, emotional, and social well-being. Parents care for and socialize children. Later in life, adult children often care for older adult parents.

The Health Resources and Services Administration (HRSA) defines family as “a group of two or more persons related by birth, marriage, or adoption who live together; all such related persons are considered as members of one family” (HRSA, 2023). This definition also considers older children who do not reside in the same home but are financially supported by the family. This definition does not consider foster children or non-related individuals functioning as part of the family unit while living in the same home. Other definitions suggest that a family is a kinship unit that remains present regardless of whether these individuals share a residence. In the current setting of communication ease, family relationships and communication can persist over long distances while influencing one another (Jabbari et al., 2023). Family structure and definition are complex and vary depending on whether social constructs, statistical analysis for census purposes, or individual beliefs and values related to the family are considered.

The government is less flexible in its definition of family. The U.S. Census Bureau defines a family as “a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together” (U.S. Census Bureau, 2023). This definition of family does not capture the many other subtle ways people define family. While this structured definition can be used as a means to track family-related patterns over several years, it excludes individuals, such as cohabitating unmarried heterosexual and same-sex couples. Legality aside, health professionals would argue that the general concept of family is more diverse and less structured than in years past. Society has given more leeway to the design of a family, making room for what works for its members (Richardson et al., 2022).

Relationship Between Families and Illness

The relationship between family and health has many facets. First, genetics and heredity significantly affect disease risk and overall health outcomes. Additionally, family dynamics and the environment have dramatic effects on individual health. This stems from the family’s health practices, health literacy, and health choices, particularly during childhood. Family choices associated with health affect a child from the early years and often set the stage for health or disease later in life.

Heredity is a complex topic that is associated with a variety of health disorders. A disorder is considered hereditary if an individual can pass it naturally from parent to offspring through their genes. This makes hereditary disorders a subset of genetic disorders. A genetic disorder is caused by a change in a genetic DNA sequence or a mutation in a gene or multiple genes. Some, but not all, genetic disorders are heritable or can be passed from one generation to the next through their genes. These mutations can be caused by environmental factors or damage to DNA. Emerging research suggests that most diseases have some genetic component, meaning that there is some damage to a gene causing the disorder either before or after birth (NIH, Human Genome, 2018). Genetic and hereditary disorders encompass both rare disorders and common diseases.

A familial disorder is a disease that tends to present among individuals from the same family line. These may be genetic in origin or have a multifactorial cause. Familial disorders that are passed from one generation to the next through genetic material are called hereditary conditions. These gene mutations may cause a disease noted at birth or a risk for developing a disease later in life. Genetic disorders may also be affected by environmental factors. For example, an individual may have a genetic mutation predisposing them to high blood pressure. Still, they may or may not develop high blood pressure or hypertension if they maintain a healthy weight, consume a nutritious diet, and exercise regularly. In this way, environmental factors can also influence the expression of genetic predisposition for specific disorders. Familial diseases include the following:

• coronary artery disease
• hypertension
• heart disease
• arteriosclerosis
• congenital heart defects
• type I diabetes
• type II diabetes
• asthma
• lung cancer
• prostate cancer
• breast cancer
• colon cancer
• osteoporosis
• thyroid disorders
• autoimmune disorders
• arthritis
• Alzheimer disease
• autism spectrum disorders
• migraine headaches

Examples of hereditary chromosomal and genetic disorders include the following:

• down syndrome
• albinism
• ankylosing spondylitis
• cystic fibrosis
• Duchenne muscular dystrophy
• Ehler-Danlos syndrome
• Huntington disease
• Marfan syndrome
• sickle-cell anemia
• familial hypercholesterolemia
• hemochromatosis

While there are many ways in which family and family history affects individual members of the family, illness also affects families as a whole. In particular, chronic diseases and illness can have a significant impact on families and family dynamics. Health and disease affect financial resources, time resources, family member relationships, and roles. In addition, illnesses of one or more individuals can affect emotional coping strategies and the ability to engage in meaningful activities together. The illness of one family member may negatively affect the health of other family members by creating sleep disruptions, altered nutrition choices, increased anxiety/depression, caregiver fatigue, limited freedom, and emotional fatigue (Golics et al., 2013).

Family social dynamics, community interaction, and cultural perceptions of illness also affect health and risk for illness. These factors influence how an individual interacts within their community in relation to housing, education, physical exercise, nutritious dietary choices, and accessing medical care. The CDC (2023) reports that low family socioeconomic status, including income level, education level, and employment status, can increase risks for certain illnesses, such as cardiovascular disease.

