Chapter 18

Key Terms:
dysfunctional families: family units that inhibit clear communication within family relationships and do
not provide psychological support for individual members.
family: two or more individuals who depend on one another for emotional, physical, and/or financial
support. Members of a family are self-defined.
family demographics: the study of the structure of families and households and the family-related
events, such as marriage and divorce, that alter the structure through the number, timing, and sequence
of the events.
family functions: behaviors or activities performed to maintain the integrity of the family unit and to
meet the family's needs, individual members' needs, and society's expectations.
family health: a dynamic, changing, relative state of well-being that includes the biological,
psychological, sociological, cultural, and spiritual factors of the family system.
family nursing: a specialty area that has a strong theory base and consists of nurses and families
working together to ensure die success of the family and its members in adapting to responses to health
and illness.
family nursing assessment: a comprehensive family data collection process used to identify the major
problems facing the family.
family nursing diagnosis: the central issue of concern with the family; this directs the interventions.
family nursing process: a dynamic, organized method of critically thinking about a family.
family nursing prognosis: a nursing judgment that predicts the probability of the family's ability to
respond to the current situation
family nursing theory: a theory whose function is to characterize, explain, or predict phenomena
(events) evident within family nursing
family structure: the characteristics of the individual members (gender, age, number) who constitute
the family unit.
functional families: family units that provide autonomy and are responsive to the particular interests
and needs of individual family members.



Objectives:
1. Explain the importance of family nursing in the community setting.
a. Since families are responsible for providing and managing care of family members as a
significant force/member of the healthcare team, nurses have many responsibilities to
the family, such as:
i. Promote family health
ii. Meet family health needs
iii. Cope with family problems within context of family structure & community
resources.
iv. Collaborate with families to develop useful interventions.
b. Nurses MUST be knowledgeable about family structures, functions, processes and roles.
Also they must be self aware (attitudes, bias, values) etc. and be open to different
family structures.
2. Describe family demographics:
a. (See definition in Key terms) An important use of Family demographics by nurses is to
forecast stresses and developmental changes experienced by families and to identify
possible solutions.
b. An important note is that family structure has had rapid changes in the 20
th
century.
3. Define:
a. Family:
b. Family Nursing
c. Family Health
d. healthy/non-healthy/resilient families:
i. Often divided into Functional vs Dysfunctional families, which was a psycho-
social assessment.
ii. Dysfunctional also called non-compliant, resistant, unmotivated. Book
advocates not using dysfunctional in nursing as all families have strengths and
weaknesses and this term implies bad family.
iii. Families with strengths, functional or resilient families often used to refer to
healthy families.
iv. Nurses have a responsibility to enhance family functioning and withstand and
rebound adversity.
4. Analyze changes in family function and structure
a. Historically, families had SIX functions (performing all six was considered healthy and
good):
i. All members contribute to economic survival
ii. Reproduction/survival of species
iii. Protection from hostile forces
iv. Pass along culture and religious faith
v. Educate their young
vi. Families confer status in society.
b. In modern times these have changed. Often, now, we dont need family members as
much for economic health, many married couples now choose to be child free, families
depend on other agencies for safety (law enforcement, fire), agencies for religious faith
(churches), education is performed by schools, and Family Name no longer needed for
status
c. New Functions in Modern Families:
i. Relationship Fxn Getting along and level of satisfaction
ii. Health Fxn Physical and Mental

