37.3 Family Dynamics Influence on Health Outcomes

Effects on Sleep Health

Sleep habits and patterns are crucial for health. Sleep is among the first level of basic needs in Maslow’s hierarchy of needs. Factors, such as nutrition, safety and security, physical environment, and emotional interactions play a role in the overall quality of sleep, which is directly related to individuals' health over time. Recent studies have found that positive family relationships and family member support are particularly important for adolescent sleep quality and duration. They experience better cognitive development, better performance in sports and school, and improved interpersonal relationships with non-family members (Maratia, 2023).

Effects on Interpersonal Relationships

The basis for interpersonal relationships begins with the family. Family relationships with low stress and a sense of security allow individuals to establish a norm for interpersonal relations. Positive family relationships promote wellness and the ability to be resilient in the face of adversity. Interpersonal conflicts arise within families, but healthy family dynamics allow individuals to resolve these conflicts in a safe and emotionally safe environment. This gives individuals a basis for resolving interpersonal conflict in the wider community and in other personal relationships.

Effects on Stress Level

Stress is affected by sleep, emotional responses, physical safety, and overall mental health. Positive family dynamics set a foundation of emotional security, which results in lower stress levels, the ability to achieve restorative sleep, and the development of coping strategies to manage varied levels of stress. Positive family dynamics minimize interpersonal stressors within these close relationships, creating more resilience when dealing with outside stressors.

Poor Sleep Quality

While sleep loss may result from specific sleep disorders, emotional stress associated with negative family dynamics can also significantly affect sleep. Poor sleep duration and quality are linked with a variety of negative health outcomes and disease conditions. Specifically, cumulative sleep loss is associated with health conditions, including hypertension, diabetes, obesity, depression, heart attack, and stroke.

Nurses can help promote better sleep for families by addressing the factors related to financial concerns, illnesses, and relationship strain, and connecting families with social workers. Nurses can address dysfunctional family patterns by promoting mental health care, encouraging socioemotional coping techniques, and referring families to trained counselors. In addition, nurses can offer all families tips for improving sleep, such as the following:

• limiting screen time, especially before bed
• providing security within the home
• providing a quiet sleep environment
• limiting consumption of digital violence
• providing healthy meals and limiting sugar and caffeine
• promoting sleep hygiene and sleep/wake routines

Handling Stressors and Developing Coping Mechanisms

Family stressors are multifactorial. Some internal family factors, including adverse childhood experiences (ACEs), may trigger a stress response. External factors can increase the stress level for the family as a whole and subsequently for individual family members. Children exposed to high stress levels and ACEs during childhood develop many lasting consequences that can affect future relationships, job performance, learning ability, and social interactions throughout life. Family interactions affect stress levels on a continuum from high-level support to severe dysfunctional stress. Stress has emotional, physical, and psychological effects that can be long-lasting. External stressors, such as illness, sudden financial strain, job loss, and death can all change family dynamics.

In families with healthy coping and high support levels, individuals will better cope and experience fewer symptoms of stress (Table 37.4). In families with poor coping skills, the effects of stress can lead to physical and mental disorders. Stress may impair communication, leading to fighting, arguments, and fatigue. For children, this may create confusion about family relationships and a sense of insecurity. This can develop even in families with strong relationships and can be harmful in families with already high stress levels.

Nurses can help families cope with stress, particularly in dealing with illness, death, or family structure changes, by encouraging family members to do the following:

• Discuss their emotions.
• Set individual and family boundaries.
• Work together.
• Listen carefully for solutions.
• Focus on healthy habits.

Nurses’ communication skills will be one of the best assets in managing families with high stress levels and poor coping skills. Nurses can model effective communication, including active listening and respect.

Nurses can focus on helping families find coping strategies that fit their family dynamics. Some families will prefer meaning-focused coping, which uncovers what a family problem means and how to address the associated feelings of distress (Algorani & Gupta, 2023). Some families will focus on the problem and finding a solution, while others will be drawn to minimizing negative emotions and creating a safe and positive environment (Algorani & Gupta, 2023). In addition, families and individuals may seek an external social support system to help cope with emotional stress. A combination of these strategies is also common and beneficial.

