Knowledge about family structure, function, and processes is essential for understanding

the complex family nteractions that affect health, illness, and well-being (Denham, 2005).
Knowledge emerging from the study of family structure, function, and process suggest concepts
and a framework that nurses can use to provide effective assessment and intervention with
families. Many internal and external family variables affect individual family members and the
family as a whole. Internal family variables include unique individual characteristics,
communication, and interactions, whereas external family variables include location of family
household, social
policy, and economic trends. Family members generally have complicated responses to all of
these factors.
Although some external factors may not be easily modifiable, nurses can assist family members
to manage change, conflict, and care needs. For instance, a sudden downturn in the economy
could result in the family breadwinner becoming unemployed.
Although nurses are unable to alter this situation directly, understanding the implications
on the family situation provides a basis for planning more effective interventions. Nurses can
assist members with coping skills, communication patterns, location of needed resources,
effective use of information, or creation of family rituals or routines (Denham, 2005).
Nurses who understand the concepts of family structure, function, and process can use
this knowledge to educate, counsel, and implement changes that enable families to cope with
illness, family crisis, chronic health conditions, and mental illness. Nurses prepared to work with
families can assist them with needed life transitions (Denham,2005). For example, when a family
member experiences a chronic condition such as diabetes, family
roles, routines, and power hierarchies may be challenged. Nurses must be prepared to address the
complex and holistic family problems resulting from illness, as well as to care for the
individual’s medical needs.
In today’s postindustrial society, families are reconfiguring and reconstructing novel
types of structures.
Froma Walsh called today’s families a“hodgepodge of multiple evolving family cultures and
structures” (Walsh, 2005a, p. 11). The structure of these families is changing to meet the
functions of the families as they respond to the current economic, social, demographic, and
political pressures in society.
Despite all of the changes in society and families, a recent U.S. survey by the Pew Research
Center
(2006, p. 1) reported the following results:
 Family members are staying in ever more frequent touch
 Families remain the greatest source of satisfaction in people’s lives
 Most parents and children live within an hour’s drive of one another
 73% of adults report almost daily contact with family members living elsewhere, and
  24% say they have a daily meal with a relative So families are not necessarily getting
further apart, but are finding different ways to connect, despite the pressures around them
to do otherwise.

Family Structure
Family structure is the ordered set of relationship swithin the family, and between the family
and other
social systems (Denham, 2005). The clearest change in American families during the past few
decades
has been in the structure. In determining the family structure, the nurse needs to identify:
 The individuals that comprise family
 The relationships between them
 The interactions between the family members
 The interactions with other social systems
 Family patterns of organization tend to be relatively stable over time, but they are
modified gradually
throughout the family life cycle and often change radically when divorce, separation, or
death occurs.

In today’s information age and global society, several ideas about the “best family” coexist
simultaneously.
Different family types have their strengths and limitations, which directly or indirectly affect
individuals and family health. Many families still adhere to more customary forms and patterns,
but many of today’s families fall into categories more clearly labeled nontraditional .Nurses will
confront families structured differently from their own families of origin and will encounter
family types that conflict with personal value systems. For nurses to work effectively with
families, they must maintain open and inquiring minds.
Discussions of family structure often begin with a focus on the decline of the nuclear
family and the
emergence of diverse family types in the American society during the late 20th century. The
notion that the traditional nuclear family is the “gold standard” by which to evaluate family
forms needs to change (Hanson, 2005). Nuclear families are defined as onewith parents and
children only. Extended families are the nuclear family plus other blood-related kin or
relationships formed by a marriage tie. Contemporary families may take on several different
forms, including single parent (biological, adoptive, step, foster), intact nuclear (biological,
adoptive), intergenerational, extended without parent present headed by grandparent (usually
grandmother), same-sex, cohabitating or domestic partnerships, and institutions (foster care,
group homes, residential or treatment centers). Regardless of the family structure, each type or
configuration has strengths and weaknesses (Denham, 2005).
 The nuclear family (parents and child) is becoming a demographic oddity as many
cultures around the world redefine what family is. The structure and norms of families are in
transition worldwide (Walsh, 2005b), and they are changing at a rapid rate (Hanson, 2005).
Although it is not uncommon to hear people say that today’s family is unstable and its future
uncertain, evidence suggests that much of what has been viewed as truth about families is merely
myth (Coontz, 1998). Many of the perceptions about families ignore the diversity that
has always existed (Allen, Fine, & Demo, 2000).
Families in the past were more homogeneous than they are today. Whereas the past norm
was a two-parent family (traditional nuclear family) living together with their biological
children, many other family forms are acknowledged and recognized today. It is important to
note that the average person born today will experience many family forms during his or her
lifetime.It is clear that life is not as simple as it used to be, and that nurses are not only
experiencing this proliferation of variation in their own personal lives but also with the patients
with whom
they work in health care settings (Kaakinen &Birenbaum, 2008).