5. Compare & Contrast the 4 family social science theoretical frameworks:
a. Structure Function Theory: Useful for assessing family health & family. Family
structure is used as the focus asses how well the structure performs its functions.
i. Family is a social system with functional requirements. (related to institutions in
society childcare function, education fxn, economic fxn, etc. which impacts
society at large)
ii. A family is a small group that has basic features common to all small groups
iii. Social systems such as families accomplish functions that serve both individuals
and society.
iv. Individuals act within a set of internal norms and values that are learned in
family primarily through socialization.
v. ADVANTAGES to Family Nursing: Comprehensive in nature, views family in
broader community in which they live
vi. DISADVANTAGES to Family Nursing: Has a static view of the family & does not
allow for change over time.
b. Systems Theory: The family system perspective encourages nurses to view clients as
participating members of a family. Nurses using this perspective determine the effects
of illness or injury on the entire family system. Emphasis is on the whole rather than on
individuals.
i. Nursing assessment of family systems includes assessment of the following:
1. Individual members
2. Subsystems
3. Boundaries
4. Openness
5. Inputs and outputs
6. Family interactions
7. Family processing
8. Adaptation or change abilities
ii. Assessment questions include, "Who is in the family system?" and "How has one
member's critical illness
iii. Assumptions of the Systems Approach
1. Family systems are greater than and different from the sum of their
parts.
2. There are many hierarchies within family systems and logical
relationships between subsystems (e.g., motherchild, family-
community).
3. There are boundaries in the family system that can be open, closed, or
random.
4. Family systems increase in complexity over time, evolving to allow
greater adaptability, tolerance to change, and growth by differentiation.
5. Family systems change constantly in response to stresses and strains
from within and from outside environments. There are structural
similarities in different family systems (isomorphism).
6. Change in one part of family systems affects the total system.
7. Causality is modified by feedback; therefore causality never exists in the
real world.
8. Family systems patterns are circular rather than linear; change must be
directed toward the cycle.
9. Family systems are an organized whole; therefore individuals within the
family are interdependent.
10. Family systems have homeostasis features to maintain stable patterns
that can be adaptive or maladaptive.
c. Developmental theory: is an attempt to integrate the small-scale (interactive
framework) and large-scale (structural framework) analyses of the other two
approaches while viewing the family as an open system in relation to structures in
society. Developmental theory explains and predicts the changes that occur to humans
or groups over time. Achievement of family developmental tasks helps individual
members accomplish their tasks.
i. This framework does the following:
1. Assists nurses in anticipating clinical problems in families
2. Identifies family strengths
3. Serves as a guide in assessing the family's developmental stage
4. Assesses the extent to which the family is fulfilling the tasks associated
with its respective stage
5. Assesses the family's developmental history
6. Assesses the availability of resources essential for performing
developmental tasks

ii. Assumptions of the theory:
1. In every family there are both individual and family developmental tasks
that need to be accomplished for every stage of the individual/family
life cycle that are unique to that particular group.
2. Families change and develop in different ways because of internal and
environmental stimulation.
3. Developmental tasks are goals to work toward rather than specific jobs
to be completed at once.
4. Each family is unique in its composition and complexity of age-role
expectations and positions.
5. Individuals and families are a function of their history. as well as the
current social structure.
6. Families have enough in common despite the way they develop over the
family life span.
7. Families may arrive at similar developmental levels through different
processes .
d. Interactional theory views families as units of interacting personalities and examines
the symbolic communications by which family members relate to one another. Within
the Family, each member occupies a position to which a number of roles are assigned.
i. Assessment of families using the interactional framework emphasizes
interaction between and among family members and family communication
patterns about health and illness behaviors appropriate for different roles.
Nurses intervene using strategies focused on the following:
1. Effectiveness of communication among members
2. Ability to establish communication between nurses and families
3. Clear and concise messages between members
4. Similarities between verbal and nonverbal communication patterns
5. Directions of the interaction
ii. Nurses can center their attention on how family members interact with one
another, so this approach is useful in explaining family communication, roles,
decision making, and problem solving.
iii. The major strength of this approach is the focus on internal processes within
families, such as roles, conflict, status, communication, responses to stress,
decision making, and socialization
iv. Processes, rather than end products, of social interactions are the major focus;
thus this framework has been used by many nurse scholars.
v. The major weakness is the broadness and lack of agreement about concepts and
assumptions of theory difficult to define.
vi. ASSUMPTIONS of the Theory:
1. Complex sets of symbols having common meanings are acquired through living in a
symbolic environment.
2. Individuals distinguish, evaluate, and assign meaning to symbols.
3. Behavior is influenced by meanings of symbols or ideas rather than by instincts,
needs, or drives; therefore the meaning an individual assigns to symbols is important
to understanding behavior.
4. The self continues to change and evolve over time through introspection caused by
experience and activity.
5. The evolving self has several dimensions: the physical body and characteristics and a
complex social self. The "me" is a conventional, habitual self that consists of
learned, repetitious responses. The "I" is spontaneous to the individual.
6. Individuals are actors as well as reactors; they select and interpret the environment to
which they respond.
7. Individuals are born into a dynamic society.
8. The nature of the infant is determined by the environment and responses to the infant
rather than by a predisposition to act in a certain way (this is now being chaJIenged).
9. Individuals learn from the culture and become the society.
10. Individuals' behavior is a product of their history, which is continually being
modified by new information.


