Learning Objectives
By the end of this section, you will be able to:
- Identify different perceptions of family
- Recognize different family assessment models
- Describe different theories of family function
Understanding the complexities of family perceptions helps nurses incorporate the family in an individual’s care plan to meet the patient’s needs best. In addition, nurses can care better for a family unit by understanding how each individual perceives the family as a whole and their specific role and value within the family. Family structures influence healthcare costs and social determinants of health, guide family assessments, and direct nursing interventions. By understanding family assessment models, nurses can properly evaluate families and family dynamics to provide personalized care. Nurses also need to understand the theories of family function to create a culture of acceptance and inclusion for all family types.
Family Perceptions
Individuals perceive family differently depending on cultural values, social norms, age, and developmental stage. These perceptions can change over one’s lifetime or fluctuate rapidly depending on family dynamics. Individuals identify with specific traits in their family structure but may also value and strive for traits of other families. These family perceptions may conflict with or align with the nurses’ own family structure. Nurses create an environment of inclusion and respect by maintaining an awareness of family structures that differ from their own and acknowledging inherent values within different family structures. In this way, they provide unbiased, compassionate, and professional care.
Children begin understanding family structure from a very young age, and that understanding develops and changes as an individual progresses through developmental stages. The various concepts of family include the type of family, family members, gender roles, family values, internal family relations, and family relations outside the family core. Many cultural, social, and personal aspects affect how family is defined for each individual. These external factors affect how individuals see their own family.
A sense of family belonging may wax and wane over a lifetime, depending on internal and external factors, such as changes in the individual and how they see themselves fitting into the wider world and family changes related to life stage changes, deaths, marriages, divorce, and births. Perceptions of family and belonging depend largely on intra-family relations, particularly the parent-child relationship, which may include non-parent guardians. Some studies show that this feeling of belonging is more pronounced in individuals living in households with two biological parents (King & Boyd, 2016). This sense of well-being tied to the feeling of belonging within the family tends to lend a protective factor, particularly in adolescents who are experiencing emotional distress, violence, depression, suicide, and poor academic performance. A sense of family belonging creates more positive outcomes (King & Boyd, 2016). Additional factors that may lead to positive family perceptions include a higher parental education level, higher overall incomes, and positive sibling relationships. While some information points to similar effects in stepparent families, little research is available on adoptive families, single-parent families, or children living with non-relational guardians. Understanding the definition of family and the roles of individuals within the family gives nurses more insight into how the perception of family affects long-term individual outcomes.
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
Patient Conversations
Breast Cancer Risk
Scenario: Raylee is a 25-year-old patient who has been a patient at the clinic for five years and has no specific concerns today. She is presenting for a general health exam.
Nurse: Let’s review your medication and supplement list and update your family history.
Patient: I’m feeling healthy now, but I decided I should keep up with my routine exams because my mom was diagnosed with breast cancer last year. She keeps telling me I need to get tested, but I don’t have any breast concerns like she did, and I take better care of myself, too.
Nurse: It sounds like your mom is concerned about your risk for breast cancer. When was your mom diagnosed with breast cancer?
Patient: She was 49 years old.
Nurse: Do you know if her oncologist recommended that you and your sister have genetic testing?
Patient: Yes, I think that’s what she wants me to do, the BRCA test. I’m just not sure that’s needed since I’m young and healthy, and I don’t smoke or drink like my mom.
Nurse: You’re right that maintaining a healthy lifestyle can help prevent cancers, but some cancers have a stronger genetic component. If your mom has told you that a BRCA test is indicated for you, this may mean she had a breast cancer type that is related to a genetic mutation that you may have inherited.
Patient: Does this mean I will get breast cancer?
Nurse: Not necessarily, but a test to see if you have this gene mutation can help you and your doctors understand your risk. I’d like to refer you to a genetic counselor. Is this okay?
Patient: Yes, I’d like to learn more about the test and decide if I want to get it done. Thank you.
Link to Learning
Watch this video on ankylosis spondylitis to learn more about this genetic rheumatological disorder that is often overlooked in young individuals.
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.