Understanding family structure enables nurses assisting families to identify effective

coping strategies
for daily life disturbances, health care crises, wellness promotion, and disease prevention
(Denham, 2005).
In addition, nurses are central in advocating and developing social policies relevant to family
health cares needs. For example, taking political action to increase the availability of appropriate
care for children could reduce the financial and emotional burden of many working and single-
parent families when faced with providing care for sick children.
 Similarly, caregiving responsibilities and health care costs for acutely and chronically ill
family members
place increasing demands on family members. Nurses well informed about different family
structures can identify specific needs of unique families, provide appropriate clinical care to
enhance family resilience, and act as change agents to enact social policies that reduce family
burdens.

FAMILY ROLES
Within the family, regardless of structure, each family position has a number of attached roles,
and each role is accompanied by expectations. After a review of the family literature, Nye (1976)
identified eight roles associated with the position of spouse/partner:
 Provider
 Housekeeper
 Child care
 Socialization
 Sexual
 Therapeutic
 Recreational
 Kinship
Additional roles that affect the family are those of family caregiver and the sick role the
person takes on during illness. Traditionally, the provider role has been assigned to husbands,
whereas wives assumed the housekeeper, child care, and other caregiving roles. With societal
changes and variations in family structure, however, the traditional enactment of these roles is
not viable for many families anymore. Families are organized by gender roles (Haddock,
Zimmerman, & Lyness, 2005), generation, and location in the family, for example, middle child,
mother,
father, stepsister, niece, and grandfather. Attitudes have changed somewhat in regard to rigid
gender role enactment (who does what), but the research shows that, in reality, little change has
occurred, and most families remain gender based (Haddock et al., 2005). For example, 70% of
all mothers work, and women continue to provide 80% of the child care and household
obligations (Walsh, 2005a).
Men are participating and doing more in the home and with child care in the family than
ever before, but this responsibility still remains largely with women. In every household,
members have to decide the ways work and responsibilities will be divided and shared. Roles are
negotiated, assigned, delegated, or assumed. Division of labor within the family household
occurs as various members assume roles, and as families change over time and over the family
life cycle. For example, family members may become unable to perform their roles, and the
family needs
to reconfigure role allocation after the birth or death of family members.
PROVIDER ROLE.
The provider role has undergone significant change in the past few decades. Whereas
American men were once viewed as the primary family breadwinner, this has changed
significantly. In today’s world, many families need more than one income to meet basic needs.
Factors that contribute to the need for increased income are an increase in number of families
with no wage earners, and an increased number of families being solely supported
by someone other than a male householder (Walsh, 2005a). Work conditions have become
increasingly stressful for men and women, and external work obligations increasingly impinge
on members’ abilities to meet familial role obligations.

HOUSEKEEPER AND CHILD CARE ROLES.

Today, many women experience significant role strain in balancing provider and other
familial roles. Women who work continue to be responsible for most housekeeping and child
care responsibilities (Haddock et al.,2005). Women who work outside the home still perform
80% of the child care and household duties (Walsh, 2005a). Although husbands’ roles in child
care are increasing, their focus is often on playing with the children rather than meeting basic
needs. Women still are primary in meeting health care needs of all family members, including
children and men.

SOCIALIZATION ROLE.
In relation to socialization of the children, the role expectations have become more
egalitarian over the past few decades (Haddock et al., 2005). Socialization includes things such
as the ways children learn to interact with others, care for themselves, create boundaries for
relationships with extended family, peers, or others, and act as citizens of the larger society.
Parents assume the major socialization roles through teaching, guiding, directing, disciplining,
and counseling children. Although involvement of both parents promotes the healthy
development of children, the father-child relationship is qualitatively different than the mother-
child relationship. Mothers assume the larger share of the responsibility for children’s
socialization.

SICK ROLE.
Individuals learn health and illness behaviors in their family of origin. Health behaviors
are related to the primary prevention of disease, and include health promotion activities to reduce
susceptibility to disease and actions to reduce the effects of chronic disease. Once a family
member becomes ill, he or she demonstrates various illness
behaviors or enacts the “sick role.” Parsons (1951) defines the classic four characteristics of a
person who is sick:
 While sick, the person is temporarily exempt from carrying out normal social and family
roles. The more severe the illness, the freer one is from role obligations.
 In general, the sick person is not held responsible for being ill.
  The sick person is expected to take actions to get well, and therefore has an obligation
to“get well.”
 The sick person is expected to seek competent professional medical care and to comply
with medical advice on how to “get well.”
Voluminous research has been conducted on the theoretical concepts of the sick role. Some
criticisms of the theory are: (1) some individuals reject the sick role; (2) some individuals are
blamed for their illness, such as alcoholics or individuals with AIDS; and (3) sometimes
independence is encouraged in persons who have a chronic illness as a way to “get well.”
Regardless of the debates about the sick role, individuals in families experience acute and
chronic illness.
Each family, depending on its family processes, defines the sick role differently. Most “sick”
people require some level of care; someone needs to assume the family caregiver role. The
caregiving role may be as simple as a stop at the store on their way home to buy chicken soup or
pick up medicines, or as involved as providing around-the-clock care for someone.
The female individuals in our society still provide the majority of the care required when
family members become sick or injured. The specific needs of families who experience health
events are discussed in other chapters in this book.