Cultural perceptions of illness are often learned first within the family unit. This can affect trust or mistrust in the healthcare system, how and when individuals seek medical care, and adherence to recommended medical or nursing interventions. Cultural values guide family reactions to illness, perceptions of illness, coping strategies, response to the idea of medications, treatment adherence, and emphasis on health. Positive family interactions predict positive coping strategies and better outcomes, even in the face of chronic disease. Nurses have the opportunity and obligation to assess families for all of these characteristics so that they can provide care tailored to the patient and that patient’s family.

Calgary Family Assessment Model

The Calgary Family Assessment Model (CFAM) and the Calgary Family Intervention Model (CFIM) were introduced in 1984 and 1994 by nurse researchers Maureen Leahey and Lorraine Wright. These practice models are widely known and used in nursing to understand families and create family-based interventions. The practice models were based on clinical practice, allowing for direct application to nurses working with patients. The founders of CFAM/CFIM acknowledge the many changes in family structure and assessment since these models were developed but are confident that the models are fluid and adaptable to contemporary circumstances affecting families (Leahey & Wright, 2016).

While the CFAM/CFIM is a theoretical framework, it directly affects nursing actions. The CFAM/CFIM focuses on identifying family strengths, weaknesses, ideals, and values. Using strategies, such as interviews, therapeutic communication, practice-based evidence, and reflection, nurses identify the strengths of each family. With this knowledge, nurses can work directly with families to co-create interventions that support their strengths (Leahey & Wright, 2016). By including the family in planning, the focus moves away from nurse-initiated interventions and empowers the family in managing illness (Leahey & Wright, 2016). The CFAM/CFIM uses interview tools to evaluate a family's structural, developmental, and functional aspects. A portion of the CFAM that is particularly applicable to modern nursing practice is the 15-minute interview (Table 37.1). The researchers outline several essential elements, referred to as key ingredients (Wright & Leahey, n.d.). This interview technique maximizes information gathering within a time frame appropriate for busy nursing practice.

Recent studies reflect the current use of the CFAM/CFIM in contemporary nursing practice across disciplines (Mileski et al., 2022; Zimansky et al., 2020). Nurses continue to use these frameworks to understand family strengths, experiences with illness, and coping strategies. The CFAM/CFIM may be beneficial for nurses in providing patient education. Understanding the family strengths allows nurses to tailor teaching methods, involve family members, and anticipate challenges that patients may experience in managing illness. Moreover, applying these models allows nurses to practice effective communication, recognize and address specific barriers to communication, and promote intervention adherence in individual patients (Mileski et al., 2022). In particular, these strategies are effective during end-of-life care, psychiatric illness, and the highly emotional periods of the disease process (Mileski et al., 2022). Using the CFAM/CFIM during the assessment of patients and their families can empower the patients and families to embrace their strengths, lean on family coping mechanisms, and feel heard in their illness journey.

Friedman’s Family Assessment Model

The Friedman Family Assessment Model was created by Dr. Marilyn Friedman and published in 1981 (Texas Woman’s University, 2023). Friedman’s Family Assessment Model is based on the concept of treating the family in addition to the individual. Friedman created a family assessment tool based on sociology concepts and her clinical nursing experience (Texas Woman’s University, 2023). The assessment tool is divided into six sections for evaluating a family (Table 37.2).

The CFAM/CFIM and the Friedman Family Assessment Model offer similar perspectives on the importance of incorporating the family in the assessment of the individual. The CFAM/CFIM has a strong focus on communication between nurses and families. This model suggests that effective interactions with families allow the nurse to obtain information crucial in patient-centered care. The CFAM/CFIM 15-minute interview is a good choice for a nurse assessing the family of a patient being admitted to an in-patient hospice facility. This will allow the nurse to understand how best to help the family and patient navigate difficult physical and emotional changes. The Friedman Family Assessment Model guides the nurse in creating family-centered care to enhance the care of individual family members. This assessment model is a good choice for a nurse working with the family of an adolescent working toward discharge from an inpatient psychiatric health facility, for example. The nurse will understand the needs of the patient as well as the family members to maintain health and safety after discharge.

