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fifth edition

Health Care
Theory, Practice, and Research
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fifth edition

Health Care
Theory, Practice, and Research
Joanna Rowe Kaakinen, PhD, RN Aaron Tabacco, RN, BSN
Professor, School of Nursing Doctoral Candidate, School of Nursing
Linfield College Oregon Health and Science University
Portland, Oregon Portland, Oregon
Deborah Padgett Coehlo, PhD, C-PNP, Shirley May Harmon Hanson, RN, PhD,
Developmental and Behavioral Specialist Professor Emeritus, School of Nursing
Juniper Ridge Clinic Oregon Health and Science University
Bend, Oregon Portland, Oregon
Adjunct Faculty, College of Nursing
Rose Steele, PhD, RN
Washington State University
Professor, School of Nursing, Faculty of Health
Spokane, Washington
York University
Toronto, Ontario, Canada
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Library of Congress Cataloging-in-Publication Data
Family health care nursing : theory, practice, and research / [edited by] Joanna Rowe Kaakinen, Deborah
Padgett Coehlo, Rose Steele, Aaron Tabacco, Shirley May Harmon Hanson. — 5th edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8036-3921-8
I. Kaakinen, Joanna Rowe, 1951- editor. II. Coehlo, Deborah Padgett, editor. III. Steele, Rose, editor. IV.
Tabacco, Aaron, editor. V. Hanson, Shirley M. H., 1938- editor.
[DNLM: 1. Family Nursing. 2. Family. WY 159.5]

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Family nursing lost an exemplary family nurse and nursing scholar in September 2012: Vivian
Rose Gedaly-Duff, our esteemed colleague and friend. As one of the editors of Family Health Care
Nursing: Theory, Practice, and Research for the third and fourth editions, Vivian worked
tirelessly to elevate our collective thoughts and work. Even as Vivian courageously battled breast
cancer, she always asked about this edition of this textbook, offering her wisdom and insight to us.
Our work in family nursing, and family nursing itself, is infinitely better because of Vivian.
We dedicate this fifth edition of Family Health Care Nursing: Theory, Practice, and Research
to Vivian Rose Gedaly-Duff. Vivian, we miss you and think of you often.
—Editorial Team

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am proud to have been the founder of Family campus. A separate Instructors’ Manual, a new feature
Health Care Nursing: Theory, Practice, and Re- of the third edition, was developed by Dr. Deborah
search with the first edition published in 1996. Padgett Coehlo when she was on faculty at Oregon
I am honored to be asked to write this particular State University (Bend, OR). This wonderful infu-
foreword, as this fifth edition of this textbook at- sion of nursing colleagues and scholars elevated this
tests and gives credence to the ongoing evolution textbook to a whole other level.
and development in the field of family nursing. After my retirement from active full-time
This edition also marks the end of my long nursing, teaching and professional practice, the capable
academic, and writing career. It is time to retire and Dr. Joanna Rowe Kaakinen assumed the leadership
step aside for the younger generation of family for the fourth edition (2010). Along with Drs. Vivian
nurses to take over. It is exciting to think about Gedaly-Duff, Deborah Padgett Coehlo, and myself,
what family nursing will look like in the future. we produced the fourth edition of this cutting-
Family Health Care Nursing: Theory, Practice, and edge family nursing textbook that included some
Research (I–V) is an ever changing and comprehen- Canadian-specific family content. For the fourth edi-
sive textbook originally developed to reflect and tion Dr. Deborah Padgett Coehlo wrote the first on-
promote the art and science of family nursing. This line teachers’ manual that accompanied this edition;
all-inclusive far-reaching compendium of integrat- two other online chapters were added to this fourth
ing theory, practice, and research continues in this edition: research in families/family nursing and
fifth edition of this textbook. international family nursing. Dr. Joanna Rowe
All editions of this distinctive textbook were Kaakinen is the lead editor of this fifth edition. In
published by F. A. Davis. I am grateful for their thinking about the sixth edition and the future
faith, trust, and support in carrying the legacy of of the text, a younger family nursing scholar
family nursing forward. This book originated when Aaron Tabacco (PhC) was added to the editorial
I was teaching family nursing at Oregon Health team. Dr. Rose Steele, our Canadian colleague from
and Science University (OHSU) School of Nursing Toronto, joined our writing team. Dr. Deborah
in Portland, Oregon. At that time there was no Coehlo continues as editor and now brings the
comprehensive or authoritative textbook on the perspective of family nursing from her pediatric
nursing care of families that matched our program practice as a PNP in Bend, Oregon. My last contri-
of study. This was the impetus I needed to write bution to this book is as editor on this fifth edition.
and edit the first edition of Family Health Care This edition has taken on a much more international
Nursing: Theory, Practice, and Research (Hanson and flair, especially for North America, as Canadian au-
Boyd, 1996). The first edition met a need of nurs- thors were added to many of the writing teams.
ing educators in many other nursing schools The first three editions of this textbook received
around the world, so F. A. Davis invited me to re- the following awards: the American Journal of
vise, update, and publish the second edition, which Nursing Book of the Year Award and the Nursing
came out in 2001. For the third edition, I asked two Outlook Brandon Selected Nursing Books Award.
additional scholars to join me in writing and editing Every new edition has been well received around
this edition: the late Dr. Vivian Rose Gedaly-Duff the world and every edition has brought forth new
from OHSU (see Dedication) and Dr. Joanna converts to family nursing. Previous editions of the
Rowe Kaakinen, then from the University of text were translated or published in Japan, Portugal,
Portland and now from Linfield College Portland India, Pakistan, Bangladesh, Burma, Bhutan, and

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viii Foreword

Nepal. I anticipate even more international interest shifted to more family-centered care and community-
for this fifth edition as the message of family nurs- based nursing. The codified version of family
ing continues to spread across the globe. It is also nursing really emerged and peaked during the
interesting to note that online sales of the book 1980s and 1990s in the United States and Canada,
come from many countries. where the movement was headquartered. Even
Contributors to this edition were selected from though this initial impetus for family nursing
distinguished practitioners, researchers, theorists, came from North America, the concept spread
scholars, and teachers from nursing and family so- quickly around the world. Asian countries, in par-
cial scientists across the United States and Canada. ticular, have embraced family nursing, and though
Like any good up-to-date textbook, some subject they initially translated books coming from the
matter stayed foundational and other subject mat- United States or Canada, they have matured to
ter changed based on current evidence. As family creating their own books and theories for family
nursing evolved, different authors and editors were nursing. The Scandinavian countries have expanded
added to the writing team. This textbook is a mas- their own scholarship and tailored family nursing
sive undertaking involving 30 committed nurses to their own unique countries and populations.
and family scholars, not to mention the staff of Today, it could be said that family nursing is with-
F. A. Davis. The five editors of this fifth edition are out borders and that no one country owns family
grateful for this national and international dedica- nursing.
tion to family nursing. Together we all continue to The International Family Nursing Association
increase nursing knowledge pertaining to the nurs- (IFNA) was established in 2009 for the purpose of
ing care of families across the globe. advancing family nursing and creating a global
This fifth edition builds on the previous edi- community of nurses who practice with families.
tions. The primary shift in the direction of this edi- The 11th International Family Nursing Conference
tion is to make family nursing practice meaningful (and the first official conference of IFNA) took
and realistic for nursing students. The first unit of place June 19–22, 2013, in Minneapolis, Minnesota,
the book addresses critical foundational knowledge USA. This new professional body (IFNA) is assum-
pertaining to families and nursing. The second unit ing the leadership for keeping family nursing at the
concentrates on theory-guided, evidence-based forefront of theory development, practice, research,
practice of the nursing care of families across the education, and social policy across the globe.
life span and in a variety of specialties. In addition Family nursing has become more than just a
to the large increase of Canadian contributors, sub- “buzzword” but rather an actual reality. Family
stantial updates took place in all chapters. A new nursing is being taught in many educational insti-
chapter, Trauma and Family Nursing, was added. tutions, practiced in multiple health care settings,
Other new or updated features of this edition in- and globally actualized by many nurses. Nursing
clude the following: care to individuals, regardless of place, occurs
within the context of families and communities—
■ A strong emphasis on evidence-based prac-
all of which can be called “family nursing.” Most
tice in each chapter.
everyone in the nursing profession agrees that a
■ Five selected family nursing theories inter-
profound, reciprocal relationship exists between
woven throughout the book.
families, health, and nursing.
■ Family case studies that demonstrate the
This book and current edition recognizes that
practice of family nursing.
nursing as a profession has a close alignment with
■ Content that addresses family nursing in both
families. Nurses share many of the responsibilities
Canada and the United States (North America).
with families for the care and protection of their
Family nursing, as an art and science, has trans- family members. Nurses have an obligation to help
formed in response to paradigm shifts in the pro- families promote and advance the care and growth
fession and in society over time. As a nursing of both individual family members and families as a
student in the United States during the 1950s, the unit. This textbook provides nursing students the
focus of care was on individuals and centered in knowledge base and the processes to become effec-
hospitals. As time passed and the profession ma- tive in their nursing care with families. Additionally,
tured, nursing education and practice expanded and families benefit when already practicing registered
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Foreword ix

nurses use this knowledge to reorganize their nurs- edge of this practice challenge for the next decade,
ing care to be more family centered and develop and will help to marshal the nursing profession
working partnerships with families to strengthen toward improving nursing care of families.
family systems. Family Health Care Nursing: Theory,
Practice, and Research was written by nurses for —SHIRLEY MAY HARMON HANSON, RN, PhD,
nurses who practice nursing care of families. PMHNP/ARNP, FAAN, CFLE, LMFT
Students will learn how to tailor their assessment Professor Emeritus, School of Nursing
and interventions with families in health and ill- Oregon Health and Science University
ness, in physical as well as mental health, across Portland, Oregon
the life span, and in all the settings in which Adjunct Faculty, College of Nursing
nurses and families interface. I firmly believe that Washington State University
this fifth edition of this textbook is at the cutting Spokane, WA
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Overview of the Fifth Edition

Ask anyone about a time they were affected by the book at the beginning of their program of study
something that happened to one of their family so that specific chapters can be assigned for specialty
members, and you will be overwhelmed with the courses throughout the curriculum. The fifth edition
intensity of the emotions and the exhaustive details. complements a concept-based curriculum design.
Every individual is influenced significantly by their For example, Chapter 16, Family Mental Health
families and the structure, function, and processes Nursing, could be assigned when students take their
within their families. Even individuals who do not mental health nursing course, and Chapter 13,
interact with their families have been shaped by Family Child Health Nursing, could be studied
their families. The importance and connection be- during a pediatric course or in conjunction with
tween individuals and their families have been stud- life-span–concept curriculum for chronic illness
ied expansively in a variety of disciplines, including and acute care courses. Thus, this textbook could
nursing. be integrated throughout the undergraduate or
As such, the importance of working in partner- graduate nursing curriculum.
ships with families in the health care system is evi-
dent. Yet many health care providers view dealing
Canadian Content
with patients’ families as an extra burden that is too
demanding. Some nurses are baffled when a family Moreover, this fifth edition builds on successes
acts or reacts in certain ways that are foreign to their of the past editions and responds to recommenda-
own professional and personal family experiences. tions from readers/users of past editions. Because
Some nurses avoid the tensions and anxiety that of the ever-evolving nature of families and the
exist in families during a crisis situation. But it is in changing dynamics of the health care system, the
just such situations that families most need nurses’ editors added new chapters, consolidated chapters,
understanding, knowledge, and guidance. The pur- and deleted some old chapters. Importantly, this
pose of this book is to provide nursing students, as fifth edition incorporates additional Canadian-
well as practicing nurses, with the understanding, specific content. Though it is true that the United
knowledge, and guidance to practice family nursing. States and Canada have different health care
This fifth edition of the textbook focuses on theory- systems, so many of the stressors and challenges
guided, evidence-based practice of the nursing care for families overlap. One of the editors for this
of families throughout the family life cycle and fifth edition, Rose Steele, is from Toronto and
across a variety of clinical specialties. helped expand our concepts about Canadian nurs-
ing. Moreover, a number of chapters in the text
have a combined author team of scholars from both
Use of the Book
Canada and the United States: Chapter 5, Family
Family Health Care Nursing: Theory, Practice, and Social Policy and Health Disparities; Chapter 12,
Research, fifth edition, is organized so that it can be Family Nursing With Childbearing Families; and
used on its own and in its entirety to structure a Chapter 17, Families and Community/Public Health
course in family nursing. An alternative approach Nursing. Two chapters in this edition were writ-
for the use of this text is for students to purchase ten by an all-Canadian team: Chapter 6, Relational

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xii Preface

Nursing and Family Nursing in Canada and Nursing, which includes Chapters 1 to 5; Unit 2:
Chapter 10, Families in Palliative and End-of-Life Families Across the Health Continuum, which in-
Care. All of the chapters in this edition include in- cludes Chapters 6 to 11; and Unit 3: Nursing
formation, statistics, programs, and interventions Care of Families in Clinical Areas, which includes
that address the individual needs of families and fam- Chapters 12 to 17. The Family Health Care Nursing
ily nurses from both Canada and the United States. Instructors’ Guide is an online faculty guide that pro-
vides assistance to faculty using/teaching family
nursing or the nursing care of families in a variety
Additions and Deletions
of settings. Each chapter also includes a Power-
This edition contains one new chapter: Chapter 11, Point presentation, Case Study Learning Activities,
Trauma and Family Nursing. Between the advanced and other online assets, which can be found at
understanding of brain function and general physi-
ology; the mind and body response to severe and/or
prolonged stress; and the increase in trauma experi-
enced by families through war, natural disasters, and UNIT 1
family violence, the need to understand, prevent,
treat, and monitor the effects of trauma on individ- Foundations in Family Health
uals and families has never been more vital. There-
Care Nursing
fore, we felt it was essential to include ways family
nurses could work with these families. All chapters Chapter 1: Family Health Care Nursing: An
have been changed and updated significantly to reflect Introduction provides foundational materials es-
the present state of “family,” current evidence-based sential to understanding families and nursing. Two
practice, research, and interventions. Many of the nursing scholars have worked on this chapter now
chapters now include a second family case study to for three editions: Joanna Rowe Kaakinen, PhD,
illustrate further the evidence discussed throughout RN, Professor at the Linfield College School of
that specific chapter. We deleted the chapter on the Nursing and Shirley May Harmon Hanson, RN,
future of families and family nursing because PhD, PMHNP/ARNP, FAAN, CFLE, LMFT,
changes in health care reform, social policy, and Professor Emeritus at Oregon Health and Science
families are occurring at such a rate that it is University School of Nursing. The chapter lays
impossible to predict what the future will hold. down crucial foundational knowledge about fami-
lies and family nursing.
The first half of the chapter discusses dimen-
Structure of the Book
sions of family nursing and defines family, family
Each chapter begins with the critical concepts to be health, and healthy families. The chapter follows
addressed within that chapter. The purpose of plac- with an explanation of family health care nursing
ing the critical concepts at the beginning of the and the nature of interventions in the nursing
chapter is to focus the reader’s thinking and learning care of families, along with the four approaches
and offer a preview and outline of what is to come. to family nursing (context, client, system, and
Another organizing framework for the book is pre- component of society). The chapter then presents
sented in Chapter 3, Theoretical Foundations for the concepts or variables that influence family
the Nursing of Families. This chapter covers the im- nursing, family nursing roles, obstacles to family
portance of using theory to guide the nursing of nursing practice, and the history of family nurs-
families and presents five theoretical perspectives, ing. The second half of the chapter elaborates on
with a case study demonstrating how to apply these theoretical ideas involved with understanding
five theoretical approaches in practice. These five family structure, family functions, and family
theories are threaded throughout the book and are processes.
applied in many of the chapter case studies. As stated Chapter 2: Family Demography: Continuity
earlier, most of the chapters include two case studies; and Change in North American Families pro-
all of the case studies contain family genograms and vides nurses with a basic contextual orientation to
ecomaps. the demographics of families and health. All three
The main body of the book is divided into three authors are experts in statistics and family demog-
units: Unit 1: Foundations in Family Health Care raphy. Three sociologists joined to update and
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Preface xiii

write this chapter: Lynne M. Casper, PhD, Profes- needs. These authors built on the traditional nurs-
sor of Sociology and Director of the South ing process model to create a dynamic systematic
California Population Research Center, University family nursing assessment approach. Assessment
of Southern California (USC); Sandra M. Florian, strategies include selecting assessment instru-
MA, PhD Candidate, who is a graduate student/ ments, determining the need for interpreters, as-
research assistant, Population Research Center at sessing for health literacy, and learning how to
USC Department of Sociology; and Peter D. Brandon, diagram family genograms and ecomaps. The
PhD, Professor, Department of Sociology, The chapter also explores ways to involve families in
University at Albany (SUNY), New York. This shared decision making, and explores analysis, a
chapter examines changes and variations in North critical step in the family nursing process that
American families in order to understand what helps focus the nurse and the family on identifi-
these changes portend for family health care nurs- cation of the family’s primary concern(s). The
ing during the first half of this century. The subject chapter uses a family case study as an exemplar to
matter of the chapter is structured to provide fam- demonstrate the family nursing assessment and
ily nurses with background on changes in the intervention.
North American family so that they can understand Chapter 5: Family Social Policy and Health
their patient populations. The chapter briefly Disparities exposes nurses to social issues that
touches on the implications of these demographic affect the health of families and strongly challenge
patterns on practicing family nursing. nurses to become more involved in the political as-
Chapter 3: Theoretical Foundations for the pects of health policy. This chapter is co-authored
Nursing of Families is co-authored by two of the by two experienced nurses in the social policy arena
editors of this textbook: Joanna Rowe Kaakinen and and a sociology professor: Isolde Daiski, RN,
Shirley May Harmon Hanson. This chapter lays the BScN, EdD, Associate Professor, School of Nurs-
theoretical groundwork needed to practice family ing, from York University, Toronto, Ontario,
nursing. The introduction builds a case for why Canada; Casey R. Shillam, PhD, RN-BC, Director
nurses need to understand the interactive relation- of the BSN program at Western Washington State
ship among theory, practice, and research. It also University, Bellingham, Washington; Lynne M.
makes the point that no single theory adequately de- Casper, PhD, Professor Sociology at the Univer-
scribes the complex relationships of family structure, sity of Southern California; and Sandra Florian,
function, and processes. The chapter then continues MA, a graduate student at the University of South-
by delineating and explaining relevant theories, ern California. These authors discuss the practice
concepts, propositions, hypotheses, and conceptual of family nursing within the social and political
models. Selected for this textbook, and explained in structure of society. They encourage the readers to
this chapter, are five theoretical/conceptual models: understand their own biases and how these
Family Systems Theory, Developmental and Family contribute to health disparities. In this chapter, stu-
Life Cycle Theory, Bioecological Theory, Rowland’s dents learn about the complex components that
Chronic Illness Framework, and the Family Assess- contribute to health disparities. Nurses are called
ment and Intervention Model. Using basic family to become politically active, advocate for vulnera-
case studies, the chapter explores how each of the five ble families, and assist in the development of
theories could be used to assess and plan interven- creative alternatives to social policies that limit ac-
tions for a family. This approach enables learners to cess to quality care and resources. These authors
see how different interventions are derived from dif- present the difficulties families face in the current
ferent theoretical perspectives. political climate in both the United States and
Chapter 4: Family Nursing Assessment and Canada, as the legal definition of family is being
Intervention is co-authored by Joanna Rowe challenged and family life evolves. The chapter
Kaakinen and Aaron Tabacco, BSN, RN, Doctoral touches on social policies, or lack of them, specifi-
Candidate, who is a Student Instructor, Under- cally policies that affect education, socioeconomic
graduate Nursing Programs at Oregon Health status, and health insurance. The chapter also
Sciences University, Portland, Oregon. The pur- explores determinants of health disparities, which
pose of this chapter is to present a systematic include infant mortality rates, obesity, asthma,
approach to develop a plan of action for the fam- HIV/AIDS, aging, women’s issues, and health
ily, with the family, to address its most pressing literacy.
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xiv Preface

UNIT 2 members in the middle to elder years. The goal of

the chapter is to describe the relevance of genetic
information within families when there is a ques-
Families Across the Health Continuum tion about genetic aspects of health or disease for
Chapter 6: Relational Nursing and Family members of the family. The chapter begins with a
Nursing in Canada is co-authored by Canadian brief introduction to genomics and genetics. The
nursing scholars Colleen Varcoe, PhD, RN, Asso- chapter then explains how families react to finding
ciate Professor and Associate Research Director at out they are at risk for genetic conditions, and
the University of British Columbia, School of decide how and with whom to disclose genetic in-
Nursing in Vancouver, British Columbia, Canada; formation, and the critical aspect of confidentiality.
and Gweneth Hartrick Doane, PhD, RN, Profes- The chapter outlines the components of conduct-
sor, School of Nursing, University of Victoria, ing a genetic assessment and history, and offers
British Columbia, Canada. Relational inquiry fam- interventions that include education and resources.
ily nursing practice is oriented toward enhancing Several specific case examples and a detailed case
the capacity and power of people/families to live a study illustrate nurses working with families who
meaningful life (meaningful from their own per- have a genetic condition.
spective). Understanding and working directly with Chapter 8: Family Health Promotion is writ-
context provides a key resource and strategy for ten by Yeoun Soo Kim-Godwin, PhD, MPH, RN,
responsive, health-promoting family nursing prac- Professor of Nursing; and Perri J. Bomar, PhD,
tice. Grounded in a relational inquiry approach, RN, Professor Emeritus, who are both from
this chapter focuses specifically on the significance the School of Nursing at the University of North
of context in family nursing practice in Canada. The Carolina, Wilmington. Fostering the health of the
chapter highlights the interface of sociopolitical, family as a unit and encouraging families to value
historical, geographical, and economic elements in and incorporate health promotion into their
shaping the health and illness experiences of fami- lifestyles are essential components of family nurs-
lies in Canada and the implications for family nurs- ing practice. The purpose of this chapter is to in-
ing practice. The chapter covers some of the key troduce the concepts of family health and family
characteristics of Canadian society, and how those health promotion. The chapter presents models to
characteristics shape health, families, health care, illuminate these concepts, including the Model of
and family nursing. Informed by a relational in- Family Health, Family Health Model, McMaster
quiry approach to family nursing, the chapter turns Model of Family Functioning, Developmental
to the ways nurses might practice more respon- Model of Health and Nursing, Family Health Pro-
sively and effectively based on this understanding. motion Model, and Model of the Health-Promoting
Chapter 7: Genomics and Family Nursing Family. The chapter also examines internal and
Across the Life Span is authored by a nursing ex- external factors through a lens of the bioecological
pert in nursing genomics, Dale Halsey Lea, MPH, systems theory that influence family health promo-
RN, CGC, FAAN, Consultant, Public Health tion. It covers family nursing intervention strate-
Genomics and Adjunct Lecturer for University of gies for health promotion, and presents two family
Maine School of Nursing. The ability to apply an case studies demonstrating how different theoreti-
understanding of genetics in the care of families is cal approaches can be used for assessing and inter-
a priority for nurses and for all health care vening in the family for health promotion. The
providers. As a result of genomic research and the chapter also discusses the role of nurses and inter-
rapidly changing body of knowledge regarding ge- vention strategies in maintaining and regaining the
netic influences on health and illness, more empha- highest level of family health. Specific interventions
sis has been placed on involving all health care presented include family empowerment, anticipa-
providers in this field, including family nursing. tory guidance, offering information, and encour-
This chapter describes nursing responsibilities for aging family rituals, routines, and time together.
families of persons who have, or are at risk for Chapter 9: Families Living With Chronic
having, genetic conditions. These responsibilities Illness is co-authored by Joanna Rowe Kaakinen
are described for families before conception, and Sharon A. Denham, DSN, RN, Professor,
with neonates, teens in families, and families with Houston J. and Florence A. Doswell Endowed
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Preface xv