Family Assessment Models
Family assessment models help nurses understand family structure and dynamics in a general sense. By assessing individual families, nurses can better recognize the impact of acute or chronic illness on the family and each member. Several models exist to help nurses evaluate families and individuals within the family context, including the Calgary Family Assessment Model and Friedman’s Family Assessment Model. These models allow nurses to gather information to make informed decisions when creating a care and treatment plan for families and individuals.
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.
Key Ingredient | Definition | Nursing Action |
---|---|---|
Manners | Maintaining culturally appropriate social behavior, including respect, politeness, and courtesy |
|
Therapeutic communication | Communication techniques that promote healthy discussion between the nurse and patient/family |
|
Family genograms and ecomaps | Diagrams illustrating patient and family demographics, behavior, interactions, and health history |
|
Therapeutic questions | Key questions that elicit answers helpful for providing nursing care |
|
Commending family and individual strengths | Positively and verbally acknowledging individual and family strengths |
|
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).
Assessment Category | Assessment Components |
---|---|
Identifying data |
|
Family development stage |
|
Environmental factors |
|
Family structure |
|
Family functions |
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Family stress, coping, and adaptation |
|
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.
Theories of Family Function
Healthcare providers, sociologists, social workers, and mental health professionals use many theories of family function. Because these theories explain the social interactions among family members and between families within a community, they provide context and are important in guiding nursing interventions. Several theories are relevant to nursing practice, including the family systems theory, Bowen family systems theory, and family communication patterns theory.
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).
Family Interaction Considerations | Family Roles |
---|---|
Emotional responses | The patient’s husband feels stressed and overwhelmed by his wife’s dementia and responds with irritation. The daughter spends a great deal of emotional energy attempting to diffuse her father’s sense of overwhelm. |
Role expectations | Because the patient is no longer able to perform ADLs and IADLs independently, the daughter and adolescent granddaughters have taken on new roles in providing this care. |
Boundaries | While the husband wishes for a continued level of privacy in his home, his wife’s condition necessitates frequent visits from family member providing caregiving. |
Loyalties | The daughter is overwhelmed by the idea of “putting mom in a nursing home.” She feels this is a betrayal, even though the family is struggling to provide enough twenty-four-hour care. |
Belief systems | The daughter strongly believes in taking personal responsibility in caring for her family, which is influencing her choice to keep her mom at home as long as possible. |
Resilience patterns | Recently, the daughter has reached out to home health for assistance. She recognizes that even though she wants to provide the best care, the level of care needed is affecting her ability to maintain balance in caring for her children and keeping her work hours. |
Communication techniques | The daughter struggles to communicate with her father who expresses his frustration with anger. She is using gentle redirection techniques when addressing challenging behaviors associated with her mom’s dementia. |
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.
Link to Learning
Watch this video on the Bowen family systems theory to learn more about this sociological theory that explains family interaction based on emotional connection.
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.
Life-Stage Context
Parenting Styles
Studies suggest that various parenting styles may affect outcomes for children. Commonly acknowledged parenting styles include the following:
- authoritarian
- authoritative
- permissive
- uninvolved
Each style has some positive and some negative attributes. Authoritarian parenting involves strict rules and punishment that often result in outward obedience. This strategy may also result in aggression or low self-esteem. Permissive parenting, while warm and nurturing, offers little structure, role-modeling, or guidance. This may lead to negative health habits, impulsive decision-making, and a lack of self-regulation. Uninvolved parenting is typically hands-off, offering minimal support, poor communication, and lack of discipline. While children raised under this parenting style may develop resilience, they also struggle with emotional connection, decision-making, and difficulty with interpersonal communication. Authoritative parenting offers a mix of nurturing relationships and appropriate boundaries, expectations, and communication. Overall, this strategy has the highest likelihood of positive long-term outcomes and the fewest negative outcomes.
Parenting styles are only one aspect affecting health habits, perceptions, and outcomes as children move into adulthood. Nurses working with families can consider these parenting styles when developing care plans. Focusing on parenting strengths while encouraging aspects of authoritative parenting may help families succeed in achieving a healthy lifestyle (Sanvictores & Mendez, 2022).