6. Explain the various steps of the family nursing process.
Outcome Present-State Testing (OPT) consists of the following steps, which have been adapted specifically to work with family
as client:
1. Family story: The family story provides essential information about individual family members and the family as a whole.
Getting the family (client) story represents the data collection process. Nurses collect data about the family via a variety of
methods (e.g., interviewing the family client, chart review, process logs, phone logs, phone conversations with other
professionals, previous visits with the family, school records).
2. Cue logic. The nurse places the data into meaningful clusters of evidence. The clusters of evidence identify problems that are
influencing the family's adaptation in the given circumstances. Nurses make connections or see relationships between the
sets or clusters of data to identify the "keystone" or foundation problem affecting the family. The keystone issue is
specifically stated as a family nursing diagnosis.
3. Framing. The role of the nurse is to help the family understand the present state and determine the best possible outcome. It
is in this step that nurses think about the family story through the frame of multiple theory-based approaches, some of which
were described earlier. By framing the problem from a theory, potential outcomes can be considered given the whole picture
of the family client.
4. Present stale and desired outcome. The keystone issue is stated as the present (priority) problem that needs to be resolved. The
outcome is stated in a positive language. By placing side by side the present state with the desired outcome, evaluation
criteria become more clear; in OPT, this step is called testing. It is these criteria that the nurse will consider to determine if
the outcome is being achieved, partially achieved, or not achieved.
5. Interventions and decision making. The nurse and family work in a partnership to design and implement a plan of action based
on the identified outcome.
6. Clinical judgment. Nurses make clinical judgments. If the plan of action is resulting in the achievement of the identified
outcome, the nurse may decide to continue with the plan of care or that it is time to put plans in place to terminate the nurse-
family partnership. If the outcome is not being achieved or is being partially achieved, it is critical that nurses step outside
the situation or event to evaluate and reflect on the whole picture.
7. Reflection. Nurses engage in purposeful, deliberate reflection to learn from the experience and build mental patterns of client
stories--dusters of evidence, keystone issues, outcomes, and interventions. This requires critical thinking on the part of
nurses.




Remember This!
1. Families are the context within which health care decisions are made. Nurses are responsible for
assisting families in meeting health care needs.
2. Family nursing is practiced in all settings.
3. Family nursing is a specialty area that has a strong theoretical base and is more than just common
sense.
4. Family demographics is the study of structures of families and households, as well as events that
alter the family such as marriage, divorce, births, cohabitation, and dual careers.
5. Demographic trends affecting the family include the age of individuals when they marry, increase in
interracial marriages with subsequent children, most divorced people remarrying, increase in dual-
career marriages, increased number of children from families in which marriage is disrupted, high
divorce rate, dramatic increase in cohabitation, increased number of children who spend time in a
single-parent family, delay of childbirth, increased number of children born to women who are
single or who have never married, and increased number of children who live with grandparents.
6. Traditionally, families have been defined as a nuclear family: mother, father, and young children. A
variety of family definitions exist, such as a group of two or more, a unique social group, and two or
more persons joined together by emotional bonds.
7. The six historical functions performed by families are economic survival, reproduction, protection,
cultural heritage, socialization of young, and conferring status. Contemporary functions involve
relationships and health.
8. Family structure refers to the characteristics, gender, age, and number of the individual members
who make up the family unit.
9. Family health is difficult to define, but it includes the biological, psychological, sociological, cultural,
and spiritual factors of the family system.
10. The four approaches to viewing families are family as context, family as client, family as a system,
and family as a component of society.
11. Structure-function theory views the family as a social system with members who have specific roles
and functions.
12. Systems theory describes families as a unit of the whole, composed of members whose interactional
patterns are the focus of attention.
13. Family developmental theory is one theoretical framework used to study families. This approach
emphasizes how families change over time and focuses on interactions and relationships among
family members.
14. Interactional theory focuses on the family as a unit of interacting personalities and examines the
communication processes by which family members relate to one another.
15. Nurses should ask clients whom they consider to be family and then include those members in the
health care plan.
16. The OPT family nursing process is a dynamic, systematic, organized method of critically thinking
about the family.
17. The purpose of the initial family interview is based on the keystone issue.
18. It is important for the nurse to recognize that the family has the right to make its own health
decisions.
19. The nurse, in working with families, must evaluate the family outcomes and response to the plan,
not the success of the interventions.
20. The Friedman Family Assessment Model takes a macroscopic approach to family assessment, which
views the family as a subsystem of society.
21. The future of family, health care, and nursing is not an exact science. However, all areas are
changing and many challenges are to be understood and overcome in this new century.