Chair in Nursing for Teaching Excellence, Texas Chapter 11: Trauma and Family Nursing is
Woman’s University, Dallas, Texas. The purpose written by Deborah Padgett Coehlo, PhD, C-PNP,
and focus of this chapter is to describe ways for PMHS, CFLE, Developmental and Behavioral Spe-
nurses to think about the impact of chronic illness on cialist, Juniper Ridge Clinic, Bend, Oregon, and ad-
families and to consider strategies for helping families junct faculty at Oregon State University. Dr. Coehlo
manage chronic illness. The first part of this chapter has been on the editorial team for two editions of
briefly outlines the global statistics of chronic illness, this text. Using theory-guided practice, this chapter
the economic burden of chronic diseases, and three helps nurses develop knowledge about trauma and
theoretical perspectives for working with families liv- family nurses’ key role in the field of trauma. It em-
ing with chronic illness. The majority of the chapter phasizes the importance of prevention, early treat-
describes how families and individuals are challenged ment, encouraging family resilience, and helping the
to live a quality life in the presence of chronic illness family to make meaning out of negative events. This
and how nurses assist these families. Specific atten- chapter also stresses an understanding of secondary
tion is drawn to families with children who have a trauma, or the negative effects of witnessing trauma
chronic illness and families with an adult member of others. This discussion is particularly salient for
living with a chronic illness. The chapter addresses family nurses, because they are some of the most
adolescents who live with a chronic illness as they likely professionals to encounter traumatized victims
transition from pediatric to adult medical care, sib- in their everyday practice. Two case studies explicate
lings of children with a chronic illness and their spe- family nursing when working with families who are
cific needs, and the needs of young caregivers who experiencing the effects of traumatic life events.
provide care for a parent who has a chronic illness.
The chapter presents two case studies: one a family
who has an adolescent with diabetes and one a family UNIT 3
helping its elderly parent and grandparent manage
living with Parkinson’s disease. Nursing Care of Families in Clinical
Chapter 10: Families in Palliative and End-of-
Life Care is written by Rose Steele, PhD, RN, Pro-
fessor, York University School of Nursing, Toronto, Chapter 12: Family Nursing With Childbearing
Ontario, Canada; Carole A. Robinson, PhD, RN, Families is written by Linda Veltri, PhD, RN, Clin-
Associate Professor, University of British Columbia, ical Assistant Professor, Oregon Health Science
Okanagan School of Nursing, British Columbia, University, School of Nursing, Ashland, Oregon,
Canada; and Kimberley A. Widger, PhD, RN, As- Campus; Karline Wilson-Mitchell, RM, CNM, RN,
sistant Professor, Lawrence S. Bloomberg Faculty of MSN, Assistant Professor, Midwifery Education
Nursing, University of Toronto, Ontario, Canada. Program, Ryerson University, Ontario, Canada; and
This chapter details the key components to consider Kathleen Bell, MSN, CNM, AHN-BC, Clinical
in providing palliative and end-of-life care, as well Associate, School of Nursing, Linfield College,
as families’ most important concerns and needs when Portland, Oregon. The focus of childbearing family
a family member experiences a life-threatening ill- nurses is family relationships and the health of all
ness or is dying. It also presents some concrete family members. Therefore, nurses involved with
strategies to assist nurses in providing optimal pal- childbearing families use family concepts and theo-
liative and end-of-life care to all family members. ries as part of developing the plan of nursing care. A
More specifically, the chapter begins with a brief review of literature provides current evidence about
definition of palliative and end-of-life care, in- the processes families experience when deciding on
cluding its focus on improving quality of life for and adapting to childbearing, including theory and
patients and their families. The chapter then out- clinical application of nursing care for families plan-
lines principles of palliative care and ways to ning pregnancy, experiencing pregnancy, adopting
apply these principles across all settings and regard- and fostering children, struggling with infertility,
less of whether death results from chronic illness or and coping with illness during the early postpartum
a sudden or traumatic event. Two evidence-based, period. This chapter starts by presenting theoretical
palliative care and end-of-life case studies con- perspectives that guide nursing practice with child-
clude the chapter. bearing families. It continues with an exploration of
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xvi Preface

family nursing with childbearing families before acutely or critically ill are seen in adult medical-
conception through the postpartum period. The surgical units, intensive care or cardiac care units, or
chapter covers specific issues childbearing families emergency departments. This chapter covers the
may experience, including postpartum depression, major stressors that families experience during hos-
attachment concerns, and postpartum illness. Nurs- pitalization of adult family members, the transfer of
ing interventions are integrated throughout this patients from one unit to another, visiting policies,
chapter to demonstrate how family nurses can help family waiting rooms, home discharge, family pres-
childbearing families prevent complications, in- ence during cardiopulmonary resuscitation, with-
crease coping strategies, and adapt to their expanded drawal or withholding of life-sustaining therapies,
family structure, development, and function. The end-of-life family care in the hospital, and organ do-
chapter concludes with two case studies that explore nation. The content emphasizes family needs during
family adaptations to stressors and changing roles these critical events. This chapter also presents a fam-
related to childbearing. ily case study in a medical-surgical setting that
Chapter 13: Family Child Health Nursing demonstrates how the Family Assessment and Inter-
is written by Deborah Padgett Coehlo. A major vention Model and the FS3I can be used as the frame-
task of families is to nurture children to become work to assess and intervene with a particular family.
healthy, responsible, and creative adults who can Chapter 15: Family Health in Mid and Later
develop meaningful relationships across the life Life is co-authored by Diana L. White, PhD,
span. Families experience the stress of normative Senior Research Associate in Human Development
transitions with the addition of each child and and Family Studies, Institute of Aging at Portland
situational transitions when children are ill. Knowl- State University, Portland, Oregon, and Jeannette
edge of the family life cycle, child development, O’Brien, PhD, RN, Assistant Professor at Linfield
and illness trajectory provides a foundation for College–Good Samaritan School of Nursing, Port-
offering anticipatory guidance and coaching at land, Oregon. The chapter employs the life course
stressful times. Family life influences the promo- perspective, family systems models, and develop-
tion of health and the experience of illness in chil- mental theories as the guiding organizational struc-
dren, and is influenced by children’s health and ture. The chapter presents evidence-based practice
illness. This chapter provides a brief history of on working with adults in mid and later life, includ-
family-centered care of children and then presents ing a review of living choices for older adults with
foundational concepts that will guide nursing prac- chronic illness, and the importance of peer rela-
tice with families with children. The chapter goes tionships and intergenerational relationships to
on to describe nursing care of well children and quality of life. This chapter includes extensive
families with an emphasis on health promotion, information about family caregiving for and by
nursing care of children and families in acute care older adults, including spouses, adult children, and
settings, nursing care of children with chronic ill- grandparents. Two case studies conclude the chap-
ness and their families, and nursing care of children ter. One family case study illustrates the integrated
and their families during end of life. Case studies generational challenges facing older adults today.
illustrate the application of family-centered care The second case study addresses care of an elderly
across settings. family member who never married and has no chil-
Chapter 14: Family Nursing in Acute Care dren. This case presents options for caregiving and
Adult Settings is written by Vivian Tong, PhD, RN, the complexity of living healthy.
and Joanna Rowe Kaakinen, PhD, RN, both profes- Chapter 16: Family Mental Health Nursing
sors of nursing at Linfield College-Good Samaritan has been completely revised for this edition. It is
School of Nursing, Portland, Oregon. Hospitaliza- written by Laura Rodgers, PhD, RN, PMHNP,
tion for an acute illness, injury, or exacerbation of a Professor of Nursing at Linfield College–Good
chronic illness is stressful for patients and their fam- Samaritan School of Nursing, Portland, Oregon.
ilies. The ill adult enters the hospital usually in a Dr. Rodgers brings to her writing both her schol-
physiological crisis, and the family most often accom- arly perspective and clinical practice as a psychiatric
panies the ill or injured family members into the hos- nurse practitioner in private practice. The chapter
pital; both the patient and the family are usually in begins with a brief demographic overview of the
an emotional crisis. Families with members who are pervasiveness of mental health conditions (MHCs)
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Preface xvii

in both Canada and the United States. The remain- Associate Professor, Washington State University
der of the chapter focuses on the impact a specific Intercollegiate College of Nursing, Vancouver,
MHC can have on the individual with the MHC, Washington. Healthy communities are comprised
individual family members, and the family as a unit. of healthy families. Community/public health
Although the chapter does not go into specific di- nurses understand the effects that communities can
agnostic criteria for various conditions, it does offer have on individuals and families, and recognize that
nursing interventions to assist families. One case a community’s health is reflected in the health ex-
study explores the impact and treatment of sub- periences of its members and their families. This
stance abuse. The second presents how a family chapter offers a description of community health
nurse can work with a family to improve the health nursing promoting the health of families in com-
of all family members when one family member munities. It begins with a definition of community
lives with paranoid schizophrenia. health nursing, and follows with a discussion of
Chapter 17: Families and Community/Public concepts and principles that guide the work of
Health Nursing is co-authored by a North Amer- these nurses, the roles they enact in working with
ican writing team: Linda L. Eddy, PhD, RN, families and communities, and the various settings
CPNP, Associate Professor, Washington State where they work. This discussion is organized
University Intercollegiate College of Nursing, around a visual representation of community health
Vancouver, Washington; Annette Bailey, PhD, nursing. The chapter ends with discussion of cur-
RN, Assistant Professor, Daphne Cockwell School rent trends in community/public health nursing
of Nursing, Ryerson University, Toronto, Ontario, and a family case study that demonstrates working
Canada; and Dawn Doutrich, PhD, RN, CNS, with families in the community.
3921_FM_i-xxiv 06/06/14 2:56 PM Page xviii
3921_FM_i-xxiv 06/06/14 2:56 PM Page xix

c o n t ri b u t o r s


Assistant Professor, Daphne Cockwell School of Professor and Houston J. and Florence A. Doswell
Nursing Endowed Chair in Nursing for Teaching Excellence,
Ryerson University College of Nursing
Toronto, Ontario, Canada Texas Woman’s University, Dallas
Dallas, Texas
Clinical Associate, School of Nursing Professor, School of Nursing
Linfield College University of Victoria
Portland, Oregon Victoria, British Columbia, Canada
Professor Emeritus, School of Nursing Associate Professor, Intercollegiate College of
University of North Carolina at Wilmington Nursing
Wilmington, North Carolina Washington State University
Vancouver, Washington
Professor, Department of Sciology L INDA L. E DDY , PhD, RN, CPNP
The University at Albany - SUNY Associate Professor, Intercollegiate College of Nursing
Albany, New York Washington State University
Vancouver, Washington
Professor of Sociology and Director, Southern S ANDRA M. F LORIAN , MA
California Population Research Center PhD Candidate, Department of Sociology
University of Southern California University of Southern California
Los Angeles, California Los Angeles, California
C-PNP, PMHS, CFLE Adjunct Lecturer, School of Nursing
Developmental and Behavioral Specialist University of Maine
Juniper Ridge Clinic Cumberland Foreside, Maine
Bend, Oregon
Adjunct Professor
Oregon State University
Professor Emeritus, School of Nursing
Bend, Oregon
Oregon Health and Science University
I SOLDE D AISKI , RN, BScN, EdD Portland, Oregon
Associate Professor, School of Nursing Adjunct Faculty, College of Nursing
York University Washington State University
Toronto, Ontario, Canada Spokane, Washington

3921_FM_i-xxiv 06/06/14 2:56 PM Page xx

xx Contributors


Professor, School of Nursing Professor, School of Nursing
Linfield College Linfield College
Portland, Oregon Portland, Oregon
PhD, MPH, RN Associate Professor, School of Nursing
Professor, School of Nursing University of British Columbia
University of North Carolina, Wilmington Vancouver, British Columbia, Canada
Wilmington, North Carolina
J EANNETTE O’B RIEN , PhD, RN Clinical Assistant Professor, School of Nursing
Assistant Professor, School of Nursing Oregon Health Science University, Ashland
Linfield College Ashland, Oregon
Portland, Oregon
C AROLE A. R OBINSON , PhD, RN Senior Research Associate, Institute on Aging
Associate Professor, School of Nursing Portland State University
University of British Columbia, Okanagan Portland, Oregon
Kelowna, British Columbia, Canada
L AURA R ODGERS , PhD, PMHNP Assistant Professor, Lawrence S. Bloomberg School of
Professor, School of Nursing Nursing
Linfield College University of Toronto
Portland, Oregon Toronto, Ontario, Canada
Director, School of Nursing RN, MSN
Western Washington University Assistant Professor, Midwifery Education Program
Bellingham, Washington Ryerson University
Toronto, Ontario, Canada
Professor, School of Nursing, Faculty of Health
York University
Toronto, Ontario, Canada
Doctoral Candidate, School of Nursing
Oregon Health and Science University
Portland, Oregon
3921_FM_i-xxiv 06/06/14 2:56 PM Page xxi



Lecturer Public Health Nurse
State University of New York City of Toronto Public Health
New Paltz, New York Toronto, Ontario, Canada
Assistant Professor Associate Professor
Hope College Lewis Clark State College
Holland, Michigan Lewiston, Idaho
Assistant Clinical Professor Associate Professor
Northern Arizona University Southern Connecticut State University
Flagstaff, Arizona New Haven, Connecticut
Associate Dean and Chair Research Associate
University of South Alabama University of Toronto
Mobile, Alabama Toronto, Ontario, Canada
Professor Professor and FNP Specialty Track Director
Otterbein College Fairfield University
Westerville, Ohio Fairfield, Connecticut
Adjunct Faculty Registered Nurse
Seattle Pacific University Scarborough Hospital
Seattle, Washington Toronto, Ontario, Canada
Professor Faculty and Nurse Practitioner
Lewis-Clark State College Douglas College
Lewiston, Idaho New West Minster, British Columbia, Canada
Faculty Instructor Nursing Instructor
Benedictine University Ohio University
Lisle, Illinois Ironton, Ohio
Professor Nurse Educator
Minnesota State University Mankato Platt College
Mankato, Minnesota Aurora, Colorado

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xxii Reviewers


Nursing Instructor Professor
Grant MacEwan College University of Tampa
Ponoka, Alberta, Canada Tampa, Florida
Professor FNP-BC, CNE
Madonna University Assistant Professor
Livonia, Michigan University of Detroit, Mercy
Detroit, Michigan
Nurse Educator J ILL S TRAWN , EdD, APRN
Globe University, Minnesota School of Business Associate Professor
Richfield, Minnesota Southern Connecticut State University
New Haven, Connecticut
Professor Manager, Pediatric Clinical Research
Pittsburg State University Hershey Medical Center
Pittsburg, Kansas Hershey, Pennsylvania
Associate Professor Professor
University of Wisconsin, Oshkosh Sault College
Oshkosh, Wisconsin Sault Ste. Marie, Ontario, Canada
Senior Instructor Assistant Clinical Professor
University of Manitoba Northern Arizona University
Winnipeg, Manitoba, Canada Flagstaff, Arizona
FAANP Assistant Professor and Family Nurse Practitioner
Assistant Professor Monmouth University
University of Tampa West Long Branch, New Jersey
Tampa, Florida
S USAN P ERKINS , MSN, RN Associate Professor
Lead Faculty and Instructor South Dakota State University
Washington State University Brookings, South Dakota
Spokane, Washington
MSc, PhD(c) Red Deer College
Professor Red Deer, Alberta, Canada
University of Saskatchewan
Saskatoon, Saskatchewan, Canada
Clinical Assistant Professor and Nurse Practitioner
T HELMA P HILLIPS , MSN, RN, NRP State University of New York, Upstate Medical
Instructor University
University of Detroit, Mercy Syracuse, New York
Detroit, Michigan
Canadore College/Nipissing University
North Bay, Ontario, Canada
3921_FM_i-xxiv 06/06/14 2:56 PM Page xxiii

table of contents

U N IT 1 Foundations in Family Health Care Nursing 1

chapter 1 Family Health Care Nursing 3
An Introduction
Joanna Rowe Kaakinen, PhD, RN
Shirley May Harmon Hanson, RN, PhD, PMHNP/ARNP, FAAN, CFLE, LMFT

chapter 2 Family Demography 33

Continuity and Change in North American Families
Lynne M. Casper, PhD
Sandra M. Florian, MA, PhD Candidate
Peter D. Brandon, PhD

chapter 3 Theoretical Foundations for the Nursing of Families 67

Joanna Rowe Kaakinen, PhD, RN
Shirley May Harmon Hanson, RN, PhD, PMHNP/ARNP, FAAN, CFLE, LMFT

chapter 4 Family Nursing Assessment and Intervention 105

Joanna Rowe Kaakinen, PhD, RN
Aaron Tabacco, BSN, RN, Doctoral Candidate

chapter 5 Family Social Policy and Health Disparities 137

Isolde Daiski, RN, BScN, EdD
Casey R. Shillam, PhD, RN-BC
Lynne M. Casper, PhD
Sandra M. Florian, MA, PhD Candidate

U N IT 2 Families Across the Health Continuum 165

chapter 6 Relational Nursing and Family Nursing in Canada 167
Colleen Varcoe, PhD, RN
Gweneth Hartrick Doane, PhD, RN

chapter 7 Genomics and Family Nursing Across the Life Span 187
Dale Halsey Lea, MPH, RN, CGC, FAAN

chapter 8 Family Health Promotion 205

Yeoun Soo Kim-Godwin, PhD, MPH, RN
Perri J. Bomar, PhD, RN

chapter 9 Families Living With Chronic Illness 237

Joanna Rowe Kaakinen, PhD, RN
Sharon A. Denham, DSN, RN

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xxiv Table of Contents

chapter 10 Families in Palliative and End-of-Life Care 277

Rose Steele, PhD, RN
Carole A. Robinson, PhD, RN
Kimberley A. Widger, PhD, RN

chapter 11 Trauma and Family Nursing 321

Deborah Padgett Coehlo, PhD, C-PNP, PMHS, CFLE

U N IT 3 Nursing Care of Families in Clinical Areas 351

chapter 12 Family Nursing With Childbearing Families 353
Linda Veltri, PhD, RN
Karline Wilson-Mitchell, RM, CNM, RN, MSN
Kathleen Bell, RN, MSN, CNM, AHN-BC

chapter 13 Family Child Health Nursing 387

Deborah Padgett Coehlo, PhD, C-PNP, PMHS, CFLE
chapter 14 Family Nursing in Acute Care Adult Settings 433
Vivian Tong, PhD, RN
Joanna Rowe Kaakinen, PhD, RN
chapter 15 Family Health in Mid and Later Life 477
Diana L. White, PhD
Jeannette O’Brien, PhD, RN

chapter 16 Family Mental Health Nursing 521

Laura Rodgers, PhD, PMHNP

chapter 17 Families and Community/Public Health Nursing 559

Linda L. Eddy, PhD, RN, CPNP
Annette Bailey, PhD, RN
Dawn Doutrich, PhD, RN, CNS

appendix A Family Systems Stressor-Strength Inventory (FS3I) 583
appendix B The Friedman Family Assessment Model (Short Form) 599

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Foundations in U N I T

Family Health
Care Nursing 1
3921_Ch01_001-032 05/06/14 10:54 AM Page 2
3921_Ch01_001-032 05/06/14 10:54 AM Page 3

Family Health Care Nursing
An Introduction
Joanna Rowe Kaakinen, PhD, RN
Shirley May Harmon Hanson, PhD, PMHNP/ARNP, FAAN, CFLE, LMFT

Critical Concepts
■ Family health care nursing is an art and a science that has evolved as a way of thinking about and working with families.
■ Family nursing is a scientific discipline based in theory.
■ Health and illness are family events.
■ The term family is defined in many ways, but the most salient definition is, The family is who the members say it is.
■ An individual’s health (on the wellness-to-illness continuum) affects the entire family’s functioning, and in turn, the
family’s ability to function affects each individual member’s health.
■ Family health care nursing knowledge and skills are important for nurses who practice in generalized and in specialized
■ The structure, function, and processes of families have changed, but the family as a unit of analysis and service
continues to survive over time.
■ Nurses should intervene in ways that promote health and wellness, as well as prevent illness risks, treat disease
conditions, and manage rehabilitative care needs.
■ Knowledge about each family’s structure, function, and process informs the nurse in how to optimize nursing care in
families and provide individualized nursing care, tailored to the uniqueness of every family system.

Family health care nursing is an art and a science, ■ Health and illness are family events.
a philosophy and a way of interacting with families ■ Families influence the process and outcome
about health care. It has evolved since the early of health care.
1980s as a way of thinking about, and working with,
All health care practices, attitudes, beliefs, be-
families when a member experiences a health prob-
haviors, and decisions are made within the context
lem. This philosophy and practice incorporates the
of larger family and societal systems.
following assumptions:
Families vary in structure, function, and processes.
■ Health and illness affect all members of The structure, functions, and processes of the family
families. influence and are influenced by individual family

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4 Foundations in Family Health Care Nursing

member’s health status and the overall health status 2010a). In addition, ANA’s Nursing: Scope and Stan-
of the whole family. Families even vary within given dards of Practice mandates that nurses provide family
cultures because every family has its own unique care (ANA, 2010b). “Nurses have an ethical and
culture. People who come from the same family of moral obligation to involve families in their health-
origin create different families over time. Nurses care practices” (Wright & Leahey, 2013, p. 1).
need to be knowledgeable in the theories of families, The overall goal of this book is to enhance
as well as the structure, function, and processes of nurses’ knowledge and skills in the theory, practice,
families to assist them in achieving or maintaining a research, and social policy surrounding nursing care
state of health. of families. This chapter provides a broad overview
of family health care nursing. It begins with an
exploration of the definitions of family and family
health care nursing, and the concept of healthy
families. This chapter goes on to describe four
approaches to working with families: family as con-
text, family as client, family as system, and family as
a component of society. The chapter presents the
varied, but ever-changing, family structures and
explores family functions relative to reproduction,
socialization, affective function, economic issues,
and health care. Finally, the chapter discusses family
processes, so that nurses know how their practice
makes a difference when families experience stress
because of the illness of individual family members.

When families are considered the unit of care—as

opposed to individuals—nurses have much broader
perspectives for approaching health care needs of
Three foundational components of family nursing
both individual family members and the family unit
are: (1) determining how family is defined, (2) un-
as a whole (Kaakinen, Hanson, & Denham, 2010).
derstanding the concepts of family health, and (3)
Understanding families enables nurses to assess the
knowing the current evidence about the elements
family health status, ascertain the effects of the family
of a healthy family.
on individual family members’ health status, predict
the influence of alterations in the health status of the
family system, and work with members as they plan What Is the Family?
and implement action plans customized for improved
There is no universally agreed-upon definition of
health for each individual family member and the
family. Now more than ever, the traditional defini-
family as a whole.
tion of family is being challenged, with Canadian
Recent advances in health care, such as changing
recognition of same-sex marriages and with several
health care policies and health care economics,
states in the United States giving same-sex families
ever-changing technology, shorter hospital stays,
the freedom to marry. Family is a word that con-
and health care moving from the hospital to the
jures up different images for each individual and
community/family home, are prompting changes
group, and the word has evolved in its meaning over
from an individual person paradigm to the nursing
time. Definitions differ by discipline, for example:
care of families as a whole. This paradigm shift is
affecting the development of family theory, prac- ■ Legal: relationships through blood ties,
tice, research, social policy, and education, and it is adoption, guardianship, or marriage
critical for nurses to be knowledgeable about and at ■ Biological: genetic biological networks among
the forefront of this shift. The centrality of family- and between people
centered care in health care delivery is emphasized ■ Sociological: groups of people living together
by the American Nurses Association (ANA) in its with or without legal or biological ties
publication, Nursing’s Social Policy Statement (ANA, ■ Psychological: groups with strong emotional ties
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Family Health Care Nursing: An Introduction 5

Historically, early family social science theorists persons in health care planning with the patient’s
(Burgess & Locke, 1953, pp. 7–8) adopted the permission.
following traditional definition in their writing:
The family is a group of persons united by ties of mar- What Is Family Health?
riage, blood, or adoption, constituting a single house-
hold; interacting and communicating with each other The World Health Organization (2008) defined
in their respective social roles of husband and wife, health to include a person’s characteristics, behav-
mother and father, son and daughter, brother and sis- iors, and physical, social, and economic environ-
ter; and creating and maintaining a common culture. ment. This definition applies to individuals and to
families. Anderson and Tomlinson (1992) sug-
Currently, the U.S. Census Bureau defines family gested that the analysis of family health must
as two or more people living together who are re- include, simultaneously, health and illness, the in-
lated by birth, marriage, or adoption (U.S. Census dividual and the collective. They underscored evi-
Bureau, 2011). This traditional definition continues dence that the stress of a family member’s serious
to be the basis for the implementation of many social illness exerts a powerful influence on family func-
programs and policies. Yet, this definition excludes tion and health, and that familial behavioral pat-
many diverse groups who consider themselves to be terns or reactions to illness influence the individual
families and who perform family functions, such as family members. The term family health is often
economic, reproductive, and affective functions, as used interchangeably with the terms family func-
well as child socialization. Depending on the social tioning, healthy families, or familial health. To some,
norms, all of the following examples could be viewed family health is the composite of individual family
as “family”: married or remarried couples with bio- members’ physical health, because it is impossible
logical or adoptive children, cohabitating same-sex to make a single statement about the family’s phys-
couples (gay and lesbian families), single-parent fam- ical health as a single entity.
ilies with children, kinship care families such as two The definition of family health adopted in this
sisters living together, or grandparents raising textbook and that applies from the previous edition
grandchildren without the parents. (Kaakinen et al., 2010) is as follows: Family health
is a dynamic, changing state of well-being, which
includes the biological, psychological, spiritual, sociologi-
cal, and culture factors of individual members and the
whole family system. This definition and approach
combines all aspects of life for individual members,
as well as for the whole family. An individual’s
health (on the wellness-to-illness continuum)
affects the entire family’s functioning, and in turn,
the family’s ability to function affects each individ-
ual member’s health. Assessment of family health
involves simultaneous data collection on individual
family members and the whole family system
(Craft-Rosenberg & Pehler, 2011).