Adverse Childhood Experiences

Some families struggle with high stress levels due to financial, socioeconomic, and interpersonal relationships. In more extreme cases, individuals experience adverse childhood experiences (ACE), negative experiences in childhood that affect long-term physical and emotional health. Some ACEs are related to family social interactions, and others are external events shaping family member interactions. ACEs are common and have varying degrees of effect on individuals based on how the family responds to the events. ACEs include the following (Wang, 2021):

• parental death
• parental mental illness
• financial hardship
• food insecurity
• housing insecurity
• physical violence
• sexual violence
• emotional violence
• community violence

Because ACEs elicit high-level stress responses, they are associated with similar disease risk as the stress from other triggers. High-level ACEs and childhood trauma have the potential to be perceived intergenerationally. One of the most important parts of breaking this cycle is recognizing, acknowledging, and addressing the ACE and its long-lasting emotional effects. Nurses can focus on encouraging adults to address childhood ACEs through appropriate psychiatric evaluation, counseling, and interventions to break the cycle (Panisch et al., 2020).

Increased Risk of Addiction

Addiction is also strongly associated with strained family dynamics. This is especially true for families in which addiction is prominent and many individuals struggle with addiction. Strong family connections can help individuals with addiction develop better coping skills. Relationships among family members affect an individual’s ability to maintain abstinence and retain confidence in their ability to achieve and maintain abstinence while in recovery (Ram et al., 2016). Mental health disorders can increase the prevalence of substance use disorders. Mental health disorders, such as anxiety and depression, when associated with ACE or dysfunctional family relationships, can lead to poor coping mechanisms, including substance misuse.

Increased Risk for Aggression

Like addiction, aggression and violence can perpetuate intergenerationally within a family and often are correlated. Aggression may develop into physical violence or emotional violence, which is harmful to all family members involved. One study showed that repeated daily negative family interactions may be more strongly associated with long-term anxiety and depression than ACEs in which the individual was victimized (Morelli et al., 2023). This study also found that the dysregulation of one family member, whether a child or a parent, and the subsequent impaired communication and relational disruptions can affect all family members long-term. Aggression and violence risk is increased by intergenerational family violence and aggression, genetic risk, high stress levels, and harsh parenting styles. Conversely, adaptive family coping, including a sense of love and warmth, structure, and a shared experience, is associated with less aggression and violence.

Effects on Cardiovascular Health

Individual family members tend to develop common habits, both positive and negative. Common health factors affected by family habits include cardiovascular and metabolic health. In addition, lifestyle factors and habits can also increase individual risk for certain types of cancers and gastrointestinal disorders (Salzmann et al., 2022).

Increased stress and dysfunctional family dynamics are associated with atherosclerosis and plaque build-up that is directly related to cardiovascular disease risk (Salzmann et al., 2022). Risks include coronary artery disease (CAD), stroke, and myocardial infarction (MI). ACEs are associated with negative family relationships and subsequently with cardiovascular disease in adulthood (AHA, 2024). One study suggests that over time negative family interactions during youth are associated with an increase in cardiovascular health risk as an adult (Chai & Almeida, 2023). Family habits that negatively affect cardiovascular health may include poor dietary and nutrition choices and lack of physical activity, while positive habits include engagement in joyful activity and shared hobbies. Nurses can address these issues at the family level by focusing interventions on improving diet, weight management, and increasing overall physical activity (Vedanthan et al., 2016).

Shared family health behaviors predict cardiovascular health and, specifically, hypertension (HTN) risk. Studies confirm that lifestyle factors, such as diet, exercise frequency, and sleep behaviors are associated with HTN risk (Gunn & Eberhardt, 2019). As discussed, family interaction and shared habits affect sleep habits and quality, which in turn affect the risk for HTN. Hypertension itself is a risk factor for progressive and severe cardiovascular disease states, including stroke, heart failure, and MI. In addition to family-behavior risk, HTN risk may also be inherited. This further increases the individual risk of developing HTN.

In caring for individuals with cardiovascular disease and HTN, nurses can focus on modifiable lifestyle changes and changes in shared family habits. Nurses can also recognize the presence of familial risk factors and discuss the importance of reducing these risks with healthy choices in sleep hygiene, dietary decisions, limiting nicotine and alcohol, and improving exercise frequency.