Family Systems Theory

The family systems theory has proven to be very powerful in understanding the family. The family systems theory claims that the family is understood best by conceptualizing it as a complex, dynamic, and changing collection of parts, subsystems, and family members. Much like a mechanic would interface with the computer system of a broken-down car to diagnose which systems are broken (transmission, electric, fuel, etc.), a nurse would interact with family members and consider how and where the systems of the family are working and where they need repair or intervention. Nurses consider systems theory in integrating healthcare interventions for an individual with the care of the family. Nurses must also consider how family dysfunction affects illness and how illness contributes to the function or dysfunction of the family.

This theory also addresses the issue of boundaries—distinct emotional, psychological, or physical separateness between individuals, roles, and subsystems in the family. Boundaries are crucial to healthy family functioning. The family systems theory addresses a variety of factors that affect the role family plays in the health of an individual. Consider a 75-year-old female with progressive Alzheimer disease who lives with her husband in an apartment attached to her daughter’s home. Her dementia is worsening, and her daughter, son-in-law, husband, and grandchildren are facing significant challenges in her care (Table 37.3).

Bowen Family System Theory

The Bowen family systems theory, developed by psychiatrist Murray Bowen, MD, is a framework for understanding human behavior within a family construct. This theory describes the family through emotional connection and family interactions in terms of systems. Bowen’s theory suggests that the interconnectedness of family members affects the way family members seek out attention, react to one another, and expect to be treated. Changes in one family member’s function, emotional state, or health directly affect others. Nurses must consider these reciprocal reactions within a family when caring for individuals experiencing a health change or crisis.

The interconnectedness of families can promote positive coping strategies, including cohesiveness, cooperation, and emotional responsiveness (Bowen Center, n.d.). This same emotional attachment among family members may also contribute to negative responses to health crises or illnesses in family members, which may include the following (Bowen Center, n.d.):

• emotional overwhelm
• isolation
• unrealistic expectations
• poor decision making

Because emotional responses to family illness can be so intense, family members responding to an illness in another family member may experience physical symptoms, anxiety, substance abuse, and/or depression (Bowen Center, n.d.). By understanding how the interconnectedness of family members affects emotional responses to illness and healthcare decision making, nurses can anticipate challenges and negative responses. Nurses can encourage appropriate coping strategies guided by specific family dynamics.

Family Communication Patterns Theory

McLeod and Chaffee developed the family communication patterns theory in the early 1970s based on the concept of co-orientation, in which two or more people experience the same physical or emotional input and develop a corresponding perception or response (Koerner & Fitzpatrick, 2006; Hunsley et al., 2024). The theory postulates that each person develops their perception of an experience and evaluates how the other person perceives the situation. Additional terms important in understanding the communication patterns theory are as follows:

• agreement: in which the individuals have the same perception
• accuracy: in which a person’s perception of the other person’s evaluation accurately reflects the other person’s actual perception
• congruence: in which an individual’s perception and the other person’s perception are similar

These concepts are essential for nurses caring for families so they can better understand interpersonal dynamics among family members. Perceiving harmony or incompatibility in accuracy, agreement, or congruence between family members’ perceptions about health and illness helps the nurse guide the family toward appropriate interventions. The more accuracy and congruence between family members on a given topic, the more likely they are to perceive a shared reality (Hunsley et al., 2024; Koerner & Fitzpatrick, 2006). This increases their ability to interact positively with one another, provide support, and maintain coping skills.

Nurses can use these concepts to help family members navigate relationships and develop healthy communication patterns, even if their perceptions differ. The original researchers developed an instrument for assessing family communication patterns. In conformity communication patterns, family members are expected to conform to hierarchical family values. In conversation communication patterns, family members are encouraged to evaluate topics independently and discuss them with the family. The communication patterns lead to four common family types that exhibit specific communication patterns:

• pluralistic: high conversation, low conformity
• consensual: high conversation, high conformity
• protective: low conversation, high conformity
• laissez-faire: low conversation, low conformity

Consider the idea of spiritual family values. In a pluralistic family structure, the parents and children will have frequent open discussions about spiritual beliefs, and children are encouraged to make their own choices regarding these values. Conversely, in a family with a consensual structure, the family openly discusses spirituality, but the children are expected to conform to specific spiritual values. In a family with a protective structure, obedience to spiritual values is expected, without a significant amount of discussion on the topic. In a family with a laissez-faire structure, the family does not discuss individual values, and children develop their own value systems based on personal experiences. The family communications pattern theory can help the nurse understand how families interact so they can tailor communications and interventions most effectively.