What Is a Healthy Family?

The definition of family adopted by this text- While it is possible to define family health, it is
book and that applies from the previous edition more difficult to describe a healthy family. Char-
(Kaakinen et al., 2010) is as follows: Family refers to acteristics used to describe healthy families or fam-
two or more individuals who depend on one another for ily strengths have varied throughout time in the
emotional, physical, and economic support. The members literature. Krysan, Moore, and Zill (1990)
of the family are self-defined. Nurses who work with described “healthy families” as “successful families”
families should ask clients who they consider to be in a report prepared by the U.S. Department of
members of their family and should include those Health and Human Services. They identified some
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6 Foundations in Family Health Care Nursing

of the ideas put forward by many family scholars each other, that occur over time and that
over time. For example, Otto (1963) was the first erode the relationship.
scholar to develop psychosocial criteria for assess- 2. Contempt: This is the most corrosive of the
ing family strengths, and he emphasized the need four characteristics between the couple.
to focus on positive family attributes instead of the Contempt includes comments that convey
pathological approach that accentuated family disgust and disrespect.
problems and weaknesses. Pratt (1976) introduced 3. Defensiveness: Each partner blames the other
the idea of the “energized family” as one whose in an attempt to deflect a verbal attack.
structure encourages and supports individuals to 4. Stonewalling: One or both of the partners
develop their capacities for full functioning and refuse to interact or engage in interaction,
independent action, thus contributing to family both verbally and nonverbally.
health. Curran (1985) investigated not only family In contrast, conflict is addressed in three ways in
stressors but also traits of healthy families, incor- positive, healthy marriages. Validators talk their
porating moral and task focus into traditional family problems out, expressing emotions and opinions,
functioning. These traits are listed in Box 1-1. and are skilled at reaching a compromise. Volatiles
For more than three decades, Driver, Tabares, are two partners who view each other as equals, as
Shapiro, Nahm, and Gottman (2011) have studied they engage in loud, passionate, explosive interac-
the interactional patterns of marital success or fail- tions that are balanced by a caring, loving relation-
ure. The success of a marriage does not depend on ship. Their conflicts do not include the four
the presence or the amount of conflict. Success of negative characteristics identified earlier. The last
a marriage depends primarily on how the couple type of couple is the Avoiders. Avoiders simply agree
handles conflict. The presence of four characteris- not to engage in conflicts, thus minimizing the cor-
tics of couple interaction was found to predict rosive effects of negative conflict resolution. The
divorce with 94% accuracy (Carrere, Buehlman, crucial point in all three styles of healthy conflict is
Coan, Gottman, & Ruckstuhl, 2000): that both partners engage in a similar style. Thus
1. Criticism: These are personal attacks that how conflict is used and resolved in the parental or
consist of negative comments, to and about couple dyad relationship suggests the health and
longevity of the family unit.
The described positive interactions occur far
BOX 1-1 more often than the negative interactions in hap-
pily married couples. These healthy family couples
Traits of a Healthy Family find ways to work out their differences and prob-
■ Communicates and listens lems, are willing to yield to each other during their
■ Fosters table time and conversation arguments, and make purposeful attempts to repair
■ Affirms and supports each member their relationship.
■ Teaches respect for others Olson and Gorall (2005) conducted a longitudi-
■ Develops a sense of trust nal study on families, in which they merged the
■ Has a sense of play and humor concepts of marital and family dynamics in the
■ Has a balance of interaction among members Circumplex Model of Marital and Family Systems.
■ Shares leisure time They found that the ability of the family to demon-
■ Exhibits a sense of shared responsibility
strate flexibility is related to its ability to alter fam-
■ Teaches a sense of right and wrong
ily leadership roles, relationships, and rules,
■ Abounds in rituals and traditions
including control, discipline, and role sharing.
■ Shares a religious core
■ Respects the privacy of each member
Functional, healthy families have the ability to
■ Values service to others
change these factors in response to situations. Dys-
■ Admits to problems and seeks help functional families, or unhealthy families, have less
ability to adapt and flex in response to changes. See
Source: From Kaakinen, J. R., Hanson, S. M. H., & Denham, S. Figures 1-1 and 1-2, which depict the differences
(2010). Family health care nursing: An introduction. In in functional and dysfunctional families in the Cir-
J. W. Kaakinen, V. Gedaly-Duff, D. P. Coehlo, & S. M. H. Hanson
(Eds.), Family health care nursing: Theory, practice and re- cumplex Model. Balanced families will function
search (4th ed.). Philadelphia, PA: F. A. Davis, with permission. more adequately across the family life cycle and
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Family Health Care Nursing: An Introduction 7

Rigid, Somewhat Flexible Very
Inflexible Inflexible Family Flexible


One person is Leadership is Leadership is There are frequent Leadership is

in charge and is democratic. equalitarian with changes in erratic and limited.
highly controlling. a democratic leadership and roles.
Roles are stable; approach to Decisions are
Negotiation is there is some role decision making. Rules are flexible impulsive.
limited. sharing. and readily adjusted.
Negotiation is open Roles are unclear
Rules do not Rules are enforced and actively and shift from
change. with few changes. includes children. person to person.

Roles are strictly Roles are shared

enforced. and are age

FIGURE 1-1 Family flexibility continuum.

Cohesion Somewhat Very Overly

Disconnected Connected Connected Connected


There is extreme Members have Strike equilibrium There is emotional There is extreme
emotional some time apart with moderate closeness and emotional
separateness. from family but also separateness and loyalty. connection, and
spend some time togetherness. loyalty is demanded.
There is little family together. More time is spent
involvement. Family members together than alone. There is little private
Joint support and can be both space. Family
Family does not decision making independent and Family members members are highly
turn to each other take place. connected to the have separate and dependent on each
for support. family. shared couple other and reactive
friends. to each other.
Decision making
is shared.

FIGURE 1-2 Family cohesion continuum.

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8 Foundations in Family Health Care Nursing

tend to be healthier families. The family commu- Another way to view family nursing practice is
nication skills enable balance and help families to conceptually, as a confluence of theories and strate-
adjust and adapt to situations. Couples and families gies from nursing, family therapy, and family social
modify their levels of flexibility and cohesion to science as depicted in Figure 1-4. Over time, family
adapt to stressors, thus promoting family health. nursing continues to incorporate ideas from family
therapy and family social science into the practice
of family nursing. See Chapter 3 for discussion
FAMILY HEALTH CARE NURSING about how theories from family social science, fam-
ily therapy, and nursing converge to inform the
The specialty area of family health care nursing has nursing of families.
been evolving since the early 1980s. Some question Several family scholars have written about lev-
how family health care nursing is distinct from els of family health care nursing practice. For ex-
other specialties that involve families, such as ample, Wright and Leahey (2013) differentiated
maternal-child health nursing, community health among several levels of knowledge and skills that
nursing, and mental health nursing. The definition family nurses need for a generalist versus special-
and framework for family health care nursing adopted ist practice, and they defined the role of higher
by this textbook and that applies from the previous education for the two different levels of practice.
edition (Kaakinen et al., 2010) is as follows: They propose that nurses receive a generalist
or basic level of knowledge and skills in family
The process of providing for the health care needs
nursing during their undergraduate work, and ad-
of families that are within the scope of nursing
vanced specialization in family nursing or family
practice. This nursing care can be aimed toward the
therapy at the graduate level. They recognize that
family as context, the family as a whole, the family
advanced specialists in family nursing have a
as a system, or the family as a component of society.
narrower focus than generalists. They purport,
Family nursing takes into consideration all four however, that family assessment is an important
approaches to viewing families. At the same time, skill for all nurses practicing with families. Bomar
it cuts across the individual, family, and community (2004) further delineated five levels of family
for the purpose of promoting, maintaining, and health care nursing practice using Benner’s levels
restoring the health of families. This framework of practice: expert, proficient, competent, ad-
illustrates the intersecting concepts of the individual, vanced beginner, and novice. See Table 1-1,
the family, nursing, and society (Fig. 1-3). which describes how the two levels of generalist
and advanced practice have been delineated fur-
ther with levels of education and types of clients
(Benner, 2001).

Family therapy

Nursing Family social
models science theory

FIGURE 1-3 Family nursing conceptual framework. FIGURE 1-4 Family nursing practice.
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Family Health Care Nursing: An Introduction 9

Table 1-1 Levels of Family Nursing Practice

Level of Practice Generalist/Specialist Education Client

Expert Advanced specialist Doctoral degree All levels
Family nursing theory development
Family nursing research
Proficient Advanced specialist Master’s degree with All levels
added experience
Beginning family nursing research
Competent Beginning specialist Master’s degree Individual in the family context
Interpersonal family nursing
Family unit
Family aggregates
Advanced beginner Generalist Bachelor’s degree with Individual in the family context
added experience
Interpersonal family nursing
(family systems nursing)
Family unit
Novice Generalist Bachelor’s degree Individual in the family context

Source: Bomar, P. J. (Ed.). (2004). Promoting health in families: Applying family research and theory to nursing practice
(3rd ed.). Philadelphia, PA: Saunders/Elsevier, with permission.

NATURE OF INTERVENTIONS 5. Family nursing is often offered in settings

where individuals have physiological or
IN FAMILY NURSING psychological problems. Together with
competency in treatment of individual
The following 10 interventions family nurses use
health problems, family nurses must recog-
provide structure to working with families regard-
nize the reciprocity between individual
less of the theoretical underpinning of the nursing
family members’ health and collective
approach. These are enduring ideas that support the
health within the family.
practice of family nursing (Gilliss, Roberts, Highley,
6. The family system is influenced by any
& Martinson, 1989; Kaakinen et al., 2010):
change in its members. Therefore, when
1. Family care is concerned with the experience caring for individuals in health and illness,
of the family over time. It considers both the the nurse must elect whether to attend to
history and the future of the family group. the family. Individual health and collective
2. Family nursing considers the community health are intertwined and will be influenced
and cultural context of the group. The fam- by any nursing care given.
ily is encouraged to receive from, and give 7. Family nursing requires the nurse to ma-
to, community resources. nipulate the environment to increase the
3. Family nursing considers the relationships likelihood of family interaction. The physi-
between and among family members, and cal absence of family members, however,
recognizes that, in some instances, all indi- does not preclude the nurse from offering
vidual members and the family group will family care.
not achieve maximum health simultaneously. 8. The family nurse recognizes that the person
4. Family nursing is directed at families whose in a family who is most symptomatic may
members are both healthy and ill regardless change over time; this means that the focus
of the severity of the illness in the family of the nurse’s attention will also change
member. over time.
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10 Foundations in Family Health Care Nursing

9. Family nursing focuses on the strengths of and pediatric health care settings. A nurse using
individual family members and the family this focus might say to an individual client: “Who
group to promote their mutual support and in your family will help you with your nightly med-
growth. ication?” “How will you provide for child care
10. Family nurses must define with the family when you have your back surgery?” or “It is won-
which persons constitute the family and derful for you that your wife takes such an interest
where they will place their therapeutic in your diabetes and has changed all the food
energies. preparation to fit your dietary needs.”
These are the distinctive intervention statements
specific to family nursing that appear continuously Family as Client
in the care and study of families in nursing, regard- The second approach to family nursing care cen-
less of the theoretical model in use. ters on the assessment of all family members. The
family nurse is interested in the way all the family
members are individually affected by the health
APPROACHES TO FAMILY NURSING event of one family member. In this approach, all
members of the family are in the foreground. The
Four different approaches to care are inherent in family is seen as the sum of individual family mem-
family nursing: (1) family as the context for indi- bers, and the focus concentrates on each individual.
vidual development, (2) family as a client, (3) family The nurse assesses and provides health care for
as a system, and (4) family as a component of soci- each person in the family. This approach is seen
ety (Kaakinen et al., 2010). Figure 1-5 illustrates typically in primary care clinics in the communities
these approaches to the nursing of families. Each where primary care physicians (PCPs) or nurse
approach derived its foundations from different practitioners (NPs) provide care over time to all
nursing specialties: maternal-child nursing, pri- individuals in a given family. From this perspective,
mary care nursing, psychiatric/mental health nurs- a nurse might ask a family member who has just be-
ing, and community health nursing, respectively. come ill: “How has your diagnosis of juvenile dia-
All four approaches have legitimate implications betes affected the other individuals in your family?”
for nursing assessment and intervention. The ap- “Will your nightly need for medication be a prob-
proach that nurses use is determined by many fac- lem for other members of your family?” “Who in
tors, including the health care setting, family your family is having the most difficult time with
circumstances, and nurse resources. Figure 1-6 your diagnosis?” or “How are the members of your
shows how a nurse can view all four approaches to family adjusting to your new medication regimen?”
families through just one set of eyes. It is important
to keep all four perspectives in mind when working Family as System
with any given family.
The third approach to care views the family as a
system. The focus in this approach is on the family
Family as Context as a whole as the client; here, the family is viewed
The first approach to family nursing care focuses as an interactional system in which the whole is
on the assessment and care of an individual client more than the sum of its parts. In other words, the
in which the family is the context. Alternate labels interactions between family members become the
for this approach are family centered or family target for the nursing interventions. The interven-
focused. This is the traditional nursing focus, in tions flow from the assessment of the family as a
which the individual is foreground and the family whole. The family nursing system approach focuses
is background. The family serves as context for the on the individual and family simultaneously. The
individual as either a resource or a stressor to the emphasis is on the interactions between family
individual’s health and illness. Most existing nurs- members, for example, the direct interactions be-
ing theories or models were originally conceptual- tween the parental dyad or the indirect interaction
ized using the individual as a focus. This approach between the parental dyad and the child. The more
is rooted in the specialty of maternal-child nursing children there are in a family, the more complex
and underlies the philosophy of many maternity these interactions become.
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Family Health Care Nursing: An Introduction 11

Family as Context Family as Client

Individual as foreground Family as foreground
Family as background Individual as background

+ + + +

Family as System Family as Component

of Society
Interactional family
Family Education

Medical Center

School ily H


FIGURE 1-5 Approaches to family nursing.

This interactional model had its start with the one family member becomes ill, it affects all other
specialty of psychiatric and mental health nursing. members of the family. Examples of questions that
The systems approach always implies that when nurses may ask in a systems approach include the fol-
something happens to one part of the system, the lowing: “What has changed between you and your
other parts of the system are affected. Therefore, if spouse since your child was diagnosed with juvenile
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12 Foundations in Family Health Care Nursing


Context Individual

FIGURE 1-6 Four views of family through a lens.

diabetes?” or “How has the diagnosis of juvenile

diabetes affected the ways in which your family is
functioning and getting along with each other?”
FIGURE 1-7 Family as primary group in society.

Family as Component of Society

The fourth approach to care looks at the family as theory, practice, education, and research; new
a component of society, in which the family is knowledge derived from family social sciences and
viewed as one of many institutions in society, sim- the health sciences; national and state health care
ilar to health, educational, religious, or economic policies; changing health care behavior and atti-
institutions. The family is a basic or primary unit tudes; and national and international political
of society, and it is a part of the larger system of events. Chapters 3 and 5 provide detailed discus-
society (Fig. 1-7). The family as a whole interacts sions of these areas.
with other institutions to receive, exchange, or give Figure 1-8 illustrates how many variables influ-
communication and services. Family social scien- ence contemporary family health nursing, making
tists first used this approach in their study of fami- the point that the status of family nursing is
lies in society. Community health nursing has dependent on what is occurring in the wider
drawn many of its tenets from this perspective as it society—family as community. A recent example
focuses on the interface between families and com- of this point is that health practices and policy
munity agencies. Questions nurses may ask in this changes are under way because of the recognition
approach include the following: “What issues has that current costs of health care are escalating and,
the family been experiencing since you made the at the same time, greater numbers of people are un-
school aware of your son’s diagnosis of HIV?” or derinsured or uninsured and have lost access to
“Have you considered joining a support group for health care. The goal of this health care reform is
families with mothers who have breast cancer? to make access and treatment available for everyone
Other families have found this to be an excellent at an affordable cost. That will require a major shift
resource and a way to reduce stress.” in priorities, funding, and services. A major move-
ment toward health promotion and family care in
the community will greatly affect the evolution of
Family health care nursing has been influenced by FAMILY NURSING ROLES
many variables that are derived from both historical
and current events within society and the profession Families are the basic unit of every society, but it is
of nursing. Examples include changing nursing also true that families are complex, varied, dynamic,
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Family Health Care Nursing: An Introduction 13

Nursing Organizations
American Nurses Association
Standards of Nursing
.. Practice
Social Policy Statement
Education Agenda for Health Care
Media Reform
Health care delivery system THEORIES National League of Nursing
Environmental Accreditation Standards
Culture Policy Related Theories/ American Association of
Agendas Colleges of Nurses
Policy Making/Agendas
Strengths Perspective
Family nursing interest groups
(i.e., ANA Council of FAMILY HEALTH
United Nations Family Stress and Coping Nurse Researchers and
Families Family Systems Western Nursing
Health Family Process Research Society) Primary care
Family Structure & National Association of Nurse (health promotion)

. Health
United States/Canada Function Practitioners Secondary care

.. Families Family Development International Family Nursing (health protection)

Self-Care Biennial Conference Tertiary care

. Economic Health Promotion (recovery/rehabilitation)

. Child Care Family Interaction Family Nursing Families
Environmental Theory/Research Health
Related Disciplines Nursing Paradigm Vulnerable to illness

.. Divorce laws
State and Local Governments
Anthropology Family Nursing Research . or dysfunction
Acute illness &

. Health care
Family Sociology
Family Psychology
Family transitions
Chronic illness and the . recovery
Chronic illness/
Family Therapy family rehabilitation
Organizations Family Science Acute illness and the
Behavioral Sciences family
National Council of Theology Health Promotion
Family Relations Social Work Single Parents and
Children's Defense Fund Health
Groves Family Conference
Marriage and Family Specialties in Nursing
Therapists Associations
Religious Organizations Family nurse practitioner
Maternal child nursing
Family and community
health nursing
Psychiatric mental health
Home health nursing
Pediatric nursing

FIGURE 1-8 Variables that influence contemporary family health care. (From Bomar, P. J. [Ed.]. [2004].
Promoting health in families: Applying family research and theory to nursing practice [3rd ed., p. 17].
Philadelphia, PA: Saunders/Elsevier, with permission.)

and adaptive, which is why it is crucial for all nurses it is a composite of what various scholars believe to
to be knowledgeable about the scientific discipline be some of the current roles of nurses. Keep in
of family nursing, and the variety of ways nurses mind that the health care setting affects roles that
may interact with families (Kaakinen et al., 2010). nurses assume with families.
The roles of family health care nurses are evolving
along with the specialty. Figure 1-9 lists the many Health teacher: The family nurse teaches about
roles that nurses can assume with families as the family wellness, illness, relations, and parenting, to
focus. This figure was constructed from some of name a few topics. The teacher-educator function
the first family nursing literature that appeared, and is ongoing in all settings in both formal and informal
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14 Foundations in Family Health Care Nursing

Technical expert Case manager facilitate family-centered care. For example, a clini-
(Deliver/supervise care) Surrogate
cal nurse specialist in a hospital may be asked to as-
Coordinator Environmental sist the family in finding the appropriate long-term
collaborator modifier care setting for their sick grandmother. The nurse
Liaison comes into the family system by request for a short
Consultant period and for a specific purpose.
Family Theory
Counselor: The family nurse plays a therapeutic
Counselor role in helping individuals and families solve prob-
Advocate lems or change behavior. An example from the
mental health arena is a family that requires help
Role model with coping with a long-term chronic condition,
Case finder such as when a family member has been diagnosed
(Epidemiologist) Researcher
Health education
with schizophrenia.
FIGURE 1-9 Family nursing roles.
“Case-finder” and epidemiologist: The family
nurse gets involved in case-finding and becomes a
ways. Examples include teaching new parents how tracker of disease. For example, consider the situation
to care for their infant and giving instructions in which a family member has been recently diag-
about diabetes to a newly diagnosed adolescent boy nosed with a sexually transmitted disease. The nurse
and his family members. would engage in sleuthing out the sources of the
transmission and in helping other sexual contacts to
Coordinator, collaborator, and liaison: The seek treatment. Screening families and subsequent re-
family nurse coordinates the care that families re- ferral of the family members may be a part of this role.
ceive, collaborating with the family to plan care.
For example, if a family member has been in a trau- Environmental specialist: The family nurse con-
matic accident, the nurse would be a key person in sults with families and other health care professionals
helping families to access resources—from inpa- to modify the environment. For example, if a man
tient care, outpatient care, home health care, and with paraplegia is about to be discharged from the
social services to rehabilitation. The nurse may hospital to home, the nurse assists the family in mod-
serve as the liaison among these services. ifying the home environment so that the patient can
move around in a wheelchair and engage in self-care.
“Deliverer” and supervisor of care and tech-
nical expert: The family nurse either delivers or Clarify and interpret: The nurse clarifies and in-
supervises the care that families receive in various terprets data to families in all settings. For example,
settings. To do this, the nurse must be a technical if a child in the family has a complex disease, such
expert both in terms of knowledge and skill. For as leukemia, the nurse clarifies and interprets in-
example, the nurse may be the person going into formation pertaining to diagnosis, treatment, and
the family home on a daily basis to consult with the prognosis of the condition to parents and extended
family and help take care of a child on a respirator. family members.