ROLE STRAIN, CONFLICT, AND OVERLOAD

Family roles are affected, some more than others, when a family member becomes ill.
Usually the women in the family add the role of family caregiver to their other roles. Nurses
have a crucial role in helping families by discussing and exploring role strain, role conflict, and
role overload. Nurses can facilitate family adaptation by helping to problem solve role
negotiations and helping families access outside resources.

ROLE STRAIN. Lack of competence in role performance may be a result of role strain. Some
researchers
have found that sources of role strain are cultural and interactional. Interactional sources of role
strain are related to difficulties in the delineation and enactment of familial roles. Heiss (1981)
identifies five sources of difficulties in the interaction process that place strain on a family
system:
 Inability to define the situation
 Lack of role knowledge
 Lack of role consensus
 Role conflict
 Role overload
The inability to define the situation creates ambiguity about what one should do in a given
scenario. Continual changes in family structures and gender roles means that members
increasingly encounter situations in which guidelines for action are unclear. Single parents,
stepparents, nonresident fathers, and cohabitating partners deal daily with situations for which
there are no norms. What right does a stepparent have to discipline the new spouse’s
child? Is a nonresident father expected to teach his child about AIDS? What name or names go
on the mail box of cohabitating partners? Regardless of whether the issues are substantive, they
present daily challenges to the people involved.
Some choose to withdraw from the situation, and others choose to redefine the situation
when they
are uncertain how to act. For instance, a blended family might want to operate in the same way
as
a traditional family but may experience conflict when thinking about who and who not to include
in family decision making. When a solution cannot be found, family members suffer the
consequences
of role strain.
Role strain sometimes results when family members lack role knowledge, or they have no
basis for choosing between several roles that might seem appropriate.In America, most people
are not clearly taught how to be parents, and much leaning is observationaland experiential.
Socialization related to caregiving of a chronically ill family member is seldom done, and many
individuals are unfamiliar with and unprepared to assume the roles necessary for providing care.
When an individual is learning how to be a parent or a caregiver, role training may
be required. Knowledge may be acquired by peer observation, trial and error, or explicit
instruction.
Parents may have limited opportunities to observe peers, and other family members may
not have the
knowledge necessary to help. Thus, the family may need to seek external resources or obtain
needed information
using other means such as child care classes, self-help groups, or instruction from health
professionals. If individuals are unable to figure out their roles in a situation, problem-solving
abilities are limited.
Family members may lack role consensus, or be unable to agree about the expectations
attached to a role. One family role that is often the source of family disagreement is the
housekeeping role, especially for dual-career couples. Men who have been socialized into more
traditional male roles are less inclined to accept responsibility for household tasks readily and
may limit the amount of time they are willing to spend on these activities. When active
participation does not meet the wife’s expectations, she tends to assume responsibility for the
greater number of household tasks. If she has been socialized into thinking that women are
accountable for traditional housekeeping roles, then she may feel guilty or neglectful if she asks
for help. Lack of agreement about the role sometimes results in familial discord and taxes levels
of satisfaction with the partner. Although persuasion, manipulation, and coercion may be used to
reduce role strain, negotiation is usually required and is most likely to be effective in reaching
consensus about things that can be done.
ROLE CONFLICT. Role conflict occurs when the expectations about familial roles are
incompatible.
For example, the therapeutic role might involve becoming a caregiver to an elderly parent, but
expectations
of this new role may be incompatible with that of provider, housekeeper, and child care provider.
Does one go to the child’s baseball game or to the doctor with the elderly parent? Role conflict
may occur when roles present conflicting demands. Individuals and families often have to set
priorities. Demands of caregiver and provider roles
may be conflicting and may conflict with other therapeutic familial tasks. The caregiver may
withdraw from activities that, in the short term, seem superfluous, but in the long term are
sources of much needed energy. Family nurses are likely to encounter members facing many
strains because of role conflict, and may need to assist by providing information and suggesting
ways the family could negotiate roles, to discover meaningful solutions.

ROLE OVERLOAD. A source of role strain closely related to role conflict is role overload. In
role overload,
the individual lacks resources, time, and energy to meet role demands. As with role conflict, the
first option usually considered is withdrawal from one of the roles. Maintaining a balance
between energy-enhancing and energy-depleting roles reduces role strain. An alternative to
withdrawing from a role might be to seek time away from some
role responsibilities that are personally satisfying and energy producing. For example, a friend of
the family member could relieve the primary caregiver for several hours. Nurses could arrange
for a home health aide to assist with personal care hygiene. The dependent family member can
be temporarily cared for in a residential facility while the other family members go on a
vacation.
It is the role of the nurse to help families who experience role strain, conflict, and
overload. Using anticipatory guidance, nurses work closely with families to discuss and define
the family flow of energy
and resources when confronted with a family caregiving situation. See Chapter 4 for ways to
work with families.