Effects on Metabolic Health

As with HTN, the risk for obesity is strongly correlated with family dynamics, shared family behaviors, and family genetic history. The World Health Organization (WHO) classified obesity as a distinct disease state based on an increased body mass and excessive fat deposits (WHO, 2024). Obesity and overweight are widely prevalent worldwide, and the percentage of adults with a higher weight and obesity is shockingly high at 43 percent and 16 percent, respectively (WHO, 2024). Recent studies show that obesity remains on the rise, particularly in children and adolescents. Drivers of obesity within the body are complex and determined by endocrine system function. Many factors play a role in obesity, though, including psychological factors, genetics, psychosocial factors, and economic factors (Wang et al., 2022). Family sedentary lifestyles, financial hardship and poverty, and unhealthy food choices are directly related to the incidence of childhood obesity (Wang et al., 2022). Other factors that predict higher obesity rates are parental depression and authoritarian, permissive, and uninvolved parenting styles. Unmodifiable family factors that affect obesity risk include ethnicity and family history of metabolic disorders such as PCOS, thyroid disorders, and type 2 diabetes.

Obesity is a complex disorder that is associated with an increased risk for many other diseases, including cancers, cardiovascular disease, HTN, diabetes, digestive disorders, lung disease, depression, and anxiety (WHO, 2024). Many of these disease states have a reciprocal correlation with obesity, both resulting from and potentiating factors that increase obesity. Nurses can focus on various family-level interventions to help improve individual and family choices and behaviors to reduce these risks.

Lifestyle Alterations

In responding to a new or ongoing illness, families must adapt by changing lifestyles and behaviors. This will depend on whether the disease is acute or chronic and whether it is stable or progressive. The family response also depends on whether the disease results in cognitive or physical impairments. Families will create changes based on the needs of the sick individual. Depending on illness, family changes may significantly improve the outcomes for the individual. For example, family-wide dietary and nutrition changes will substantially reduce obesity and cardiovascular risk. For individuals with chronic or progressive diseases, long-term changes in physical activity, tobacco use, alcohol use, and diet often improve physical symptoms.

Role Modifications

In response to illness, particularly acute or progressive diseases, families often experience a change in roles. For example, in an older adult diagnosed with Alzheimer disease, moving into a child’s home and experiencing more dependence changes the role of the parent to a more dependent role and the adult child to a caregiver role for the parent. This is sometimes referred to as role reversal. This can be a source of tension between family members, particularly as the older adult adapts to a change in independence and autonomy. Role modification also develops if a parent in a young family becomes ill; older children may need to take on caregiving roles for younger children.

In chronic illness, the parent or child may take on a sick role in which their social roles, such as work outside the home and family work, change. This affects the whole family and can lead to resentment if not openly addressed. The family and individual can work together to address this sick role in a way that benefits all and improves the quality of life for the sick individual and the overall interactions and relationships between family members. Sibling roles also change during illness, but it is highly dependent on the type of illness. In long-term or progressive diseases, such as cancer, sibling relationships are affected by not only the outcome of the sibling’s illness but also how parents and other family members react to the illness.

Socioeconomic Adjustments

Illness can present a high financial burden, especially if it is a progressive or chronic illness. Medical treatments and procedures pose a substantial economic burden. In addition, patients experiencing disease and family members providing care, particularly for children, may lose work hours, resulting in additional financial strain. Changes in the frequency of social interactions, work hours, and community support may change over the course of an illness. Families may struggle with coping, grief, and fear, all of which can affect the way families interact within their social network and can directly affect economic input into the family.

Task and Function Changes

Family tasks and functions change depending on the lifecycle stage of the family at the time of illness, as well as which family member develops the illness. Caregiver tasks may increase depending on the type of illness. The function of the family may also change. In families with adult children, a sudden illness may create a resumption of direct parental caregiving activities. In families where a parent becomes ill, children may take on household duties, caregiving for the parent or younger siblings, and even begin working to help support the family financially. This may affect their ability to perform school functions, which can have long-term socioeconomic effects on the child and the family. Leisure time may also be affected, creating an environment of stress and fatigue that increases the risk for depression and anxiety.