Family advocate: The family nurse advocates for Surrogate: The family nurse serves as a surrogate
families with whom he works; the nurse empowers by substituting for another person. For example,
family members to speak with their own voice, or the the nurse may stand in temporarily as a loving par-
nurse speaks out for the family. An example is a school ent to an adolescent who is giving birth to a child
nurse advocating for special education services for a by herself in the labor and delivery room.
child with attention-deficit hyperactivity disorder.
Researcher: The family nurse should identify
Consultant: The family nurse serves as a consultant practice problems and find the best solution for
to families whenever asked or whenever necessary. dealing with these problems through the process of
In some instances, she consults with agencies to scientific investigation. An example might be
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Family Health Care Nursing: An Introduction 15

collaborating with a colleague to find a better does not address the whole family or members of
intervention for helping families cope with incon- families. Likewise, the medical and nursing diagnos-
tinent elders living in the home. tic systems used in health care are disease centered,
and diseases are focused on individuals and have lim-
Role model: The family nurse is continually serv- ited diagnostic codes that pertain to the family as a
ing as a role model to other people. A school nurse whole. To complicate matters further, most insur-
who demonstrates the right kind of health in per- ance companies require that there be one identified
sonal self-care serves as a role model to parents and patient, with a diagnostic code drawn from an indi-
children alike. vidual disease perspective. Thus, even if health care
providers are intervening with entire families, com-
Case manager: Although case manager is a con- panies require providers to choose one person in the
temporary name for this role, it involves coordina- family group as the identified patient and to give that
tion and collaboration between a family and the person a physical or mental diagnosis, even though
health care system. The case manager has been em- the client is the whole family. Although there are
powered formally to be in charge of a case. For family diagnostic codes that address care with fami-
example, a family nurse working with seniors in the lies, insurance companies may not pay for care for
community may become assigned to be the case those codes, especially if the care is more psycholog-
manager for a patient with Alzheimer’s disease. ical or educational in nature. See Chapter 4 for a
detailed discussion on diagnostic codes.
The established hours during which health care
OBSTACLES TO FAMILY NURSING systems provide services pose another obstacle
PRACTICE to focusing on families. Traditionally, office hours
take place during the day, when family members
There are several obstacles to practicing family cannot accompany other family members. Recently,
nursing. A vast amount of literature is available some urgent care centers and other outpatient set-
about families, but there has been little taught tings have incorporated evening and weekend hours
about families in the nursing curricula until into their schedules, making it possible for family
the past three decades. Most practicing nurses have members to come in together. But many clinics and
not had exposure to family theory or concepts dur- physician offices still operate on traditional Monday
ing their undergraduate education and continue to through Friday, 9:00 a.m. to 5:00 p.m. schedules,
practice using the individualist paradigm. Even thus making it difficult for all family members to at-
though there are several family assessment models tend together. These obstacles to family-focused
and approaches, families are complex, so no one as- nursing practice are slowly changing; nurses should
sessment approach fits all family situations. There continue to lobby for changes that are more con-
is a paucity of valid and reliable psychometrically ducive to caring for the family as a whole.
tested family evaluation instruments.
Furthermore, some students and nurses may be- HISTORICAL PERSPECTIVES
lieve that the study of family and family nursing is
“common sense,” and therefore does not belong A brief historical outline of the development of the
formally in nursing curricula, either in theory or specialty of family nursing will help nurses under-
practice. Nursing also has strong historical ties with stand how nurses have actually always provided
the medical model, which has traditionally focused care for the family from several different view-
on the individual as client, rather than the family. points. An outline of the history of families in
At best, families have been viewed in context, and North America is presented to provide an overview
many times families were considered a nuisance in of the family development up until present time.
health care settings—an obstacle to overcome to
provide care to the individual.
Another obstacle is the fact that the traditional
History of Family Nursing
charting system in health care has been oriented to Family health nursing has roots in society from pre-
the individual. For example, charting by exception historic times. The historical role of women has been
focuses on the physical care of the individual and inextricably interwoven with the family, for it was the
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16 Foundations in Family Health Care Nursing

responsibility of women to care for family members with families as a whole. Nevertheless, before and
who fell ill and to seek herbs or remedies to treat the during World War II, nursing became more
illness. Women have been the primary child care focused on the individual, and care became central-
providers throughout history. In addition, through ized in institutional and hospital settings, where it
“proper” housekeeping, women made efforts to pro- remained until recently.
vide clean and safe environments for the maintenance Since the 1950s, at least 19 disciplines have stud-
of health and wellness for their families (Bomar, 2004; ied the family and, through research, produced fam-
Ham & Chamings, 1983; Whall, 1993). ily assessment techniques, conceptual frameworks,
During the Nightingale era in the late 1800s, the theories, and other family material. Recently, this
development of nursing families became more interdisciplinary work has become known as family
explicit. Florence Nightingale influenced both the social science. Family social science has greatly in-
establishment of district nursing of the sick and fluenced family nursing in the United States, largely
poor, and the work of “health missionaries” because of the professional interdisciplinary group
through “health-at-home” teaching. She believed called National Council of Family Relations and its
that cleanliness in the home could eradicate high large number of family publications. Many family
infant mortality and morbidity rates. She encour- nurses have become active in this organization. In
aged family members of the fighting troops to addition, some nurses are now receiving advanced
come into the hospitals during the Crimean War degrees in family social science departments around
to take care of their loved ones. Nightingale sup- the country.
ported helping women and children achieve good Nursing theorists started in the 1960s to system-
health by promoting both nurse midwifery and atize nursing practice. Scholars began to articulate the
home-based health services. In 1876, in a docu- philosophy and goals of nursing care. Initially, theo-
ment titled “Training Nurses for the Sick Poor,” rists were concerned only with individuals, but grad-
Nightingale encouraged nurses to serve in nursing ually, individuals became viewed as part of a larger
both sick and healthy families in the home environ- social system. Also in the 1960s, the NP movement
ment. She gave both home-health nurses and began espousing the family as a primary unit of care
maternal-child nurses the mandate to carry out in practice, although the grand theories of nursing
nursing practice with the whole family as the unit focused primarily on the individual and not families.
of service (Nightingale, 1979). The 1980s saw a shift in focus to families as a
In colonial America, women continued the unit of care in America and Canada. Small numbers
centuries-old traditions of nurturing and sustaining of people across these countries gathered together
the wellness of their families and caring for the ill. to discuss and share family nursing concepts. Fam-
During the industrial revolution of the late 18th ily nurses started defining the scope of practice,
century, family members began to work outside the family concepts, and how to teach this information
home. Immigrants, in particular, were in need of to the next generation of nurses. Family nursing
income, so they went to work for the early hospi- has both old and new traditions and definitions.
tals. This was the real beginning of public health The discipline and science of family nursing is now
and school nursing. The nurses involved in the beyond youth, more like a young adult, but still
beginning of the labor movement were concerned in a state of growing up and maturing. The first na-
with the health of workers, immigrants, and tional family nursing conferences were held in the
their families. Concepts of maternal-child and United States (Portland, Oregon) in 1986–1989.
family care were incorporated into basic curricu- The International Family Nursing Conferences
lums of nursing schools. In fact, maternity nursing, (IFNC) began in the late 1980s and has been held
nurse midwifery, and community nursing histori- around the world every 2 or 3 years since that time.
cally focused on the quality of family health. The 11th International Family Nursing Confer-
Margaret Sanger fought for family planning. Mary ence was held in June 2013 in Minneapolis, Min-
Breckenridge formed the famous Frontier Nursing nesota. The International Family Nursing
Service (midwifery) to provide training for nurses Association (IFNA) grew out of IFNC and became
to meet the health needs of mountain families. active in 2009–2010. See Table 1-2 for a composite
A concerted expansion of public health nursing of historical factors that contributed to the devel-
occurred during the Great Depression to work opment of family health as a focus in nursing.
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Family Health Care Nursing: An Introduction 17

Table 1-2 Historical Factors Contributing to the Development of Family Health as a Focus in
Time Period Events
Pre-Nightingale era Revolutionary War “camp followers” were an example of family health focus before Florence Nightingale’s
Mid-1800s Nightingale influences district nurses and health missionaries to maintain clean environment for patients’
homes and families.
Family members provided for soldiers’ needs during Civil War through Ladies Aid Societies and Women’s
Central Association for Relief.
Late 1800s Industrial Revolution and immigration influence focus of public health nursing on prevention of illness,
health education, and care of the sick for both families and communities.
Lillian Wald establishes Henry Street Visiting Nurse Service (1893).
Focus on family during childbearing by maternal-child nurses and midwives.
Early 1900s School of nursing established in New York City (1903).
First White House Conference on Children occurs (1909).
Red Cross Town and Country Nursing Service was founded (1912).
Margaret Sanger opens first birth control clinic (1916).
Family planning and quality care become available for families.
Mary Breckinridge forms Frontier Nursing Service (1925).
Nurses are assigned to families.
Red Cross Public Health Nursing Service meets rural health needs after stock market crash (1929).
Federal Emergency Relief Act passed (1933).
Social Security Act passed (1935).
Psychiatry and mental health disciplines begin family therapy focus (late 1930s).
1960s Concept of family as a unit of care is introduced into basic nursing curriculum.
National League for Nursing (NLN) requires emphasis on families and communities in nursing curriculum.
Family-centered approach in maternal-child nursing and midwifery programs is begun.
Nurse-practitioner movement, programs to provide primary care to children begin (1965).
Shift from public health nursing to community health nursing occurs.
Family studies and research produce family theories.
1970s Changing health care system focuses on maintaining health and returning emphasis to family health.
Development and refinement of nursing conceptual models that consider the family as a unit of analysis
or care occur (e.g., King, Newman, Orem, Rogers, and Roy).
Many specialties focus on the family (e.g., hospice, oncology, geriatrics, school health, psychiatry, mental
health, occupational health, and home health).
Master’s and doctoral programs focus on the family (e.g., family health nursing, community health
nursing, psychiatry, mental health, and family counseling and therapy).
ANA Standards of Nursing Practice are implemented (1973).
Surgeon General’s Report focuses on healthy people, health promotion, and disease prevention (1979).
1980s ANA Social Policy Statement (1980).
White House Conference on Families.
Greater emphasis is put on health from very young to very old.
Increasing emphasis is placed on obesity, stress, chemical dependency, and parenting skills.
Graduate level specialization begins, with emphasis on primary care outside of acute care settings, health
teaching, and client self-care.

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18 Foundations in Family Health Care Nursing

Table 1-2 Historical Factors Contributing to the Development of Family Health as a Focus in
Time Period Events
Use of wellness and nursing models in providing care increases.
Promoting Health/Preventing Disease: Objective for the Nation (1980) is released by U.S. Department
of Health and Human Services.
Family science develops as a discipline.
Family nursing research increases.
National Center for Nursing Research is founded, with a Health Promotion and Prevention Research section.
First International Nursing Conference occurs in Calgary, Canada (1988).
1990s Healthy People 2000: National Health Promotion and Disease Prevention Objective (1990) is released
by U.S. Department of Health and Human Services.
Nursing’s Agenda for Health Care Reform is developed (ANA, 1991).
Family leave legislation is passed (1991).
Journal of Family Nursing is created (1995).
2000s Nursing’s Agenda for the Future is written (ANA, 2002).
Healthy People 2010 and Healthy People 2020 are released from U.S. Department of Health and
Human Services.
The quality and quantity of family nursing research continue to increase, especially in the international
Family-related research is clearly a goal of the National Institute of Nursing Research Themes for the
Future (NINR, 2003).
World Health Organization document Health for All in the 21st Century calls for support of families.
The National Council on Family Relations prepared the NCFR Presidential Report 2001: Preparing
Families for the Future.
International Family Nursing Conferences start meeting every 2 years instead of every 3 years.

Adapted from Bomar, P. J. (Ed.). (2004). Promoting health in families: Applying family research and theory to
nursing practice (3rd ed.). Philadelphia, PA: Saunders/Elsevier.

History of Families remained somewhat constant over time. Families

were then and are now a part of the larger commu-
A brief macro-analytical history of families is im- nity and constitute the basic unit of society.
portant to an understanding of family nursing. The It is postulated that the family structure, process,
past helps to make the present realities of family and function were a response to everyday needs in
life more understandable, because the influence of prehistoric times, just as they are in modern times.
the past is evident in the present. This historical As communities grew, families and communities
approach provides a means of conceptualizing fam- became more institutionalized and homogeneous
ily over time and within all of society. History helps as civilization progressed. Family culture was that
to dispel preferences for family forms that are only aspect of life derived from membership in a partic-
personally familiar and broaden nurses’ views of the ular group and shared by others. Family culture
world of families. was composed of values and attitudes that allowed
early families to behave in a predictable fashion.
Prehistoric Family Life Man and woman dyads are the oldest and most
Archaeologists and anthropologists have found tenacious unit in history. Biologically, human chil-
evidence of prehistoric family life, existing before dren need care and protection longer than other
the time of written historical sources. These fam- animals’ offspring. These needs led humans to
ily forms varied from present-day forms, but the form long-term relationships. Economic pairing
functions of the family have been assumed to have was not always the same as reproductive pairing,
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Family Health Care Nursing: An Introduction 19

but it was a by-product of reproductive pairing. Society today is still living with bequests of pa-
Moreover, a variety of skills were required for liv- triarchal family life. Women are still struggling to
ing, and no single person possessed all skills; there- get out from under the rules and expectations of
fore, male and female roles began to differ and the state and of men. The women’s movement and
become defined. Early in history, children were the National Organization for Women (NOW) are
part of the economic unit. As small groups of con- two of the forces that have improved the level of
jugal families formed communities, the complexity equality of women in modern society. A lot more
of the social order increased. work needs to be done on the issues of equality for
all Americans, including gender differences.
European History In recent years, men have also begun identifying
Many Americans are of European ancestry and stem the bondage they experience. They cannot meet all
from the family structure that was present there. of the needs of families and feel inadequate for fail-
Social organizations called families emphasized ing to do so. This is especially true of men who can-
consanguineous (genetic) bonds. The tendency to- not access the resources of money, occupation, and
ward authority was concentrated in a few individuals occupational status through education. A men’s
at the top of the hierarchical structure (kings, lords, movement is afoot that is promoting male causes,
fathers). Men were the heads of families. although this movement is not as dynamic as it may
Property of family transferred through the male be in the future. One of the organizations support-
line. Women left home to join their husbands’ ing this work is the National Congress for Men.
families. Mothers did not establish strong bonds
with their daughters because the daughters even- North American Families
tually left their homes of origin to join their hus- North American society and families were molded
bands’ families of origin. Women and children from the beginning by economic logic rather than
were property to be transferred. Marriage was a consanguineous logic. America does not have the
contract between families, not individuals. Ex- history of Europe’s preindustrial age. English pa-
tended patriarchal family characteristics prevailed triarchy was not transplanted in its pure form to
until the advent of industrialism. America. Both women and men had to labor in the
New World. This gave women new power. Also,
Industrialization the United States had an ethic of achieved status
Great stability existed within family systems until rather than status inherited through familial lines.
the Industrial Revolution. The revolution first ap- Children were also experiencing a changing sta-
peared in England around 1750 and spread to tus in American families. Originally, they were part
Western Europe and North America. Some believe of the economic unit and worked on farms. Then
that the nuclear family idea started with the Indus- with the great immigration of the early 1900s, the
trial Revolution. Extended families had always been expectation shifted to parents creating a better
the norm until families left farms and moved into world for their children than they themselves had.
the cities, or until men left their families in order To do this, children had to become more educated
to work in the factories. Some women stayed at to deal with the developing society. Each generation
home, maintaining the house and caring for the of children has generally obtained more education
children, while other women and children took up and income than their parents; they left the family
labor in the city factories. farms and moved to distant cities. As a result of this
When factories of the Industrial Revolution change, parents lost assurance that their children
started to be built, people began moving about. The would take care of them during their old age.
state had begun to provide services that families pre- In addition, the functions of families were
viously had performed for their members. Informal changing greatly. The traditional roles that families
contractual arrangements between public and state played were being displaced by the growing num-
power and nuclear families took place, in which the bers and kinds of social institutions. Families began
state gave fathers the power and authority over their increasingly surrendering to public agencies many
families in exchange for male individuals giving the of the socialization functions they previously per-
state their loyalty and service. Women were not formed, such as child education, health care, and
expected to love husbands but to obey them. child care.
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20 Foundations in Family Health Care Nursing

Families Today of information, or creation of family rituals or

Today, families cannot be separated from the larger routines (Kaakinen et al., 2010).
system of which they are a part, nor can they be sep- Nurses who understand the concepts of family
arated from their historical past. Some people argue structure, function, and process can use this knowl-
that families are in terrible condition, like a rudder- edge to educate, counsel, and implement changes
less ship in the dark. Other people hail the changes that enable families to cope with illness, family cri-
that continue to occur in families, and approve the sis, chronic health conditions, and mental illness.
diversity and options that address modern needs. Nurses prepared to work with families can assist
Idealizing past family arrangements and decrying them with needed life transitions (Kaakinen et al.,
change has become commonplace in the media. Just 2010). For example, when a family member expe-
as some families of both the past and present engage riences a chronic condition such as diabetes, family
in behaviors that are destructive to individuals and roles, routines, and power hierarchies may be chal-
other social institutions, there are families of the lenged. Nurses must be prepared to address the
past and present that provide healthy environments. complex and holistic family problems resulting
The structure, function, and processes of families from illness, as well as to care for the individual’s
have changed, but the family will continue to sur- medical needs.
vive and thrive. It is, in fact, the most tenacious unit
in society (Kaakinen et al., 2010).
Family Structure
Family structure is the ordered set of relationships
FAMILY STRUCTURE, FUNCTION, within the family, and between the family and other
AND PROCESS social systems (Denham, 2005). There are many
tools available for nurses to use in conducting
Knowledge about family structure, functions, and assessments of family structure. The most funda-
processes is essential for understanding the com- mental tools are family genograms and ecomaps,
plex family interactions that affect health, illness, which will be introduced later in this chapter.
and well-being (Kaakinen et al., 2010). Knowl- These tools are not new in nursing, but their pop-
edge emerging from the study of family structure, ularity among nurses and other providers is grow-
function, and process suggests concepts and a ing due to the clearly perceived value of the
framework that nurses can use to provide effective knowledge they generate. Genograms and ecomaps
assessment and intervention with families. Many are beginning to make their way out of more ob-
internal and external family variables affect indi- scure settings such as specialty genetics clinics and
vidual family members and the family as a whole. into mainstream home health, public health, and
Internal family variables include unique individual even acute care settings (Svarvardoittir, 2008).
characteristics, communication, and interactions, In terms of family nursing assessment and inter-
whereas external family variables include location vention, it is logical to begin with the “who” of
of family household, social policy, and economic families before moving to the “how” or “why.” In
trends. Family members generally have compli- determining the family structure, the nurse needs
cated responses to all of these factors. Although to identify the following:
some external factors may not be easily modifi-
■ The individuals who comprise the family
able, nurses can assist family members to manage
■ The relationships between them
change, conflict, and care needs. For instance, a
■ The interactions between the family members
sudden downturn in the economy could result in
■ The interactions with other social systems
the family breadwinner becoming unemployed.
Although nurses are unable to alter this situation Family patterns of organization tend to be rela-
directly, understanding the implications on the tively stable over time, but they are modified gradu-
family situation provides a basis for planning more ally throughout the family life cycle and often change
effective interventions that may include financial radically when divorce, separation, or death occurs.
support programs for families. Nurses can assist In today’s information age and global society, sev-
members with coping skills, communication pat- eral ideas about the “best family” coexist simultane-
terns, location of needed resources, effective use ously. Different family types have their strengths and
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Family Health Care Nursing: An Introduction 21

limitations, which directly or indirectly affect indi- Families in the past were more homogeneous
viduals and family health. Many families still adhere than they are today. Whereas the past norm in
to more customary forms and patterns, but many predominately Caucasian families was a two-
of today’s families fall into categories more clearly parent family (traditional nuclear family) living to-
labeled nontraditional (Table 1-3). Nurses will con- gether with their biological children, many other
front families structured differently from their own family forms are acknowledged and recognized
families of origin and will encounter family types today. It is important to note that the average per-
that conflict with personal value systems. For nurses son born today will experience many family forms
to work effectively with families, they must maintain during his or her lifetime. Figure 1-10 depicts the
open and inquiring minds. many familial forms that the average person can
live through today. Nurses are not only experienc-
ing this proliferation of variation in their own per-
Table 1-3 Variations of Family and Household sonal lives but also with the patients with whom
Structures they work in health care settings (Kaakinen &
Family Type Composition Birenbaum, 2012).
Nuclear dyad Married couple, no children
Understanding family structure enables nurses
assisting families to identify effective coping
Nuclear Husband, wife, children (may or
may not be legally married)
strategies for daily life disturbances, health care
crises, wellness promotion, and disease preven-
Binuclear Two postdivorce families with
children as members of both
tion (Denham, 2005). In addition, nurses are cen-
tral in advocating and developing social policies
Extended Nuclear family plus blood relatives
relevant to family health care needs. For example,
Blended Husband, wife, and children of taking political action to increase the availability
previous relationships
of appropriate care for children could reduce the
Single parent One parent and child(ren) financial and emotional burden of many working
Commune Group of men, women, and children and single-parent families when faced with pro-
Cohabitation Unmarried man and woman sharing viding care for sick children. Similarly, caregiving
(domestic partners) a household responsibilities and health care costs for acutely
Homosexual Same-gender couple and chronically ill family members place increas-
Single person (adult) One person in a household ing demands on family members. Nurses well
informed about different family structures can

r Single

Developmental process Marr

Childhood Adulthood ied/a
famil ing

bi Married
og Sp

ica ou


er l/s se
s in

Lives in


rtn te






Single- Single-
Family of Cohabi- Commuter Cohabi- Stepfamily
parent Stepfamily parent
origin tation marriage tation
family family

FIGURE 1-10 An individual’s potential family life experiences.

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22 Foundations in Family Health Care Nursing

identify specific needs of unique families, provide family has been organized around the biological
appropriate clinical care to enhance family re- function of reproduction. Reproduction was
silience, and act as change agents to enact social viewed as a major concern for thousands of years
policies that reduce family burdens. when populating the earth was continually threat-
ened by famine, disease, war, and other life uncer-
tainties. Norms about sexual intercourse affect the
Family Functions
fertility rate. Fertility rate is “the average number
A functional perspective has to do with the ways of children that would be born per woman if all
families serve their members. One way to describe women lived to the end of their childbearing years
the functional aspect of family is to see the unit and bore children according to a given fertility rate
as made up of intimate, interactive, and interde- at each age” (World Factbook, 2013). In general,
pendent persons who share some values, goals, global fertility rates are in decline, with the most
resources, responsibilities, decisions, and commit- pronounced decline being in industrialized coun-
ment over time (Steinmetz, Clavan, & Stein, 1990). tries, especially Western Europe (World Factbook,
Family function relates to the larger purposes or 2013). Global concerns about overpopulation and
roles of families in society at large. It is important environmental threats, as well as personal views of
to be clear that there is a distinction between the morality and financial well-being, have been rea-
concepts of family function (the prescribed social sons for limiting numbers of family births.
and cultural obligations and roles of family in soci- Since the 1980s, the reproductive function has
ety) and family functioning (the processes of family become increasingly separated from the family
life). Family functioning has been described as “the (Kaakinen et al., 2010). As mores and norms
individual and cooperative processes used by devel- change over time, it is not deemed “unacceptable”
oping persons as to dynamically engage one an- in many industrialized countries for birth to occur
other and their diverse environments over the life outside of marriage. Abstinence, various forms of
course” (Denham, 2003a, p. 277). Family function contraception, tubal ligation, vasectomy, family
includes the ways a family reproduces offspring, in- planning, artificial insemination, and abortion have
teracts to socialize its young, cooperates to meet various degrees of social acceptance as means to
economic needs, and relates to the larger society. control reproduction. Many aspects of reproduc-
Nurses should ask about specific characteristics that tion continue to be the subject of social and ethical
factor into achieving family or societal goals, or controversy. Nurses working with families find
both. Families’ functional processes such as social- themselves at the forefront of practical issues
ization, reproduction, economics, and health care related to providing care in this complex context.
provision are areas nurses can readily assess and The ethical dilemmas surrounding abortion,
address during health care encounters. Nursing for example, seem compounded by technological
interventions can enhance the family’s protective advances that affect reproduction and problems
health function when teaching and counseling is of infertility. Reproductive technologies are guided
tailored to explicit learning needs. Family cultural by few legal, ethical, or moral guidelines. Artificial
context and individual health literacy needs are insemination by husband or donor, in vitro fertil-
closely related to functional needs of families. ization, surrogate mothers, and artificial embry-
Nurses become therapeutic agents as they assist onization, in which a woman other than the woman
families to identify social supports and locate com- who will give birth to and raise the child donates
munity resources during times of family transitions an egg for fertilization, create financial and moral
and health crisis. Five specific family functions are dilemmas. Although assistive reproductive tech-
worth deeper investigation here: reproductive, nologies can provide a biological link to the child,
socialization, affective, economic, and health care. some families are choosing to adopt children. Many
are wrangling over the issues implicit in cross-racial
Reproductive Functions of the Family and cross-cultural adoptions. Reproductive tech-
The survival of a society is linked to patterns of re- nologies and adoption are being considered by
production. Sexuality serves the purposes of pleas- all family types to add children to the family unit.
ure and reproduction, but associated values differ Religious, legal, moral, economic, and technologi-
from one society to another. Traditionally, the cal challenges will continue to cause debates in the
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Family Health Care Nursing: An Introduction 23

years ahead about family control over reproduc- to others changes in role relationships and new ex-
tion, such as gender selection of child. pectations. Understandings about families’ unique
rites of passage can assist nurses working with
Socialization Functions of the Family diverse health care needs.
A major function for families is to raise and social-
ize their children to fit into society. Families have Affective Functions of the Family
great variability in the ways they address the phys- Affective function has to do with the ways family
ical and emotional needs, moral values, and eco- members relate to one another and those outside
nomic needs of children, and these patterns are the immediate family boundaries. Healthy families
influenced specifically by the role of parenting and are able to maintain a consistent level of involve-
somewhat by the larger society (Grusec, 2011). ment with one another, yet at the same time, not
Children are born into families without knowledge become too involved in each other’s lives (Peterson
of the values, language, norms, morals, communi- & Green, 2009). The healthiest families have em-
cation, or roles of the society in which they live. A pathetic interaction where family members care
major function of the family continues to be to so- deeply about each other’s feeling and activities, and
cialize them about family life and ground them in are emotionally invested in each other. Families
the societal identity of which they are a part. The with a strong affective function are the most effec-
function of the family relative to socialization in- tive type of families (Peterson & Green, 2009). All
cludes protection, mutual reciprocity or interde- families have boundaries that help to buffer stresses
pendence between family members, control, and pressure of systems outside the family on its
guided learning, and group participation, and all members. Healthy families protect their bound-
these functions are assumed to be operative in all aries, but at the same time, give members room to
cultures (Grusec, 2011). negotiate their independence. Achieving this bal-
Although the family is not the only institution ance is often difficult in our fast-paced culture. And
of society that participates in socialization of chil- it is particularly difficult in families with adoles-
dren, it is generally viewed as having primary re- cents (Peterson & Green, 2009). Emotional in-
sponsibility for this function. When children fail to volvement is a key to successful family functioning.
meet societal standards, it is common to blame this Researchers have identified several characteristics
on family deficits and parental inadequacies; how- of strong families. Among these are expressions of
ever, it is important to keep in mind that the issues appreciation, spending time together, strong com-
are more complex than simple finger pointing. mitment to the family, good communication, and
Today, patterns of socialization require appro- positive conflict resolution (Peterson & Green,
priate developmental care that fosters dependence 2009). When family members feel that they are
and leads to independence (Denham, 2005). Social- supported and encouraged and that their personal
ization is the primary way children acquire the so- interests are valued, family interaction becomes
cial and psychological skills needed to take their more effective.
place in the adult world. Parents combine social Families provide a sense of belonging and iden-
support and social control as they equip children tity to their members. This identity often proves to
to meet future life tasks. Parental figures interact be vitally important throughout the entire life cycle.
in multiple roles such as friends, lovers, child care Within the confines of families, members learn de-
providers, housekeepers, financial providers, recre- pendent roles that later serve to launch them into
ation specialists, and counselors. Children growing independent ones. Families serve as a place to learn
up within families learn the values and norms of about intimate relationships and establish the foun-
their parents and extended families. dation for future personal interactions. Families
Another role of families in the socialization provide the initial experience of self-awareness,
process is to guide children through various rites which includes a sense of knowing one’s own gen-
of passage. Rites of passage are ceremonies that an- der, ethnicity, race, religion, and personal charac-
nounce a change in status in the ways members are teristics. Families help members become acquainted
viewed. Examples include events such as a baptism, with who they are and experience themselves in
communion, circumcision, puberty ritual, gradua- relationships with others. Families provide the sub-
tion, wedding, and death. These occasions signal stance for self-identity, as well as a foundation for
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24 Foundations in Family Health Care Nursing

other-identity. Within the confines of families, in- conditions significantly affect families. When
dividual members learn about love, care, nurtu- economies become turbulent so become families’
rance, dependence, and support of the dying. structures, functions, and processes. People make
Resilience implies an ability to rebound from decisions about when to enter the labor force, when
stress and crisis, the capacity to be optimistic, solve to marry, when to have children, and when to retire
problems, be resourceful, and develop caring sup- or come out of retirement based on economic fac-
port systems. Although unique traits alter potential tors (Bianchi, Casper, & King, 2005). For a detailed
for emotional and psychological health, individuals discussion on family and economics, see Chapter 2.
exposed to resilient family environments tend to Family income provides a substantial part of fam-
have greater potential to achieve normative devel- ily economics, but an equally important aspect has to
opmental patterns and positive sibling and parental do with economic interactions and consumerism re-
relationships (Denham, 2005). lated to household consumption and finance. Money
Research on parent-child interactions needs management, housing decisions, consumer spending,
to consider the quantity and quality of time spent insurance choices, retirement planning, and savings
together, the kinds of activities engaged in, and pat- are some of the issues that affect family capacity
terns of interaction to understand member feelings to care for the economic needs of its members
toward each other. More needs to be known about (Lamanna & Reidmann, 2011. These values and
relationships with nonresidential parents as well as skills are passed down to children within the family
families characterized by polyamory, families in structure. Financial vulnerability and bankruptcy
which there is more than one loving sexual relation- have increased for middle-class families (Denham,
ship at the same time with the consent and knowl- 2005). The ability of the family to earn a sufficient
edge of all partners (Pallotta-Chiarolli, 2006). income and to manage its finances wisely is a critical
Variables such as the quality of couples’ relation- factor related to economic well-being.
ships, the ways families’ conflicts are handled, In order to meet their own economic needs and
whether abuse or violence has previously occurred maintain family life and health, family members
in the households or members’ lives, frequency of take upon themselves a number of contributory
children’s contact with nonresidential parents, roles for obtaining and utilizing the wages. Family
shared custody arrangements, and emotional rela- nurses should explore the types of resources avail-
tionships between parents and children appear to be able or lacking as families engage in providing
important predictors of family affective functions. health care functions to their members.
Affective functions can best be understood by
gathering information from all of the various mem- Health Care Functions of the Family
bers involved within a household; lack of access to Family members often serve as the primary health
all points of view within families should not prevent care providers to their families. Individuals regu-
nurses from gaining knowledge from those to larly seek services from a variety of health care pro-
whom they have access. It is quite reasonable to in- fessionals, but it is within the family that health
quire about the perceptions and experiences of instructions are followed or ignored. Family mem-
some individuals through key family informants, bers tend to be the primary caregivers and sources
but nurses must always remember that more certain of support for individuals during health and illness.
knowledge should come from the specific individu- Families influence well-being, prevention, illness
als themselves, particularly as family members are care, maintenance care associated with chronic ill-
known to have diverse viewpoints on issues that af- ness, and rehabilitative care. Family members often
fect health and family life. Shared or discrepant care for one another’s health conditions from the
views among family members have an important cradle to the grave. Families can become particu-
influence on the overall functioning of families’ larly vulnerable when they encounter health
management of illness (Knafl, Breitmayer, Gallo, & threats, and family-focused nurses are in a position
Zoeller, 1996 Knafl, Deatrick, & Gallo, 2008). where they can provide education, counseling, and
assistance with locating resources. Family-focused
Economic Functions of the Family care implies that when a single individual is the tar-
Families have an important function in keeping get of care, the entire family is still viewed as the
both local and national economies viable. Economic unit of care (Denham, 2003a).
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Family Health Care Nursing: An Introduction 25

Health care functions of the family include many crisis situations, such as natural disasters, wars, or
aspects of family life. Family members have differ- personal crises. The family’s current modes of op-
ent ideas about health and illness, and often these eration may become ineffective, and members are
ideas are not discussed within families until prob- confronted with learning new ways of coping with
lems arise. Availability and cost of health care in- change. For example, when coping with the stress
surance is a concern for many families, but many of a chronic illness, families experience alterations
families lack clarity about what is and is not covered in role performance and in power. When individ-
until they encounter a problem. Lifestyle behav- uals are unable to perform usual roles, other mem-
iors, such as healthy diet, regular exercise, and al- bers are expected to assume them. A shift in family
cohol and tobacco use, are areas that family roles may result in the loss of individual power.
members may not associate with health and illness During times of change, family nurses can assist
outcomes. Risk reduction, health maintenance, re- family members to communicate, make decisions,
habilitation, and caregiving are areas where families identify ways to cope with multiple stressors, re-
often need information and assistance. Family duce role strain, and locate needed resources.
members spend far more time taking care of health Family communication patterns, member inter-
issues of family members than professionals do. actions, and interaction with social networks are sev-
eral areas related to family processes that nurses
need to assess systematically. Nursing interventions
Family Processes
that promote resiliency in family processes vary with
Family process is the ongoing interaction between the degree of strain faced by the family. Families
family members through which they accomplish have complex needs related to adaptation, goal at-
their instrumental and expressive tasks (Denham, tainment, integration, pattern, and tension manage-
2005). Family process indicators describe the inter- ment. When family processes are ineffective or
actions between members of a family, including disrupted, the families and their members may be at
their relationships, communication patterns, time risk for problems pertinent to health outcomes, and
spent together, and satisfaction with family life the family itself could be in danger of disintegrating.
(World Family Map, 2013). In part, family process Following is a discussion of a few family processes
makes every family unique within its own particular that nurses can influence through their relationships
culture. Families with similar structures and func- with families in caregiving situations. The family
tions may interact differently. Family process, at processes covered here include family coping, family
least in the short term, appears to have a greater ef- roles, family communication, family decision mak-
fect on the family’s health status than family struc- ing, and family rituals and routines.
ture and function, and in turn, processes within
families are more affected by alterations in health Family Coping
status. Family process certainly appears to have the Every family has its own repertoire of coping
greatest implications for nursing actions. For ex- strategies, which may or may not be adequate in
ample, for the chronically ill, an important deter- times of stress, such as when a family member ex-
minant for successful rehabilitation is the ability to periences an altered health event such as the diag-
assume one’s familial roles. For rehabilitation nosis of diabetes, a stroke, or a fractured leg in a
to occur, family members have to communicate biking accident. Coping consists of “constantly
effectively, make decisions about atypical situa- changing cognitive and behavioral efforts to man-
tions, and use a variety of coping strategies. The age specific external and/or internal demands that
usual familial power structure may be threatened are appraised as taxing or exceeding the resources
or need to change to address unique individual of the person” (Lazarus & Folkman, 1984, p. 141).
needs. Ultimately, the success or failure of the Families with support can withstand and rebound
adaptation processes will affect individual and from difficult stressors or crises (Walsh, 2011b),
family well-being. which is referred to as family resilience. “Family re-
Alterations in family processes most likely occur silience is the successful coping of family members
when the family faces a transition brought about by under adversity that enables them to flourish with
developmental changes, adding or subtracting family warmth, support, and cohesion” (Black & Lobo,
members, an illness or accident, or other potential 2008, p. 33).
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26 Foundations in Family Health Care Nursing

Not all families have the same ability to cope be- demonstrate resilience or the capacity to survive in
cause of multiple reasons. There is no universal list the midst of struggle, adversity, and long-term con-
of key effective factors that contribute to family re- flict. Families who recover from crisis tend to be
siliency, but a review of research and literature by more cohesive, value unique member attributes,
Black and Lobo (2008) found the following simi- support one another without criticism, and focus
larities across studies for those families that cope on strengths (Black & Lobo, 2008).
well: a positive outlook, spirituality, family member
accord, flexibility, communication, financial man- Family Roles
agement, time together, mutual recreational inter- Understanding family roles is crucial in family
ests, routines and rituals, and social support (Black nursing as it is one area in which nurses can help
& Lobo, 2008). According to Walsh (2011b) some families to adapt, negotiate, give up expectations,
key processes in family resiliency include belief sys- or find additional resources to help decrease family
tem, organizational patterns, and family communi- stress during times when a family member is ill.
cation. The family’s belief system involves making Within the family, regardless of structure, each
meaning of adversity, maintaining a positive out- family position has a number of attached roles, and
look, and being able to transcend adversity through each role is accompanied by expectations. After a
a spiritual/faith system (Walsh, 2011b). The fami- review of the family literature, Nye (1976) identi-
lies’ organization patterns, which speak to their fied eight roles associated with the position of
flexibility, connectedness, and social and economic spouse/partner:
resources, help the family maintain resilience.
■ Provider
Finally, families who communicate with clarity,
■ Housekeeper
allow open emotional expression, and have a col-
■ Child care
laborative problem-solving approach facilitate fam-
■ Socialization
ily resiliency (Walsh, 2011b).
■ Sexual
Nurses have the ability to support families in
■ Therapeutic
times of stress and crisis through empowering
■ Recreational
processes that work well and are familiar to the
■ Kinship
family. Using a strengths-based approach, family
nurses help families to adjust and adapt to stressors With the rates of divorce and cohabitation in
(Black & Lobo, 2008; Walsh, 2011c). Nurses can North America, traditional roles such as provider
help families in establishing priorities and respond- and child care role are stressed and unfold differ-
ing to everyday needs when a health event occurs ently. In addition, other roles are added relative to
that threatens family stability. For example, when relationship, such as father who lives apart from
an unexpected death in the family occurs, family children, stepparent, and/or half-sibling.
members are called on to make multiple decisions. Traditionally, the provider role has been as-
At the same time, they may not be able to remem- signed to husbands, whereas wives assumed the
ber phone numbers, think of whom to call in what housekeeper, child care, and other caregiving roles.
order, decide who should pick up the kids, deter- With societal changes and variations in family
mine which funeral home to use, or decide how or structure, however, the traditional enactment of
what to tell children or aging parents. Helping these roles is not viable for some families anymore
families to work through steps and set priorities (Gaunt, 2013). In two-parent heterosexual families,
during this situation is an important aspect of fam- the roles are still primarily organized by gender,
ily nursing. with men as breadwinners and women as primary
Even families who function at optimal levels caregivers (Scott & Braun, 2009). Other family
may experience difficulties when stressful events roles form based on generation or location in the
pile up. Even families that cope well may still feel family (Haddock, Zimmerman, & Lyness, 2005),
stressed (Black & Lobo, 2008). Today’s families such as, for example, middle child, mother, father,
encounter many challenges that leave them vulner- stepsister, niece, and grandfather. Attitudes have
able to a myriad of stressors. Vulnerability can re- changed somewhat in regard to rigid gender role
sult from poverty, illness, abuse, and violence. enactment (who does what), but the research shows
Coping capacities are enhanced whenever families that, in reality, little change has occurred, and most
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Family Health Care Nursing: An Introduction 27

families remain gender based (Haddock et al., the family members, such as obesity (Slater,
2005; Scott & Braun, 2009). Sevenhuysen, Edginton, & O’Neil, 2012).
What has changed relative to family roles is the
number of mothers who work outside of the home Housekeeper and child care roles: Today,
and the role of the father. The rate of mothers with many women experience significant role strain in
infants under 1 year old working outside of the balancing provider and other familial roles.
home is 55.8% (Bureau of Labor Statistics, 2011). Women who work continue to be responsible for
Even though more women work outside of the most housekeeping and child care responsibilities
home and men are participating and doing more in (Haddock et al., 2005). Women who work outside
the home and with child care in the family than the home still perform 80% of the child care and
ever before, the responsibility for child care still re- household duties (Walsh, 2011a). In a survey by
mains largely with women (Kaakinen et al., 2010). Hewlett and Luce (2006), 77% of women and 66%
The role of the father has changed, but the degree of men who worked over 60 hours a week said they
of change is unsure. A 2011 Pew Research Center were unable to maintain their household, 66% of
report indicates that one in four children under the sample reported they did not get sufficient
the age of 18 years lives apart from their father sleep, and half reported not getting enough exer-
(Livingston & Parker, 2011). Many fathers who cise. Although husbands’ roles in child care are in-
live with their children are active in their day-to- creasing, their focus is often on playing with the
day activities. Fathers who live apart from their children rather than meeting basic needs. Women
children are often involved in e-mail and phone still are primary in meeting health care needs of all
conversations and visitation in varying amounts of family members, including children and men.
time. But 27% of the fathers who do not live with
their children indicate that they have not been in
Sick role: Individuals learn health and illness be-
communication with their children in the last year.
haviors in their family of origin. Health behaviors
In general, the Pew report found no consensus on
are related to the primary prevention of disease, and
whether or not today’s fathers are more involved
include health promotion activities to reduce sus-
in the family life of their children than previous
ceptibility to disease and actions to reduce the effects
generations of fathers (Livingston & Parker, 2011).
of chronic disease. Kasl and Cobb (1966) identified
In every household, members have to decide the
three types of health behaviors in families:
ways work and responsibilities will be divided and
shared. Roles are negotiated, assigned, delegated, ■ Health behavior is any activity undertaken by
or assumed. Division of labor within the family a person believing himself to be healthy for
household occurs as various members assume roles, the purpose of preventing disease or detecting
and as families change over time and over the fam- it at an asymptomatic stage.
ily life cycle. For example, family members need to ■ Illness behavior is any activity, undertaken by
reconfigure role allocation after the birth or death a person who feels ill, to define the state of
of family members. his health and to discover a suitable remedy.
■ Sick-role behavior is any activity undertaken
Provider role: The provider role has undergone for the purpose of getting well, by those who
significant change in the past few decades. Whereas consider themselves ill.
American men were once viewed as the sole pri-
Once a family member becomes ill, she demon-
mary family breadwinner, this has changed signifi-
strates various illness behaviors or enacts the “sick
cantly. In today’s world, many families need more
role.” Parsons (1951) defines four characteristics of
than one income to meet basic needs. Work con-
a person who is sick:
ditions have become increasingly stressful for men
and women, and external work obligations impinge ■ While sick, the person is temporarily exempt
on members’ abilities to meet familial role obliga- from carrying out normal social and family
tions. For example, working mothers in Canada roles. The more severe the illness, the freer
were found to rely on processed and fast conven- one is from role obligations.
ience foods in the majority of meal preparations, ■ In general, the sick person is not held
thus increasing the risk of poor health outcomes for responsible for being ill.
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28 Foundations in Family Health Care Nursing

■ The sick person is expected to take actions to The inability to define the situation creates am-
get well, and therefore has an obligation to biguity about what one should do in a given sce-
“get well.” nario. Continual changes in family structures and
■ The sick person is expected to seek compe- gender roles means that members increasingly en-
tent professional medical care and to comply counter situations in which guidelines for action
with medical advice on how to “get well.” are unclear. Single parents, stepparents, nonresi-
dent fathers, and cohabitating partners deal daily
Voluminous research has been conducted on the
with situations for which there are no norms. What
theoretical concepts of the sick role. Some criti-
right does a stepparent have to discipline the new
cisms of the Parsons perspective the sick role are as
spouse’s child? Is a nonresident father expected to
follows: (1) some individuals reject the sick role; (2)
teach his child about AIDS? What name or names
some individuals are blamed for their illness, such
go on the mailbox of cohabitating partners? Who
as alcoholics or individuals with AIDS; and (3)
can sign for consent when divorced parents share
sometimes independence is encouraged in persons
who have a chronic illness as a way to “get well.”
Regardless of whether the issues are substantive,
Regardless of the theoretical debates about the
they present daily challenges to the people in-
sick role, individuals in families experience acute and
volved. Some choose to withdraw from the situa-
chronic illness. Each family, depending on its family
tion, and others choose to redefine the situation
processes, defines the sick role differently. Most
when they are uncertain how to act. For instance,
“sick” people require some level of care; someone
a blended family might want to operate in the same
needs to assume the family caregiver role. The care-
way as a traditional family but may experience con-
giving role may be as simple as a stop at the store on
flict when thinking about which members to in-
the way home to buy chicken soup or pick up med-
clude in family decision making. When a solution
icines, or as involved as providing around-the-clock
cannot be found, family members suffer the conse-
care for someone. The female individuals in our so-
quences of role strain.
ciety still provide the majority of the care required
Role strain sometimes results when family
when family members become sick or injured.
members lack role knowledge, or they have no
basis for choosing between several roles that
Role strain, conflict, and overload: Family roles
might seem appropriate. In America, most people
are affected, some more than others, when a family
are not taught how to be parents, and much
member becomes ill. Usually the women in the
learning is observational and experiential. Social-
family add the role of family caregiver to their
ization related to caregiving of a chronically ill
other roles. Nurses have a crucial role in helping
family member seldom occurs, and many individ-
families adjust to illness by discussing and exploring
uals are unfamiliar with and unprepared to as-
role strain, role conflict, and role overload. Nurses
sume the roles necessary for providing care.
can facilitate family adaptation by helping to
When an individual is learning how to be a parent
problem-solve role negotiations and helping fam-
or a caregiver, role training may be required.
ilies access outside resources.
Knowledge may be acquired by peer observation,
Lack of competence in role performance may
trial and error, or explicit instruction. Parents
be a result of role strain. Some researchers have
may have limited opportunities to observe peers,
found that sources of role strain are cultural and
and other family members may not have the
interactional. Interactional sources of role strain
knowledge necessary to help. Thus, the family
are related to difficulties in the delineation and en-
may need to seek external resources or obtain
actment of familial roles. Heiss (1981) identifies
needed information using other means such as
five sources of difficulties in the interaction process
child care classes, self-help groups, or instruction
that place strain on a family system:
from health professionals. When individuals are
■ Inability to define the situation unable to figure out their roles in a situation, it
■ Lack of role knowledge limits their problem-solving abilities.
■ Lack of role consensus Family members may lack role consensus, or be
■ Role conflict unable to agree about the expectations attached to
■ Role overload a role. One family role that is often the source
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Family Health Care Nursing: An Introduction 29

of family disagreement is the housekeeping role, The dependent family member can be temporarily
especially for dual-career couples. Men who have cared for in a residential facility while the other
been socialized into more traditional male roles family members go on a vacation, which is called
are less inclined to accept responsibility for house- respite care.
hold tasks readily and may limit the amount of It is the role of the nurse to help families who
time they are willing to spend on these activities. experience role strain, conflict, and overload. Using
When active participation does not meet the anticipatory guidance, nurses work closely with
wife’s expectations, she tends to assume responsi- families to discuss and define the family flow of en-
bility for the greater number of household tasks. ergy and resources when confronted with a family
If she has been socialized into thinking that caregiving situation. See Chapter 4 for ways to
women are accountable for traditional housekeep- work with families who experience stress related to
ing roles, she may feel guilty or neglectful if she caregiving and caregiving roles.
asks for help. Lack of agreement about the role
sometimes results in familial discord and impedes Family Communication
satisfaction with the partner. Negotiation is likely Communication is an ongoing, complex, chang-
the most effective way to reach consensus about ing activity and is the means through which
things that can be done. people create, share, and regulate meaning in a
Role conflict occurs when expectations about transactional process to make sense of their world
familial roles are incompatible. For example, the (Dance, 1967). In all families, communication
therapeutic role might involve becoming a care- is continuous in that it defines their present reality
giver to an elderly parent, but expectations of this and constructs family relationships (Dance, 1967).
new role may be incompatible with that of It is through communication that families find
provider, housekeeper, sexual partner, and child ways to adapt to changes as they seek family sta-
care provider. Does one go to the child’s baseball bility. Families that are highly adaptive change
game or to the doctor with the elderly parent? more easily in response to demands. Families with
Role conflict may occur when roles present con- low adaptability have a fixed or more rigid style of
flicting demands. Individuals and families often interacting (Olson & Gorall, 2005). “Family
have to set priorities. Demands of caregiver and adaptability is manifested in how assertive family
provider roles may be conflicting and may conflict members are with each other, the amount of con-
with other therapeutic familial tasks. The care- trol in the family, family discipline practices,
giver may withdraw from activities that, in the negotiation, how rigid family roles are adhered to,
short term, seem superfluous, but in the long term and the nature and enforcement of rules in the
are sources of much-needed energy. Family family” (Segrin & Flora, 2011, p. 17).
nurses are likely to encounter members facing Family communication affects family physical
many strains because of role conflict, and may and mental health. Most programs and interven-
need to assist by providing information and sug- tion strategies for improving family communica-
gesting ways the family could negotiate roles to tion are beyond the role and experience of nurses
discover meaningful solutions. with undergraduate education. The role of the
A source of role strain closely related to role nurse is to facilitate family communication at times
conflict is role overload. In role overload, the in- when families are stressed by changes that occur
dividual lacks resources, time, and energy to meet with its members, such as birth of an infant, growth
role demands. As with role conflict, the first option and development issues of children, when family
usually considered is to withdraw from one of members become ill, or the death of family mem-
the roles. Maintaining a balance between energy- bers. It is the role of the nurse to assist family com-
enhancing and energy-depleting roles reduces role munication to achieve healthful outcomes.
strain. An alternative to withdrawing from a role
might be to seek time away from some role re- Family Decision Making
sponsibilities. For example, a friend of the family Communication and power are family processes
member could relieve the primary caregiver for that influence decision making. Family decision
several hours. Nurses could arrange for a home- making is not an individual effort but a joint one.
health aide to assist with personal care hygiene. Most health care decisions should be made from a
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30 Foundations in Family Health Care Nursing

family perspective. Each decision has at least five of each family member and the family as a whole
features: the person raising the issue, what is being (Buchbinder et al., 2009). The importance and
said about the issue, supporting action to what is value of rituals in everyday life has been clearly ex-
being said, the importance of what is being said, plored in anthropological and sociological litera-
and the responses of the individuals (Friedman, ture, but the significance of rituals is largely
Bowden, & Jones, 2003). ignored by nurses (Denham, 2003b).
Decision making provides opportunity for vari- Assessing rituals and routines related to specific
ous family members to make a contribution to the health or illness needs provides a basis to envision
process, support one another, and jointly set and distinct family interventions and to devise specific
strive to achieve goals. Disagreements within a plans for health promotion and disease manage-
family are natural, because members often have dif- ment, especially when adherence to medical regi-
ferent points of view. It is important for members mens is critical or caregiving demands are
to share their various viewpoints with one another. burdensome to the families (Fiese, 2007). For
Problem solving is part of the decision-making example, when a family member develops type
process, and frequently means that differences in 2 diabetes, the whole family may adapt its cooking,
opinion and emotions need consideration. eating, and shopping habits to accommodate
Family communication processes influence the needs of this family member (Denham,
decision-making outcomes. In the Pew Research Manoogian, & Schuster, 2007). It enhances com-
Center (2006) report on family communication, pliance with chronic illness treatment when the
46% of the 3,014 subjects indicated that they family incorporates illness regimens into the basic
turned to their families for help and advice when family tasks and practices (Buchbinder et al., 2009).
they had problems. Keep in mind that in family
conflicts, the expression of anger is not necessarily
destructive, but contempt, belligerence, and defen- SUMMARY
siveness are counterproductive (Gottman, Coan,
Carrere, & Swanson, 1998). Nurses working with This chapter provides an introduction and broad
families can facilitate family communication skills overview to family health care nursing. The follow-
to help families find an effective way for resolving ing major concepts were discussed in this chapter:
differences and making decisions. ■ Family health care nursing is an art and a
Families want to be involved in varying degrees science that has evolved as a way of thinking
with health care decisions. Families are often about and working with families.
asked to help make end-of-life decisions, not to ■ Family nursing is a scientific discipline based
resuscitate a loved one or to withdraw/withhold in theory.
life-sustaining therapies. See Chapter 4 for infor- ■ Health and illness are family events.
mation on shared decision making. ■ The term family is defined in many ways, but
the most salient definition is, The family is
Family Rituals and Routines who the members say it is.
Family rituals and routines have been studied for ■ An individual’s health (on the wellness-
decades, beginning with Bossard and Boll (1950). to-illness continuum) affects the entire
Rituals are associated with formal celebrations, tra- family’s functioning, and in turn, the
ditions, and religious observances with symbolic family’s ability to function affects each
meaning, such as bar mitzvahs, weddings, funerals. individual member’s health.
Routines are patterned behaviors or interactions ■ Family health care nursing knowledge and
that closely link to daily or regular activities, such skills are important for nurses who practice
as bedtime procedure, mealtimes, greetings, and in generalized and in specialized settings.
treatment of guests (Buchbinder, Longhofer, & ■ The structure, function, and processes of
McCue, 2009). Families have unique rituals and families have changed, but the family as a
routines that provide organization and give mean- unit of analysis and service continues to
ing to family life. When family rituals and routines survive over time.
are disrupted by illness, the family system as a ■ Nurses should intervene in ways that pro-
whole is affected; therefore, it can affect the health mote health and wellness, as well as prevent
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Family Health Care Nursing: An Introduction 31

illness risks, treat disease conditions, and Driver, H., Tabares, A., Shapiro, A., Nahm, E. Y., & Gottman,
manage rehabilitative care needs. J. M. (2011). Couple interaction in happy and unhappy mar-
riages. In F. Walsh (Ed.), Normal family processes: Growing
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diversity and complexity (4th ed., pp. 57–77. New York, NY:
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Review, 7(1), 48–53. dysfunction: From a deficits to a strengths perspective (4th ed.,
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Family Demography
Continuity and Change in North
American Families
Lynne M. Casper, PhD
Sandra M. Florian, MA, PhD Candidate
Peter D. Brandon, PhD

Critical Concepts
■ Economic, social, and cultural changes have increased family diversity in North America. More families are maintained
by single mothers, single fathers, cohabitating couples, and grandparents than in the past.
■ Increases in women’s labor force participation, especially among mothers, have reduced the amount of nonwork
time that families have to attend to health care needs.
■ North Americans are more likely to live alone than they were a few decades ago. Thus, people are less likely to have
family members living with them who can assist them when they become ill or injured.
■ The Great Recession has increased the likelihood that young adults will remain in or return to their parents’ homes
after graduating from school. Many of them cannot find a stable job that pays enough for them to live on their own.
In the United States, many young adults do not have health insurance and, thus, do not seek health care regularly.
■ More North Americans are immigrants than was the case a few decades ago. Family nurses provide care for an in-
creasingly ethnically, culturally, and linguistically diverse population.
■ Single-mother families are particularly vulnerable. They are more likely to live in poverty than are other families. These
mothers are usually the sole wage earners and care providers in their families. Thus, these families are more likely
than other families both to be monetarily poor and to face stringent time constraints.
■ Single-father families have been increasing in recent decades and fathers are spending more time caring for their children.
Nurses will be increasingly likely to encounter fathers who bring their children in for checkups or medical treatments.
■ Cohabitation among opposite- and same-sex couples continues to rise in North America. In the United States,
because cohabitating relationships are not legally sanctioned in many states and localities, partners may not have
the right to make health care decisions on behalf of each other or for the other partner’s children.

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34 Foundations in Family Health Care Nursing

Critical Concepts (cont.)

■ Couples who are having trouble conceiving are increasingly turning to the medical profession for help. Births resulting
from assisted reproductive technologies (ARTs) are on the rise in North America. The ART process is expensive, time
consuming, and often increases health risks for the women and children involved.
■ Many children in North America are adopted. These children need time to adjust to their new circumstances and are
more likely than other children to have special health care needs.
■ Stepfamilies are common among North American families. Legal arrangements in these families can be complicated;
it is not always clear who has the right to make health care decisions for children in these families.
■ Many children are raised by or receive regular care from their grandparents. These grandparents may or may not
have legal responsibility for their grandchildren, but may seek medical care for them.
■ The aging of the population, as well as the impending retirement of the baby-boom generation, presents significant
challenges for both informal caregivers and the health care system. The need for nurses who specialize in caring for
elderly persons will continue to increase.

If there is one “mantra” about family life in the last stabilized, as did the living arrangements of young
half century, it is that the family has undergone adults and elderly persons. The divorce rate in-
tremendous change. No other institution elicits as creased substantially in the mid-1960s and 1970s,
contentious debate as the North American family. reached its peak in 1980, slightly declined during the
Many argue that the movement away from marriage 1990s, and has remained relatively constant since
and traditional gender roles has seriously degraded then. In the United States, between 43% and 46% of
family life. Others view family life as amazingly marriages contracted today are expected to end in di-
diverse, resilient, and adaptive to new circumstances vorce (Schoen & Canudas-Romo, 2006). The rapid
(Cherlin, 2009; Popenoe, 1993; Stacey, 1993). growth in cohabitation among unmarried adults has
Any assessment of the general “health” of family also slowed. In Canada, divorce rates also increased
life in North America, and the health and well-being during the 1970s and 1980s, peaked slightly later in
of family members, especially children, requires a 1987, but have slightly declined since then. In 2008,
look at what is known about demographic and so- 41% of marriages were expected to end in divorce
cioeconomic trends that affect families. A pragmatic within the first 30 years (Statistics Canada, 2012b).
approach to family nursing requires an understand- Yet, family life is still evolving. Young adults
ing of the broader changes in family within the pop- have often postponed marriage and children to
ulation. The latter half of the 20th century was complete higher education before attempting to
characterized by tumultuous change in the econ- enter labor markets that have become inhospitable
omy, civil rights, and sexual freedom and by dra- to poorly educated workers. Accompanying this
matic improvements in health and longevity. delay in marriage was the continued increase in
Marriage and family life felt the reverberations of births to unmarried women. By 2010, 41% of all
these societal changes. births in the United States were to unmarried
In the first decades of the 21st century, as North women (Martin et al., 2012).
Americans reassess where they have come from and Within marriage or marriage-like relationships,
where they are going, one thing stands out—rhetoric the appropriate roles for each partner are shifting as
about the dramatically changing family may be a step North American societies accept and value more
behind the reality. Recent trends suggest a quieting equal roles for men and women. The widening role
of changes in the family in Canada, as well as the of fathers has become a major agent of change in the
United States, or at least of the pace of change. Little family. More father-only families exist than in the
change occurred in the proportions of two-parent or past, and after divorce, fathers are more likely to
single-parent families since the mid-1990s (U.S. share custody of children with the mother. Within
Census Bureau, 2011d). After a significant increase two-parent families, fathers are also more likely to be
in the proportion of children living with unmarried involved in the children’s care than in the past
parents, the living arrangements of children (Hernandez & Brandon, 2002). In addition, the
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Family Demography: Continuity and Change in North American Families 35

number of same-sex couples has been increasing, what these changes portend for family health care
and a larger proportion of them are now raising chil- nursing during the first half of this century. This
dren. Family roles in same-sex couples are more chapter draws on information pertaining to fam-
likely to be negotiated than in opposite-sex families. ily demography from a variety of data sources
Whether the slowing, and in some cases, cessa- (Box 2-1). The reader should note that family
tion, of change in family living arrangements is a nursing is not the major focus of this chapter.
temporary lull or part of a new, more sustained The subject matter of the chapter is structured to
equilibrium will only be revealed in the next provide family nurses with background on
decades of the 21st century. New norms may be changes in the North American family so that
emerging about the desirability of marriage, the they can understand their patient populations.
optimal timing of children, and the involvement The chapter does briefly touch upon the impli-
of fathers in child rearing and mothers in bread- cations of these demographic patterns for prac-
winning. Understanding the evolution of North ticing family nursing.
American families and the implications these Where possible, statistics have been reported for
changes have for family nursing requires taking the both the United States and Canada, but compara-
pulse of contemporary family life. ble data for Canada were not always readily acces-
This chapter examines changes and variations sible for the topics covered in this chapter. Readers
in North American families in order to understand should note that data are not always collected in the

BOX 2-1
Sources of Information on Demography and Public Health

Many of the statistics discussed in this chapter draw Moreover, several large health-related surveys are
on information from the Current Population Surveys conducted by the National Center for Health Statistics.
(CPS) collected by the U.S. Census Bureau. This is a The National Health Interview Survey (NHIS) is a large,
continuous survey of about 60,000 households, se- continuous survey of about 43,000 households per year,
lected at random to be representative of the national covering the civilian, noninstitutionalized population of
population. Each household is interviewed monthly for the United States. The NHIS is the major source of infor-
two 4-month periods. During February through April of mation on health status and disability, health-related
each year, the CPS collects additional demographic and behaviors, and health care utilization for all age groups.
economic data, including data on health insurance The National Health and Nutrition Examination Survey
coverage, from each household. This Annual Demo- (NHANES) includes physical examinations, mental health
graphic Supplement is the most frequently used source questionnaires, dietary data, analyses of urine and blood,
of data on demographic and economic trends in the and immunization status from a random sample of
United States and is the data source for the majority Americans (about 10,000 in each 2-year cycle). NHANES
of statistics presented in this chapter regarding changes also collects some basic demographic and income data. It
in the family. is the major source of information on trends in obesity,
For estimates for small areas or subgroups of the pop- cholesterol status, and a host of other conditions in the
ulation, demographers often used data from the “long national population, and in particular age groups and
form” of the decennial census, which collected data from racial/ethnic groups. The National Survey of Family
one-sixth of all households. The census collects a range of Growth (NSFG) is the primary source of information on
economic and demographic information, including in- marriage and divorce trends, pregnancy, contraceptive
comes and occupations, housing, disability status, and use, and fertility behaviors, and the ways in which they
grandparent responsibility for children. The census cannot vary among different groups and over time. Birth and
match the detail found in more specialized surveys. For death certificates, sent by hospitals and funeral homes to
example, only four short questions measure disability for state offices of vital events registration, provide the raw
children; surveys designed for precise and complete material for calculating fertility and mortality rates and life
estimates of disabilities will usually have dozens of such expectancy. The data are collected from the states and
questions. Since 2004, the American Community Survey analyzed by the National Center for Health Statistics.
replaced the sample data from the census and now In Canada, the National Population Health Survey has
provides a more continuous flow of estimates for states, interviewed a panel of respondents every 2 years since
cities, counties, and even towns and rural areas, for which 1994 to track changes in health-related behaviors, risk
estimates were made only once a decade. factors, and health outcomes.
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36 Foundations in Family Health Care Nursing

same year and that some family indicators are in greater numbers. Historically, unmarried mothers
defined and measured differently across the two (either never married or formerly married) of
countries. young children had higher labor force participation
rates than married mothers. These women often
were the only earners in their families. One notable
A CHANGING ECONOMY change has been the increase in the combination of
AND SOCIETY paid work and mothering among married mothers.
In 1960, for example, in the United States, only
Consider the life of a North American young 19% of married mothers with children younger
woman reaching adulthood in the 1950s or early than age 6 were in the labor force. By 2011, the
1960s. Such a woman was likely to marry straight proportion increased to 62% (U.S. Census Bureau,
out of high school or to take a clerical or retail sales 2011e). In Canada, 28% of women with children
job until she married. She would have moved out under the age of 3 were employed in 1976 com-
of her parents’ home only after she married to form pared with 64% in 2009. Among mothers with
a new household with her husband. This young children under the age of 16 living at home, the
woman was likely to marry by about age 20 in the proportion is even higher at 73% (Statistics
United States (U.S. Census Bureau, 2008), age 22 Canada, 2010). Another truly remarkable change
in Canada, and begin a family soon thereafter. If has been the increase in the labor force participa-
she were working when she became pregnant, she tion of single mothers from 44% to 77% between
would probably have quit her job and stayed home 1980 and 2011 (U.S. Census Bureau, 2011j).
to care for her children and husband while her hus- In Canada, the proportion of single mothers who
band had a steady job that paid enough to support were employed in 1976 was 28% and increased
the entire family. Thus, usually someone was at to 69% in 2009 (Statistics Canada, 2010). What
home who had the time to care for the health needs does this trend imply for family nursing? The
of family members, to schedule routine checkups majority of North American families with young
with doctors and dentists, and to take family mem- children in the mid-20th century had mothers who
bers to these appointments. were home full-time to care for the health needs of
Fast-forward to the first decades of the 21st cen- family members, whereas at the beginning of the
tury. A young woman reaching adulthood in the 21st century such families were in the minority.
first decades of the 21st century is not likely to
marry before her 26th birthday. She will probably
Changes in the Economy
attend higher education and is likely to live by her-
self, with a boyfriend, or with roommates before Economic conditions have an influence on young
marrying. She may move in and out of her parents’ people’s decisions about when to enter the labor
house several times before she gets married. Like force, when to marry, and when to have children
her counterpart reaching adulthood in the 1950s, (and how many children to have). After World War
she is likely to marry and have at least one child, II, the United States and Canada enjoyed an eco-
but the sequence of those events may well be re- nomic boom characterized by rapid economic
versed. She probably will not drop out of the labor growth, full employment, rising productivity,
force after she has children, although she may cur- higher wages, low inflation, and increasing earn-
tail the number of hours she is employed. She is ings. A man with a high-school education in the
much more likely to divorce, and possibly even to 1950s and 1960s could secure a job that paid
remarry, compared with a young woman in the enough to allow him to purchase a house, support
1950s or 1960s. Because she is more likely to be a a family on one income, and join the swelling ranks
single mother and to be working outside of the of the middle class.
home, she is also not as likely to have the time nec- The economic realities of the 1970s and 1980s
essary to devote to caring for the health of family were quite different. The two decades after the
members. oil crisis, which began in 1973, were decades of
A dramatic change in women’s participation in economic change and uncertainty marked by a
the labor market occurred after 1970, as mothers shift away from manufacturing and toward serv-
with young children began entering the labor force ices, stagnating or declining wages (especially for
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Family Demography: Continuity and Change in North American Families 37

less-educated workers), high inflation, and a men are more likely to play a role in looking after
slowdown in productivity growth. The 1990s the health of family members than they were in
were just as remarkable for the turnaround: sus- previous decades.
tained prosperity, low unemployment, and eco- Before World War II, most men worked nearly
nomic growth that seems to have reached many to the end of their lives. Retirement was a privi-
in the poorest segments of society (Farley, 1996; lege for the wealthy or the fortunate workers
Levy, 1998). The Great Recession, which began whose companies provided pensions. Currently,
in 2008, reversed this trend, and many men and with increases in life expectancy and healthier
women joined the ranks of the unemployed. lives, the passage of the Social Security Acts in
When the economy is on such a roller coaster, 1936 and 1938 in the United States, and the in-
family life often takes a similar ride. Marriage oc- stitution of provincial (in the 1920s) and federal
curred early and was nearly universal in the decades (since 1952) pensions in Canada, most workers
after World War II; mothers remained in the home can look forward to at least a modest guaranteed
to rear children as the baby-boom generation was income for themselves and their spouses and
born and nurtured. When baby boomers hit work- minor children. Social Security benefits constitute
ing age in the 1970s, the economy was not as hos- more than half of the household income for two-
pitable as it had been for their parents. They thirds of Americans older than 65. The increased
postponed marriage, delayed having children, and availability of public pensions made possible a
found it difficult to establish themselves in the growing period of retirement for most workers, a
labor market. steady decrease in poverty rates for older people,
Many of the baby boomers’ own children began and an increase in the proportion of older people
reaching working age in the 1990s and 2000s, when maintaining their own households separately from
individuals’ economic fortunes were increasingly their adult children.
dependent on their educational attainment. Those
who attended higher education were much more
Changing Family Norms
likely to become self-sufficient and to live inde-
pendently from their parents (Rosenfeld, 2007). In 1950, in North America, there was one domi-
High-school graduates who did not go to higher nant and socially acceptable way for adults to live
education discovered that jobs with high pay and their lives. Those who deviated could expect to be
benefits were in relatively short supply. In the censured and stigmatized. The “ideal” family was
United States, a high-school graduate in full-time composed of a homemaker-wife, a breadwinner-
work earned about 25% (allowing for inflation) less father, and two or more children. Americans shared
than a comparable new worker would have earned a common image of what a family should look like
20 years earlier (Farley, 1996). The increasing rel- and how mothers, fathers, and children should be-
ative benefits of further education encouraged have. These shared values reinforced the impor-
more young men and women to delay marriage and tance of the family and the institution of marriage
attend higher education. (McLanahan & Casper, 1995). This vision of fam-
Partly because of these changes in the econ- ily life showed amazing staying power, even as its
omy, both men and women are remaining single economic underpinnings were eroding. For this
longer and are more likely to leave home to pur- 1950s-style family to exist, North Americans had
sue higher education, to live with a partner, and to support distinct gender roles, and the economy
to launch a career before taking on the responsi- had to be vibrant enough for an average man to
bility of a family of their own. The traditional support a family financially on his own.
gender-based organization of home life (in which Government policies and business practices per-
mothers have primary responsibility for care of petuated this family type by reserving the best jobs
the home and children and fathers provide finan- for men and discriminating against working
cial support) has not disappeared, but young women when they married or had a baby. Begin-
women today can expect to be employed while ning in the 1960s, though, women and people from
raising children, and young men are more likely minority backgrounds gained legal protections in
to share in some child-rearing and household the workplace and discriminatory practices began
tasks. Thus, in the first decades of this century, to recede.
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38 Foundations in Family Health Care Nursing

A transformation in attitudes toward family be- was nearly 79 years for Americans (National Cen-
haviors also took place. People became more ac- ter for Health Statistics, 2008) and 81 years for
cepting of divorce, cohabitation, and sex outside Canadians (World Health Organization, 2011). An
marriage; less sure about the universality and per- American woman who reached age 60 in 2009
manence of marriage; and more tolerant of blurred could expect to live an additional 25 years, on av-
gender roles and of mothers working outside the erage, and a 60-year-old American man would live
home (Bianchi, Raley, & Casper, 2012; Cherlin, another 22 years. For Canadians, life expectancy
2009). Society became more open-minded about a at age 60 is even higher—26 years for women and
variety of living arrangements, family configura- 23 years for men. Women continue to outlive men
tions, and lifestyles. in North America, though the gender gap in recent
Although the transformation of many of these years has shrunk somewhat, primarily because
attitudes occurred throughout the 20th century, the of the delayed effects of smoking trends (men have
pace of change accelerated in the 1960s and 1970s. always been more likely to smoke than women, but
These years brought many political, social, and they have reduced smoking much more than
medical upheavals affecting gender issues and views women in recent decades). The gap in life ex-
of the family. The women’s liberation movement pectancy between men and women means that
included a highly publicized, although unsuccessful, women tend to outlive their husbands and women
attempt to pass the Equal Rights Amendment predominate in the older age groups. About 60%
(ERA) to the Constitution of the United States. of the population 75 years and older in the United
New and effective methods of contraception were States and Canada are women (Statistics Canada,
introduced in the 1950s and 1960s. In 1973, the 2012d).
U.S. Supreme Court ruled that state laws banning Partly because more North Americans are sur-
abortion were unconstitutional. In Canada, abor- viving until older ages, and partly because of a
tion was illegal until 1969 when the law was long-term decline in fertility rates, the propor-
changed to allow abortions for health reasons. Pop- tion of the population aged 65 or older has
ular literature and music heralded the sexual revo- grown. In 1900, only 1 of every 25 Americans was
lution and an era of “free love.” In all industrialized aged 65 or older (nearly 3% of the total popula-
countries, a new ideology was emerging during tion). By 2011, the proportion was more than
these years that stressed personal freedom, self- 3 in 25 (13% of the total population). In 2011,
fulfillment, and individual choice in living arrange- the first of some 78 million baby boomers
ments and family commitments (Bianchi et al., reached their 65th birthdays, and the rate of in-
2012; Cherlin, 2009). People began to expect more crease of the population of elderly persons began
out of marriage and to leave marriages that failed to to accelerate. By 2030, it is expected that one in
fulfill their expectations. Certainly not all Americans five Americans will be aged 65 or older. The sce-
approved of all these changes in beliefs and behav- nario for Canada is similar, although Canada has
iors. The general North American culture changed, a slightly higher proportion of the population
though, as divorce and single parenting became aged 65 and older; in 2011, 14.8% of Canada’s
more widespread realities. population was 65 years and older compared with
13.3% of U.S. residents (Statistics Canada,
2011a; U.S. Census Bureau, 2011d).
An Aging Society
People do not suddenly become old on their
For Americans born in 1900, the average life 65th birthday, of course. Together with improve-
expectancy was less than 50 years. But the early ments in life expectancy have come improvements
decades of the 20th century brought such tremen- in the disability rates at older ages, so that North
dous advances in the control of communicable Americans are not only living longer than in the
diseases of childhood that life expectancy at birth past but also enjoying more years of life without
increased to 70 years by 1960. Rapid declines chronic illness or disabilities. In the United States,
in mortality from heart disease—the leading cause 65 is still a convenient marker for “old age” in
of death—significantly lengthened life expectancy health policy terms, because it is the age at which
for those aged 65 or older after 1960 (Treas & most Americans become eligible for medical and
Torrecilha, 1995). By 2009, life expectancy at birth hospital insurance funded mainly by the federal
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Family Demography: Continuity and Change in North American Families 39

government through Medicare. By 65, as well, 1.1 million in 2011. Immigration has likewise in-
most workers (both men and women) have left full- creased in Canada from about 140,000 in 1980 to
time work, though many continue to work part- 249,000 in 2011. In 2011, 66% of legal immigrants
time, or for part of the year, often at different jobs were admitted to the United States because family
than those they pursued during most of their ca- members already living there petitioned the gov-
reers. Given the growing number of elderly per- ernment to grant them entry (U.S. Department of
sons, the Canadian government will raise the Homeland Security, 2012). For Canada, the corre-
eligible age for Old Age Security (OAS) from 65 to sponding figure is 61% (Citizenship and Immigra-
67 between 2023 and 2029 to ease pressures on the tion Canada, 2011). Immigrant visas were also
OAS budget and to ensure the program’s sustain- granted for economic reasons, usually after em-
ability (Service Canada, 2012). ployers petitioned the government for admission
The aging of the population is often considered of persons with special skills or for humanitarian
a major cause of increasing demand for medical reasons, including asylum granted to refugees be-
services and of the growth in medical expenditures. cause of well-founded fear of persecution in their
Population aging is, indeed, one factor, because home countries. In the United States and Canada,
older people in every country consume more med- immigration laws provide refugees with resettle-
ical care than younger adults. The major causes of ment assistance including temporary health care
increased health expenditures in industrialized services. The goal of these programs is to promote
countries, however, have been changes in medical and improve the health of refugees, as well as
technology, including increased use of pharmaceu- to control the potential spread of any contagious
ticals, rather than the simple growth of the popu- diseases brought into the country by these immi-
lation of elderly persons (Reinhardt, 2003). grants. The benefits of these health programs
Increased life expectancy translates into ex- are restricted to the prevention and treatment
tended years spent in family relationships. A couple of disease that poses a risk to the public health
who marry in their twenties could spend the next and safety (Citizenship and Immigration Canada,
50 years together, assuming they remain married. 2012; U.S. Centers for Disease Control and
Couples in the past were much more likely to ex- Prevention, 2010).
perience the death of one spouse earlier in their In addition to legal immigrants, an estimated
adult years. Longer lives (together with lower birth 10.8 million illegal immigrants lived in the United
rates) also mean that people spend a smaller por- States in 2010, either because they entered without
tion of their lives parenting young children. More detection or because they stayed longer than
parents live long enough to be part of their grand- allowed by a temporary visa (Hoefer, Rytina, &
children’s and even great-grandchildren’s lives Baker, 2011). In 2010, the U.S. Census Bureau es-
(Bengtson, 2001). Many adults are faced with the de- timated that there were 40 million U.S. residents
mands of caring for extremely elderly parents about born outside the country, nearly 13% of the total
the time they reach retirement age and begin to ex- population (Grieco et al., 2012). Because immi-
perience health limitations of older age themselves. grants tend to arrive in the United States early in
their working careers, they are younger, on aver-
age, than the overall U.S. population and account
Immigration and Ethnic Diversity
for a larger share of young families. In 2010, for ex-
In 1965, the U.S. Congress amended the Immigra- ample, 20% of all births in the United States were
tion and Naturalization Act to create a fundamental to mothers born outside the country (U.S. Census
change in the nation’s policy on immigration. Visas Bureau, 2010e). Illegal immigrants are ineligible
for legal immigrants were no longer to be based on for any type of federal public benefits including
quotas for each country of origin; instead, prefer- welfare, Social Security, and health services such as
ence would be given to immigrants joining family Medicaid and Medicare (U.S. Department of
members in the United States. The legislation also Health and Human Services, 2009).
removed limitations on immigration from Latin Estimates based on 2007 U.S. American Com-
America and Asia. The numbers of legal immi- munity Survey data reveal that 55 million people
grants to the United States increased, to an average older than age 5 speak a language other than Eng-
of 900,000 persons per year in the 1990s and to lish at home, the most common being Spanish
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40 Foundations in Family Health Care Nursing

(34.5 million) and Chinese (2.5 million). In the average, nurses are more likely to be dealing with
United States, half of adults 18 to 40 years old who the health care needs of older women than of men.
speak Spanish at home reported that they could Extended lives and delayed childbearing have in-
not speak English well (Shin & Kominski, 2010). creased the chances that adults will experience the
Keep in mind, however, that the overwhelming double whammy of having to provide care and
majority of those who do not speak English well financial support for their children and their par-
are recent immigrants. More than 96% of the ents. Families in these situations can face consider-
native-born who speak Spanish at home report able time and money pressures.
that they can speak English well (Saenz, 2004). In At the same time that changing gender roles
Canada, although English and French are still point to more men in families taking on caregiving
dominant, more than 200 languages are now spo- duties, more women are in the labor force and un-
ken in the country. In 2011, 6.6 million people, available to care for family members, and it is
representing nearly 20% of the Canadian popula- doubtful that the increase in men’s time in caregiv-
tion, reported speaking a language other than ing will fully compensate for the decrease in
English or French at home. Of them, a third, or women’s time. Individuals and families are increas-
2.1 million, reported speaking only a language ingly turning to extended kin and informal care
other than English or French at home, primarily providers to meet their health needs. Societal
Asian languages. The 10 most common foreign changes also influence individuals’ life-course
languages spoken in 2011 in Canada were Punjabi, trajectories. All these changes in individual lives
Chinese (not specified), Cantonese, Spanish, and family relationships are transforming North
Tagalog, Arabic, Mandarin, Italian, Urdu, and American households and families and, in turn,
German (Statistics Canada, 2012h). changing the context in which health needs are de-
The majority of foreign-born U.S. residents live fined and both formal and informal health care are
in states that are the traditional “gateways” to provided. Nurses are more likely to encounter
immigrant populations: California, New York, fathers seeking health care for their children, and
Florida, Texas, and Illinois. In recent decades, individuals whose health needs are met by informal
however, significant increases have occurred in the extended kin or untrained caretakers, especially
immigrant populations of most parts of the coun- among the fragile and older populations.
try, including the rural South and the Upper Mid- The growth of the immigrant population, and
west, which had seen few immigrants for most of its spread throughout both the United States and
the 20th century (Singer, 2004). Canada, has meant that patient populations in
many regions are more racially and ethnically
diverse than in the past. Working with a diverse
Implications for Health Care Providers pool of immigrant and refugee populations, health
The aging and the growing diversity of the American care providers may encounter health conditions
and Canadian populations, combined with shifts and diseases unusual in North America. Nurses in
in the economy and changing norms, values, North America work with families whose cultural
and laws, have altered the context for the nursing backgrounds, perceptions of sickness, and expecta-
care of families. As the population ages, the tions of healers may be different from those
demand will increase for nurses who specialize in with which they are familiar. Everyone providing
caring for elderly persons, and even those who do health care can expect to face both the challenges
not choose a geriatric specialty will find that older and the professional rewards of adapting to a
people constitute an increasing portion of the diverse patient population.
patient population. Improvements in health and
physical functioning among those aged 60 to 70
reduce the need for care among this group. Yet LIVING ARRANGEMENTS
rates of population growth are greatest for those
aged 80 and older, implying an increased demand The demographic changes for individuals dis-
for care among the “oldest old” who are likely to cussed earlier in this chapter are reflected
suffer from poorer health and require substantial in changes in living arrangements, which have
care. Because women continue to outlive men, on become more diverse over time. For most statistical
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Family Demography: Continuity and Change in North American Families 41

purposes, a family is defined as two or more peo- conform to the traditional notion of a breadwinner/
ple living together who are related by blood, mar- homemaker family.
riage, or adoption (Casper & Bianchi, 2002).
Most households (defined by the U.S. Census
Living Arrangements of Elderly Persons
Bureau as one or more people who occupy a
house, apartment, or other residential unit, as op- Improvements in the health and financial status of
posed to “group quarters” such as nursing homes older Americans helped generate a revolution in
or student dormitories) are maintained by fami- lifestyles and living arrangements among elderly
lies. Demographic trends, including late mar- persons. Older North Americans now are more
riage, divorce, and single parenting, have resulted likely to spend their later years with their spouse or
in a decrease in the “family share” of U.S. and live alone, rather than with adult children as in the
Canadian households. In 1960, in the United past. The options and choices differ between eld-
States, 85% of households were family house- erly women and elderly men, however, in large part
holds; by 2012, just 66% were family households because women live longer than men, yet have
(U.S. Census Bureau, 2012). Married-couple fewer financial resources.
family households with children under 18 consti- At the beginning of the 20th century, more than
tuted 44% of all households in 1960, but only 70% of Americans aged 65 or older resided with kin
20% of all households in 2012 (authors’ calcula- (Ruggles, 1994). In part because of increased
tions from U.S. Census Bureau, 2012). Nonfam- incomes of elderly persons but also because of
ily households, which consist primarily of people declining numbers of children and increased di-
who live alone or who share a residence with vorce rates, the proportion of elderly adults living
roommates or with a partner, have been on the alone has increased dramatically. Just 15% of wid-
rise. The fastest growth was among persons living ows aged 65 or older lived alone in 1900, whereas
alone, although much of this growth occurred 66% lived alone in 2011 (Ruggles, 1996; U.S. Census
during the 1960s and 1970s. The proportion of Bureau, 2011b). In 2011, 44% of the population
households with just one person more than dou- aged 65 and older lived alone (U.S. Census Bureau,
bled from 13% to 27% between 1960 and 2012 2011l).
(authors’ calculations from U.S. Census Bureau, A woman is likely to spend more years living
2012). Thus, fewer Americans live with family alone after a spouse dies than will a man because
members who can help care for them when they life expectancy is about 3 years longer for an elderly
are ill or injured. woman than for an elderly man, and because
In Canada, in 1981, two-thirds of households women usually marry men older than themselves.
were single-family households maintained by As a result, older American women are nearly twice
married or cohabitating couples, but by 2011 the as likely as men to be living alone (37% vs. 19%)
percentage declined to 56% (Statistics Canada, (U.S. Census Bureau, 2011b). This pattern is sim-
2011c). As in the United States, the percentage ilar in Canada; for example, in 2011 among Cana-
of households that contained two parents with dians aged 65 and older, 32% of women lived alone
children declined from 36% in 1981 to 26% in compared with only 16% of men (Statistics
2011. The proportion of Canadian households Canada, 2011b). Just under half of all American
that contained one person grew from 20% in women aged 75 and older live by themselves (U.S.
1981 to 28% in 2011. Single-person households Census Bureau, 2011b). Living alone can mean de-
were the fastest growing type of household lays in getting attention for illness or injury and can
(Casper & Bianchi, 2002). With the diversity of complicate arrangements for informal care or
family forms that have emerged, nurses are in- transportation to formal care when needed.
creasingly likely to encounter patients who are Elderly American women are also more than
living alone and have no one to help them in the twice as likely as men to be living with someone
home should they become seriously ill. Nurses other than their spouse (19% vs. 9%), in part be-
will come into contact with more single-mother cause they tend to live longer and reach advanced
families who are more likely than other types of ages when they are most likely to need the physical
families to be time poor and cash strapped. In care and the financial help others can provide
fact, most families with children today do not (authors’ calculations from U.S. Census Bureau,
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42 Foundations in Family Health Care Nursing

2012). In the United States, 43% of adults over 65 differences in the living arrangements of elderly
will reside in assisted living facilities at some point persons. Immigrants and ethnic minorities are more
in their lives. In Canada, a larger proportion of likely than whites to live with an elderly relative
women (33%) than men (22%) aged 85 and older not only because of their often limited economic
lived in institutional settings in 2011 (Statistics circumstances, but also because their cultural norms
Canada, 2011b). Elderly men who need help with and values stipulate moral obligations to care for
activities of daily living (ADLs) such as eating, the elderly (Cohen & Casper, 2002; Glick & Van
bathing, or getting around generally receive infor- Hook, 2002).
mal care from their wives, whereas elderly women Despite the trend toward independent living
with disabilities are more likely to rely on assistance among older Americans, many of them are not able
from grown children, to live with other family to live alone without assistance. Many families who
members, or to enter a nursing home (Silverstein, have older kin in frail health provide extraordinary
Gans, & Yang, 2006). care. One study in New York City, for example,
To explain trends in living arrangements among found that 40% of those who reported caring for
elderly persons, researchers have focused on a an elderly relative devoted 20 or more hours per
variety of constraints and preferences that shape week to such informal care, and 80% of caregivers
people’s living arrangement decisions (Bianchi, had been providing care for more than a year
Hotz, McGarry, & Seltzer, 2008). The number and (Navaie-Walsier et al., 2001).
sex of children generally affect the likelihood that Despite the growth of home-health services and
an elderly person will live with relatives. The adult day-care centers, most long-term care con-
greater the number of children, the greater the sists of care provided informally, usually by spouses
chances that there will be a son or daughter who or younger relatives (Stone, 2000). Adult women,
can take care of an elderly parent. Daughters are in particular, are likely to have primary responsi-
more likely than sons to provide housing and care bility for home care of frail elderly persons, often
for an elderly parent, presumably as an extension including parents-in-law. Some evidence suggests
of the traditional female caretaker role and stronger that female caregivers experience greater levels of
norms of filial responsibility. Geographical distance stress than do male caregivers (Yee & Schulz,
from children is also a key factor; having children 2000). Research has shown that even relatively low-
who live nearby promotes co-residence when living cost interventions, such as support groups and tele-
independently is no longer feasible for the elderly phone counseling, to assist informal caregivers can
person (Haxton & Harknett, 2009; Silverstein greatly reduce the harmful effects of such stress on
et al., 2006). caregivers’ health (Belle & REACH II Investiga-
Older Americans with higher income and bet- tors, 2006).
ter health are more likely to live independently
(Klinenberg, 2012). In the United States, since
Living Arrangements of Young Adults
1940, growth in Social Security benefits ac-
counted for half of the increase in independent The young-adult years (ages 18–30) have been
living among elderly persons (McGarry & described as “demographically dense” because
Schoeni, 2000). By contrast, elderly Americans in these years involve many interrelated life-altering
financial need are more likely to live with rela- transitions (Rindfuss, 1991). Between these ages,
tives (Klinenberg, 2012). young people usually finish their formal schooling,
Social norms and personal preferences also leave home, develop careers, marry, and begin
determine the choice of living arrangements for families, but these events do not always occur in
elderly persons (Seltzer, Lau, & Bianchi, 2012; this order. Delayed marriage extends the period
Silverstein et al., 2006). Many elderly individuals during which young adults can experiment with
are willing to pay a substantial part of their in- alternative living arrangements before they adopt
comes to maintain their own residence, which sug- family roles. Young adults may experience any
gests strong personal preferences for privacy and number of independent living arrangements
independence (Klinenberg, 2012). Social norms before they marry, as they change jobs, pursue
involving family obligations and ties may be espe- education, and move into and out of intimate re-
cially important when examining racial and ethnic lationships. They may also return to their parents’
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Family Demography: Continuity and Change in North American Families 43

homes for periods of time, if money becomes tight necessary in today’s labor market, is expensive, and
or at the end of a relationship. living at home may be a way for families to curb
In 1890, half of American women had married higher education expenses. Even when young
by age 22, and half of American men had married adults attend school away from home, they still fre-
by age 26. The ages of entry into marriage dipped quently depend on their parents for financial help
to an all-time low during the post–World War II and may return home after graduation if they can-
baby-boom years, when the median age at first not find a suitable job.
marriage reached 20 years for women and 23 years The percentage of young men living in their
for men in 1956. Age at first marriage then began parents’ homes was 59% in 2011, about the same
to increase and reached 26 years for women and as in 1970, whereas the percentage increased for
28 years for men by 2009 (Kreider & Ellis, 2011b). young women from 39% to 50% (U.S. Census
In Canada, the average age at marriage increased Bureau, 2011i). In Canada, the proportion of
from 25 years in 1972 to 31 years in 2008 for men young adults who resided with their parents in-
and from 23 years to 29 years for women (Statistics creased dramatically from 28% in 1981 to 44% in
Canada, 2008). In 1960, it was unusual for a woman 2006 (Statistics Canada, 2007).
to reach age 25 without marrying; only 10% of Young adults who leave home to attend school,
women aged 25 to 29 had never married (Casper join the military, or take a job have always had, and
& Bianchi, 2002). In 2011, 50% of women aged continue to have, high rates of “returning to the
25 to 29 in the United States and 64% of men in nest” and have become known as “boomerang chil-
the same age group had never been married (U.S. dren.” Those who leave home to get married have
Census Bureau, 2011h). had the lowest likelihood of returning home,
This delay in marriage has shifted the family and although returns to the nest have increased over
living arrangement behaviors in young adulthood time even in this group.
in three important ways. First, later marriage coin- American parents often take in their children
cides with a greater diversity and fluidity in living after they return from the military or school, or
arrangements in young adulthood. Second, delay- when they are between jobs. In the past, however,
ing marriage has accompanied an increased likeli- many American parents apparently were reluctant
hood of entering a cohabitating union before to take children in if they had left home simply to
marriage. Third, the trend to later marriage affects gain “independence.” This is not true today. Before
childbearing; it tends to delay entry into parent- the 1970s, leaving home for simple independence
hood and, at the same time, increases the chances was probably the result of friction within the fam-
that a birth (sometimes planned but more often un- ily, whereas today, leaving and returning home
intended) occurs before marriage (Bianchi & seems to be a common part of a successful transi-
Casper, 2000). tion to adulthood (Klinenberg, 2012; Rosenfeld,
Many demographic, social, and economic fac- 2007). In the past, a young adult may have been
tors influence young adults’ decisions about where reluctant to move back in with parents because a
and with whom to live (Casper & Bianchi, 2002). return home implied failure; fewer stigmas are
Family and work transitions are influenced greatly attached to returning home these days (Casper &
by fluctuations in the economy, as well as by chang- Bianchi, 2002).
ing ideas about appropriate family life and roles for Changing demographic behaviors among young
men and women. Since the 1980s, the transition to adults and their living arrangements have implica-
adulthood has been hampered by recurring reces- tions for family health care nursing. In contrast to
sions, tight job markets, slow wage growth, and the situation in Canada, in the United States,
soaring housing costs, in addition to the confusion young adults often lack health insurance and, in
over roles and behavior sparked by the gender rev- many cases, are not financially independent, reduc-
olution. Even though young adults today may pre- ing the likelihood that they will receive routine
fer to live independently, they may not be able to checkups or seek medical care when the need arises
afford to do so (Rosenfeld, 2007). Many entry-level (Casper & Haaga, 2005). The increasing numbers
jobs today offer low wages, yet housing costs have of people showing up in emergency rooms and
soared, putting independent living out of reach for urgent care settings put additional pressure on the
many young adults. Higher education, increasingly health care providers, especially nurses. Also, the
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44 Foundations in Family Health Care Nursing

acuity level of the medical problems in these young control, economic changes, and increased individ-
adults is greater because they did not seek earlier ualism and secularization (Bianchi et al., 2012;
treatment. Cherlin, 2009). Youths reaching adulthood in the
past two decades are much more likely to have wit-
nessed their parents’ divorce than any generation
Unmarried Opposite-Sex Couples
before them. Some have argued that cohabitation
One of the most significant household changes allows a couple to experience the benefits of an
in the second half of the 20th century in North intimate relationship without committing to mar-
America was the increase in men and women living riage. If a cohabitating relationship is not success-
together without marrying. The increase of cohab- ful, one can simply move out; if a marriage is not
itation outside marriage appeared to counterbalance successful, one suffers through a sometimes
some of the delay of marriage among young adults lengthy and difficult divorce.
and the overall increase in divorce. Unmarried- Nevertheless, most adults in the United States
couple households made up less than 1% of U.S. eventually do marry. In 2011, 90% of women aged
households in 1960 and 1970 (Casper & Cohen, 50 to 54 had been married at least once (U.S. Census
2000). This share increased just over 2% by 1980, Bureau, 2011h). An estimated 88% of U.S. women
and to nearly 9% by 2011, representing 7.6 million born in the 1960s will eventually marry; however,
family groups (U.S. Census Bureau, 2011m). considerable differences exist by race/ethnicity
Unmarried-couple households also are increas- (Raley, 2000). For example, 88% of African
ingly likely to include children. In 1978, 24% of American women reaching adulthood in the 1960s
unmarried-couple households included children would eventually marry, compared with only 66%
younger than 15; by 2011, 40% of unmarried- coming of age in the 2000s. The meaning and per-
partner family groups included children. Although manence of marriage may be changing, however.
the percentage of U.S. households consisting of an Marriage used to be the primary demographic
unmarried couple is small, many Americans have event that marked the formation of new house-
lived with a partner outside marriage at some point. holds, the beginning of sexual relations, and the
Nearly 62% of the couples who married between birth of a child. Marriage also implied that an
1997 and 2002 had lived together before marriage, individual had one sexual partner, and it theoreti-
up from 49% in 1985 to 1986, and a big jump from cally identified the two individuals who would par-
just 8% of first marriages in the late 1960s (Bumpass ent any child born of the union. The increasing
& Lu, 2000; Kennedy & Bumpass, 2008). social acceptance of cohabitation outside marriage
In Canada, cohabitating couples are known as has meant that these linkages can no longer be
common-law couples. The 2001 Canadian Census assumed. Couples began to set up households that
showed that increasing proportions of families were might include the couple’s children, as well as chil-
headed by common-law couples, from 5.6% in 1981 dren from previous marriages or other relation-
to 13.8% in 2001. By 2011 this figure increased to ships (Casper & Bianchi, 2002). Similarly, what it
17% (Statistics Canada, 2012e). As in the United meant to be single was no longer always clear, as
States, more Canadian children are living with the personal lives of unmarried couples began to
common-law (cohabitating) parents. Nearly 44% of resemble those of their married counterparts.
common-law couples in 2011 have children under Cohabitating households can pose unique
age 24 residing with them. In 2011, about 910,700 challenges for health care providers, especially in
children aged 0 to 14 (16.3% of the total) lived the United States. Because cohabitating relation-
with common-law parents, up from 12.8% in 2001 ships are not legally sanctioned in most states,
(Statistics Canada, 2012e). In both countries, the partners may not have the right to make health
pace of the increase in cohabitation has slowed some- care decisions on behalf of each other or of the
what since the rapid rise in the 1970s and 1980s. other’s children (Casper & Haaga, 2005). Cohab-
Why has cohabitation increased so much? Re- itating couples report poorer health and have
searchers have offered several explanations, includ- lower incomes than do married couples, on aver-
ing increased uncertainty about the stability of age (Waite & Gallagher, 2000). Thus, although
marriage, the erosion of the stigma associated with they are more likely to need health care services,
cohabitation and sexual relations outside of they may be less likely to have the financial ability
marriage, the wider availability of reliable birth to secure them.
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Family Demography: Continuity and Change in North American Families 45

Same-Sex Couples two-parent common-law families, and 24% were

lone-parent (single-parent) families (authors’
The number of same-sex couples has increased sub- calculations from Statistics Canada, 2011c). In
stantially in North America over the past couple of 2011, 26% of American families were mother-
decades. A conservative estimate shows that the num- only families and only 4% were father-only fami-
ber of same-sex couples in the United States grew by lies. “Lone-parent families” in Canada increased
80% from 358,390 in 2000 to 646,464 in 2010 from 9% of all families (including those with
(Lofquist, Lugaila, O’Connell, & Feliz, 2012). In no children) in 1971 to about 16% in 2011, in-
Canada, the number of same-sex couples increased cluding 13% lone mothers and 3% lone fathers.
by 42.4% from 45,345 in 2006 to 64,575 in 2011, of The changes in marriage, cohabitation, and non-
which nearly a third were married couples (Statistics marital childbearing over the past few decades
Canada, 2012e). The vast majority of same-sex cou- have had a profound effect on North American
ples live in common-law or cohabitating relation- families with children and are changing our
ships. Before 2000, same-sex marriage was not legally images of parenthood.
recognized. In 2005, however, after the Netherlands This section discusses individuals’ and couples’
and Belgium, Canada became the third country to transitions into parenthood, beginning with cur-
legalize same-sex marriage. Following legalization, rent trends in fertility, the increased use of assisted
the number of same-sex married couples in Canada reproductive technologies (ARTs) to achieve par-
almost tripled from 7,465 in 2006 to 21,015 in 2011 enthood, and trends and patterns in adoption. As
(Statistics Canada, 2012e). In the United States, fed- individuals become parents, different types of fam-
eral law provides each state with autonomy to grant ily forms emerge. The section explores single
marriage recognition and legal rights to same-sex motherhood, fathering, and child rearing within
couples. In 2004, Massachusetts became the first state cohabitation and same-sex couple families. The
to legalize same-sex marriage; since then, a number section concludes with a discussion of the impor-
of states and jurisdictions have followed suit. Never- tant role grandparents are playing in rearing and
theless, same-sex marriage is still not legally caring for grandchildren.
recognized in most states.
Although the division of labor for parenting and
household chores in same-sex families tends to be Fertility
more egalitarian than among opposite-sex couples, In the United States and Canada, fertility has ex-
same-sex couples are not as “genderless” as has hibited a trend of long-term decline for more than
been previously suggested. This equality often a century, interrupted by the baby-boom period
changes as couples transition to parenthood, when and other small fluctuations. In recent decades, fer-
one of the partners usually becomes more involved tility rates in most developed countries have fallen
in child rearing, assumes more responsibility for below the level required to replace the population.
housework, and often becomes the partner in Replacement-level fertility refers to the required
charge of caring for the health of the children and number of children each woman in the population
seeking health services for them. would have to bear on average to replace herself
and her partner, and it is conventionally set at 2.1
children per woman for countries with low mortal-
PARENTING ity rates. This threshold is set slightly above 2 in
order to account for a negligible rate of childhood
Even with the increase in divorce and cohabita- mortality and a small proportion of individuals who
tion, postponement of marriage, and decline in do not survive to their reproductive age (Preston,
childbearing, most North American adults have Heuveline, & Guillot, 2001).
children, and most children live with two parents. The U.S. fertility decline has not been very dras-
In 2011, 64% of families with children were two- tic; thus, the United States is an atypical case
parent, married families and an additional 5% among developed countries. Figure 2-1 shows the
were two-parent, unmarried families (U.S. Census trends in fertility rates since the 1930s for the
Bureau, 2011a). In Canada, in 2011, the level was United States and Canada, respectively. As this
comparable: 62% of Canadian families with chil- graph shows, both countries experienced a post-
dren were married two-parent families, 14% were WWII baby boom during the 1950s and 1960s,
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46 Foundations in Family Health Care Nursing

Total Fertility Rate for the U.S. and Canada: The causes behind the secular trends in fertility
1930–2010 decline can be grouped into socioeconomic, ideolog-
4.5 ical, and institutional factors. Among socioeconomic
4.0 factors are the increase in women’s opportunity
3.5 costs and the rising cost of rearing children. The
3.0 socioeconomic position of women has drastically
2.5 changed since the 1960s. Economic changes have
2.0 also made it more difficult to maintain a family on
1.5 the income of a single earner. Women’s education
1.0 and labor force participation increased considerably
0.5 during this period. In addition, changes in laws and
0.0 civil rights have reduced discriminatory practices
1930 1940 1950 1960 1970 1980 1990 2000 2010 against women. All of these changes have resulted in
FIGURE 2-1 Total fertility rate for the United States increases in women’s wages, although they have not
and Canada: 1930–2010. (Data from Martin et al., 2012; yet reached parity with men’s. As women’s incomes
Statistics Canada, 2011d.)
and career opportunities have improved, women’s
opportunity costs of not participating in the labor
market have increased, thus reducing women’s fer-
after which fertility began to decline again. Since tility intentions. At the same time, higher educational
the 1980s, the United States has exhibited fertility expectations for children and rising living standards
rates close to replacement level. In 2010, the total have substantially increased the costs of raising chil-
U.S. fertility rate was 1.93 children per woman dren (Lino, 2012).
(Martin et al., 2012). In Canada, however, the fer- Cultural and ideological changes, such as the
tility decline has been of greater magnitude; in growth in individualism and the desire for self-
2010, the fertility rate was 1.63 (Statistics Canada, realization, have decreased the appeal of long-term
2012a). Persistent levels of below replacement fer- commitments, including childbearing (Bianchi
tility have raised concerns regarding population et al., 2012; Cherlin, 2009). The accentuation of
shrinkage. Fewer births also imply a subsequent individual autonomy and the rise of feminism have
contraction of the working-age population that, increased the desirability for more symmetrical
coupled with increases in life expectancy, reduces gender roles. However, institutions dealing with
the tax base that supports health care and retire- family life still exhibit high levels of gender in-
ment benefits for the aging population (Lee, 2003). equality. Equal opportunities for women in educa-
In the United States and Canada, a significant pro- tion and employment are often curtailed within
portion of population growth during recent families as women continue to pay a penalty for
decades has come from immigration. having children in the form of reduced career in-
Fertility varies by demographic characteristics. volvement and income prospects. This asymmetry
In the United States, except for Asians, immigrants accentuates the incompatibility of childbearing and
tend to exhibit higher fertility rates than the native- labor force participation (McDonald, 2000).
born population. In 2010, native-born women had In addition, in the 1960s more effective birth con-
on average 1.8 children, whereas foreign-born trol methods became available, providing couples
women had 2.2 children (U.S. Census Bureau, with better means to control their fertility. More-
2010d). Fertility also varies by race and ethnicity. over, favorable attitudes toward nonmarital sex and
In 2010 in the United States, fertility was the high- cohabitation have also weakened the link between
est among Hispanic women (2.3), followed by sex, marriage, and childbearing (Casper & Bianchi,
African Americans (2.0), and the lowest rate was 2002). Thus, most developed countries have experi-
observed among white and Asian women (1.80) enced a considerable rise in nonmarital births to sin-
(U.S. Census Bureau, 2010d). The differences are gle and cohabitating mothers. In 2010, 41% of all
greater by educational level. Women with less than births in the United States were to unmarried
a high school education had on average 2.56 births, women, of which 58% were to cohabitating women
whereas women with a graduate or professional de- (Martin et al., 2012). In Canada, births to unmarried
gree had only 1.67 births (U.S. Census Bureau, women have also increased, representing 27.3% of
2010d). all births in 2007 (U.S. Census Bureau, 2012).
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Family Demography: Continuity and Change in North American Families 47

The birth rate for teenagers has decreased sub- 1992 Fertility Clinic Success Rate and Certification
stantially in both countries, although in the United Act. According to this definition, ARTs include
States this rate is more than twice that observed in all fertility treatments in which both eggs and
Canada. In Canada in 2008, only 4% of all births sperm are handled. In general, ART procedures in-
were to women ages 15 to 19, compared with 9% volve surgically removing eggs from a woman’s
in the United States in 2010. The birth rate for ovaries, combining them with sperm in the labora-
teenagers in Canada was 14.3 births per 1,000 tory, and returning them to the woman’s body or
women in 2008, down from 26.1 in 1981 (Milan, donating them to another woman. According to
2011). The U.S. teenage birth rate for women ages this definition, treatments in which only sperm are
15 to 19 was 34.3 births per 1,000 women in 2010, handled are not included (i.e., intrauterine—or
down from 52.2 in 1981 (Martin et al., 2012). The artificial—insemination), nor are procedures in
United States still exhibits one of the highest rates which a woman takes medications only to stimulate
of teenage pregnancy in the industrialized world. egg production without the intention of having
Nonetheless, women increasingly have been eggs retrieved (U.S. Centers for Disease Control
delaying childbearing since the 1960s; thus, the av- and Prevention, 2012).
erage age at first birth has risen in both countries. ARTs have been used in the United States since
In 2010, the average age at first birth in the United 1981 to help women become pregnant, most com-
States was 25.4 (Martin et al., 2012). In 2008 in monly through the transfer of fertilized human
Canada, the average age at first birth was 28.1, up eggs into a woman’s uterus (in vitro fertilization).
from 23.5 in the mid-1960s (Milan, 2011). How- Deciding whether to undergo this expensive and
ever, the onset of fertility varies by race/ethnicity time-consuming treatment can be difficult. World-
in the United States. Whereas the average age at wide, an estimated 9% of couples meet the defini-
first birth for African American and Hispanic tion of infertility, with 50% to 60% of them
women was slightly above 23 years in 2010, for seeking care (Boivin, Bunting, Collins, & Nygren,
white women it was 26.3. Asian and Pacific Is- 2007). In the United States, approximately 7% of
landers exhibited the highest average age at first married couples reported at least 12 months of un-
birth at 29.1 (Martin et al., 2012). Thus, childbear- protected intercourse without conception, while
ing for middle-class whites and Asians is increas- 2% of women reported having visited an infertility-
ingly becoming concentrated in the late twenties related clinic within the past year (Chandra,
and early thirties. Martinez, Mosher, Abma, & Jones, 2005). In
Overall, these trends imply not only that Canada, the estimated percentage of couples expe-
women are having fewer children, but also that riencing infertility in 2010 ranged from 11.5% to
they are increasingly having children at older 15.7%, depending on the definition of infertility
ages. Nurses are more likely to encounter more used. Infertility treatment costs sum up to well over
educated and mature mothers and pregnant three billion dollars annually in the United States
women. However, as women wait longer to have (Myers et al., 2008). As women wait longer to have
their first child, complications in pregnancies and their first child, the likelihood of age-related infer-
deliveries will become more common. Moreover, tility increases. Although there is some controversy
age-related infertility will be more likely to affect about whether the proportion of the population
these women, increasing the rate of involuntary with self-reported infertility is increasing, stable, or
infertility. As delays in fertility continue, a larger decreasing, there has been a clear increase in the
pool of women approaching the end of their use of ARTs (Stephen & Chandra, 2006; Sunderam
reproductive years will seek the services of as- et al., 2012).
sisted reproductive technology. The number of in vitro fertilization (IVF) cycles
performed in the United States increased from ap-
Assisted Reproductive proximately 30,000 in 1996 (Myers et al., 2008) to
over 147,000 in 2010, resulting in 47,090 live births
Technologies (ARTs) (deliveries of one or more living infants) and 61,564
Although various definitions have been used for infants (U.S. Centers for Disease Control and Pre-
assisted reproductive technologies (ARTs), the cur- vention, 2012). Over this time, the proportion of
rent definition used by the U.S. Centers for Dis- deliveries in the United States resulting from ARTs
ease Control and Prevention (CDC) is based on the has increased from 0.37% in 1996 to 0.94% in
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48 Foundations in Family Health Care Nursing

2005. In 2009, ARTs accounted for 1.4% of U.S. Although data on psychological outcomes of
births (Sunderam et al., 2012). In Canada 3,428 ba- women who become pregnant after infertility treat-
bies were born through ARTs in 2007 (Assisted ment are quite limited, the available data suggest
Human Reproduction Canada, 2011). ARTs often that women have outcomes as good as, and perhaps
result in multiple births, such as twins, triplets, and better than, women who get pregnant from spon-
so on, which increases health risks for children and taneous conception. Based on the available litera-
mothers. In the United States and Canada, nearly ture, there are no differences in parenting skills
30% of all ART births result in multiple births. when comparing singleton pregnancies resulting
Due to high costs and increased health risks, the from ART to spontaneous conceptions (Myers
Assisted Human Reproduction Canada (AHRC) et al., 2008). In fact, mothers of infants resulting
agency has set as a goal to reduce the rate of mul- from ART appear to have better outcomes. By con-
tiple births resulting from ARTs (AHRC, 2011). trast, there is some evidence that fathers may do
A growing number of same-sex couples seeking worse on some scales. The multiple gestations and
to become parents are also turning to ARTs to preterm births that frequently result with ART
achieve this goal: in the case of lesbians, usually significantly increase stress and depressive symp-
through the use of a sperm donor and artificial in- toms, especially for mothers of infants with chronic
semination; and in the case of gay men, through the disabilities.
use of an egg donor and/or a surrogate. It is worth Births resulting from ART are more likely to in-
noting that male same-sex couples face greater volve multiple births, pregnancy complications,
challenges than female same-sex couples to become preterm delivery, and low birth weight, all of which
parents, not only because fertility centers are less may pose substantial risks to the health of mothers
likely to accept male gay patients, but also because and infants. Additionally, children born as a result
the procedure is more expensive as it involves ob- of ART experience relatively worse neurodevelop-
taining both an oocyte donor and a gestational sur- mental outcomes, higher rates of hospitalization,
rogate, that is, a woman who will carry the zygote and more surgeries than other children. There is
and take the pregnancy to term (Greenfeld, 2007). little evidence, however, that the relatively worse
outcomes for ART babies are a direct result of in-
fertility treatments; infertility treatments are more
likely to be used by couples with a history of
subfertility—difficulty achieving and sustaining
pregnancy without medical assistance—and worse
outcomes typically result for the children of these
couples, irrespective of whether they have received
infertility treatments (Myers et al., 2008).
In sum, family nurses will likely encounter a
growing number of opposite-sex couples seeking
infertility treatment, as well as same-sex couples
who wish to become parents. This process is time
consuming, expensive, and stressful for all of the
parties involved. Unsuccessful attempts to become
pregnant are likely to be met with sorrow, anger,
and regret. Nurses should be aware of the delicate
circumstances surrounding this type of care. They
should also be aware of the heightened risk of mul-
tiple births, potential birth defects, and increased
women’s health risks.

Accurate trends on adoption in the United States
are difficult to obtain, but U.S. Census Bureau data
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Family Demography: Continuity and Change in North American Families 49

indicate that the number of adopted children 69% were adopted by someone who was previously
increased in the 1990s from about 1.6 million in their foster parent (Vandivere et al., 2009). Because
1991 to 2.1 million in 2004 and then decreased to these children were removed from their homes due
1.4 million in 2009 (Kreider & Ellis, 2011a). Other to abuse or neglect, they are more likely than other
data show that in 2007 there were approximately children, and even than those adopted through dif-
1.7 million adopted children living in the United ferent means, to have special health care needs—in
States (Vandivere, Malm, & Radel, 2009). Box 2-2 2007 54% had special needs.
illustrates the three primary forms of adoption in In 2007, about 677,000 or 38% of adopted chil-
the United States: foster care adoption, private dren were adopted privately from sources other
domestic adoption, and international adoption. than foster care. Of these, 41% were adopted by
According to the U.S. Administration for Chil- relatives and 44% were adopted by someone who
dren and Families, the number of adoptions from knew them before the adoption (including rela-
foster care has ranged from 50,000 to 57,000 an- tives). Almost one-third of these children have spe-
nually between 2002 and 2011, with some fluctua- cial health care needs. The majority of children
tions and no clear trend (U.S. Department of adopted privately in the United States were placed
Health and Human Services, 2011). In 2007, with their adoptive family as newborns or when
661,000 children were adopted from foster care, they were younger than 1 month old (62%).
representing 37% of all adopted children. Of foster International adoptions increased from about
care–adopted children, 23% were adopted by rela- 15,700 in 1999 to about 23,000 children in 2004.
tives, 40% were adopted by someone who knew Since 2004, they have been steadily decreasing to
them before the adoption (including relatives), and 9,300 in 2011 due to stricter laws and regulations

BOX 2-2
Three Primary Forms of Adoption in the United States

Foster Care Adoption children and to ensure that placements made are in the
Children adopted from foster care are those who were best interests of children. For adoptions from countries
removed from their families due to their families’ inability not part of the Hague Convention, U.S. law dictates that
or unwillingness to provide appropriate care and were children have to be orphans in order to immigrate into
placed under the protection of the state by the child the United States. The Hague Convention seems to have
protective services system. Public child welfare agencies contributed to the decrease in international adoptions.
oversee such adoptions, although they sometimes For example, in 2007 24% of all international adoptions
contract with private adoption agencies to perform of children under age 18 were from Guatemala, but in
some adoption functions. March 2008, the U.S. Department of State announced
that it would not process Guatemalan adoptions until fur-
Private Domestic Adoption
ther notice, due to concerns about the country’s ability to
These children were adopted privately from within the adhere to the guidelines of the Hague Convention. Addi-
United States and were not part of the foster care system tionally, in 2008, Guatemala stopped accepting any new
at any time before their adoption. Such adoptions may adoption cases (U.S. Department of State, 2011).
be arranged independently or through private adoption Other countries have also implemented stricter regula-
agencies. tions for international adoptions. For example, as of May
International Adoption 2007, China enacted a rigorous policy requiring adoptive
This group includes children who originated from coun- parents be married couples between the ages of 30 and
tries other than the United States. Typically, adoptive 50 with assets of at least $80,000 and in good health
parents work with private U.S. adoption agencies, which (including not being overweight). In November 2012 a
coordinate with adoption agencies and other entities in bilateral adoption agreement between the United States
children’s countries of origin. Changes in international and Russia increased safeguards for and monitoring of
adoption laws have made it more difficult to adopt Russian children adopted by U.S. parents (U.S. Department
children from abroad. Starting in 2008, the Hague of State, 2011). In addition, China and other countries,
Convention on Protection of Children and Co-operation such as Russia and Korea, are attempting to promote
in Respect of Intercountry Adoption has been regulating domestic rather than international adoption (Lee, 2007;
adoptions from several countries. Its purpose is to protect Voice of Russia World Service in English, 2007).
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50 Foundations in Family Health Care Nursing

(U.S. Department of State, 2011). Internationally one or both adoptive parents are of a different race,
adopted children make up the smallest group, num- culture, or ethnicity than their child. The majority
bering about 444,000 or 25% of all adopted chil- of adopted children have non-Hispanic white par-
dren. Of these adopted children, 29% have special ents but are not themselves non-Hispanic white.
health care needs. More than 7 in 10 adopted chil- Transracial adoptions are most common for chil-
dren in 2011 came from just five countries—China dren whose families adopted internationally. Over-
(28%), Ethiopia (19%), Russia (10%), South Korea all, about half of adopted children are male
(8%), and the Ukraine (7%). In Canada, interna- (49%)—33% of internationally adopted children
tional adoptions have also slightly decreased from are male, while 57% of children adopted from fos-
an average of 2,000 adoptions per year during the ter care are male (Vandivere et al., 2009). Adopted
1990s and early 2000s. In 2010, 1,946 children were children are less likely than biological children in
adopted from abroad. In the same year, nearly 6 in the general population to live in households below
10 international adoptions to Canada came from the poverty line (12% compared with 18%). How-
China (24%), Haiti (9%), the United States (8%), ever, nearly half of children adopted from foster
Vietnam (7%), Ethiopia (6%), and Russia (5%) care (46%) live in households with incomes no
(Hilborn, 2011). higher than two times the poverty threshold. Over
Since 2008, the Hague Convention on Protec- two-thirds of adopted children (69%) live with two
tion of Children and Co-operation in Respect of married parents; they are just as likely to do so
Intercountry Adoption has been regulating adop- as children in the general population (Vandivere
tions from approximately 75 countries. The stricter et al., 2009).
law adopted by the Hague Convention has proba- The majority of adoptive children engage in en-
bly contributed to the decline in international richment activities with their families, and in fact
adoption (see Box 2-2). In the past several years, they are more likely to have some of these positive
many countries have changed their adoption re- experiences than all children in the population
quirements, thus making it harder to adopt. All (Vandivere et al., 2009). As youngsters, adopted
of these legal changes have reduced the number of children are more likely than all children to be read
international adoptions in the United States. to every day (68% compared with 48%), to be sung
Social and demographic changes coupled with to or told stories every day (73% compared with
changing laws have altered the context of adoption. 59%), and to participate in extracurricular activities
Recent developments in reproductive medicine, as school-age children (85% compared with 81%).
such as intrauterine insemination and in vitro fer- A small percentage of adopted children have par-
tilization, seem to have contributed to the decline ents who report parental aggravation (for example,
in adoption in recent years by reducing the demand feeling the child was difficult to care for, or feeling
for adoption. At the same time, never-married angry with the child). Parental aggravation is more
mothers have become less likely to put their infants common among parents of adopted children than
up for adoption—in 1973, 9% of births were placed among all parents (11% compared with 6%).
for adoption compared to just 1% in the 1990s and This socioeconomic and demographic portrait
2000s, reducing the supply of infants for domestic of adopted children has implications for family
adoptions (Jones, 2008). nursing. First, although most adoptive children
According to a recent study conducted at the fare well with regard to health, educational
U.S. Department of Health and Human Services, achievement, and social and cognitive develop-
overall, 87% of adopted children have parents who ment, those who are adopted through foster care
said they would “definitely” make the same deci- are disproportionately disadvantaged. Second, be-
sion to adopt their child, knowing everything then cause most parents of adopted children do not
that they now know about their child. More than share with them their genetic endowment and be-
90% of adopted children ages 5 and older have par- cause the medical histories of the biological par-
ents who perceived their child’s adoption experi- ents are often unknown, diagnosis for these
ence as “positive” or “mostly positive” (Vandivere children can be more challenging than for biolog-
et al., 2009). ical children. Third, the substantial proportion of
According to this study, overall, 40% of the transracial adoptive families requires special atten-
adopted children are in transracial adoptions; either tion. For decades, adoptive parents who were of a
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Family Demography: Continuity and Change in North American Families 51

different race than their child were taught to be average annual rate of increase slowed considerably
color blind regarding their adoptive children and during the 1980s and was near 0% after 1994 (Casper
to raise them according to the culture of the par- & Bianchi, 2002). By 2011, single mothers who
ent. More recently, adoption social workers have maintained their own households accounted for 25%
encouraged adoptive parents to embrace the of all families with children, up from 6% in 1950
child’s culture of origin and to help their children (U.S. Census Bureau, 2011c). Almost 1.4 million
develop positive racial and ethnic identities. As more single mothers lived in someone else’s house-
most of these parents are white, however, they may hold, bringing the total number of single mothers to
be unaware of the nuances of the culture the child over 10 million (U.S. Census Bureau, 2011c). In
is coming from and may not have the capacity to 2011 in Canada, there were 1.2 million lone mothers
teach their children how to deal with bias and dis- and 328,000 lone fathers with children of any age liv-
crimination (Shiao, Tuan, & Rienzi, 2004). Nurses ing with them (Statistics Canada, 2012e).
should be sensitive to these differences and help Single mothers with children at home face a
guide the parents in understanding how to help multitude of challenges. They usually are the pri-
their children. mary breadwinners, disciplinarians, playmates, and
Finally, unlike biological families, many adoptive caregivers for their children. They must manage
families emerge out of loss for all members—for the financial and practical aspects of a household
example, foster parents who are not able to have bi- and plan for the family’s future. Many mothers
ological children; biological parents who are relin- cope remarkably well, and many benefit from
quishing their children; and adoptive children who financial support and help from relatives and from
are losing or have lost their biological parents. This their children’s fathers.
unique family form requires an adjustment period Women earn less than men, on average, and be-
for all of those involved. Separations of adoptive cause single mothers are usually younger and less
children from biological parents at birth deprive educated than other women, they are often at the
children of the bioregulatory channels that exist be- lower end of the income curve. Never-married sin-
tween a mother and her baby—from breathing, to gle mothers are particularly disadvantaged; they are
respiration, to heart rate and blood pressure. Tak- younger, less well educated, and less often em-
ing away a baby at birth cuts off this regulation and ployed than are divorced single mothers and mar-
may cause children to cry more often, become ried mothers. Single mothers often must curtail
angry or confused, or behave badly simply because their work hours to care for the health and well-
they do not understand the separation (Verrier, being of their children.
1993). Nurses should be aware that unusual behav- Despite the fact that the majority of American
iors such as these among adoptive children may not single mothers are not poor, they are much more
stem from illness or health-related causes. likely to be poor than other parents. Single-parent
families are officially defined as poor if they have
incomes under the poverty line, which for a single
Single Mothers
mother with two children translates into an annual
How many single mothers are there? This turns income of less than $18,123 in 2011. Overall, 20%
out to be a more difficult question to answer from of U.S. children lived in poverty in 2009. Children
official statistics than it would first appear. Over in two-parent families had the lowest rate at 13.3%,
time, it is easiest to calculate the number of single followed by children living in father-only families
mothers who maintain their own residence. In the at 19.9%. Children in mother-only families had the
United States between 1950 and 2011, the number highest poverty rate at 38.1%. Poverty and family
of such single-mother families increased from structure are highly correlated with race in the
1.3 million to 8.7 million (U.S. Census Bureau, United States. Children in black and Hispanic
2011c). These estimates do not include single single-mother families exhibit the highest poverty
mothers living in other persons’ households but do rate at about 45% compared with white children in
include single mothers who are cohabitating with two-parent families, who have the lowest rate at
a male partner. The most dramatic increase was 8.6% (Kreider & Ellis, 2011a).
during the 1970s, when the number of single- The family income of children who reside with a
mother families was increasing at 8% per year. The never-married single mother is less than one-fourth
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52 Foundations in Family Health Care Nursing

that of children in two-parent families (Bianchi & Why have mother-child families increased in
Casper, 2000). Almost three of every five children number and as a percentage of North American
who live with a never-married mother are poor. families? Explanations tend to focus on one of two
Mothers who never married are much less likely to trends. First is women’s increased financial inde-
get child support from the father than are mothers pendence. More women entered the labor force and
who are divorced or separated. Whereas 43% of di- women’s incomes increased relative to those of men,
vorced mothers with custody of children younger and welfare benefits for single mothers expanded
than 21 received some child support from the chil- during the 1960s and 1970s. Women today are less
dren’s father, fewer than 25% of never-married dependent on a man’s income to support themselves
mothers reported receiving regular support from and their children, and many can afford to live in-
their child’s father (U.S. Census Bureau, 2010c). dependently rather than stay in an unsatisfactory
Children who live with a divorced mother tend relationship. Second, the job market for men has
to be much better off financially than are children tightened, especially for less-educated men. As the
of never-married mothers. Divorced mothers are North American economy experienced a restructur-
substantially better educated and more often em- ing in the 1970s and 1980s, the demand for profes-
ployed than are mothers who are separated or who sionals, managers, and other white-collar workers
never married. Even so, the average incomes of expanded, whereas wages for men in lower-skilled
families headed by divorced mothers is less than jobs declined in real terms (Casper & Bianchi, 2002).
half that of two-parent families. Over the past two decades, this pattern has contin-
In 2010, three million Canadians lived in low ued due to technological advances and outsourcing
income and about 546,000 or 8.1% of children displacing manufacturing and other lower-skilled
younger than 18 lived in low-income families jobs (Bianchi et al., 2012). Men still earn more than
(Statistics Canada, 2012c). Canadian lone-parent women, on average, but the earnings gap narrowed
families with children younger than 18 are much steadily between the 1970s and 2000 as women’s
more likely to have low incomes, and thus, more earnings increased and men’s earnings remained flat
likely to be poor (First Call: BC Child and Youth or declined. In the past decade, the gender-earnings
Advocacy Coalition, 2011). Among children living gap has been relatively constant because both men’s
in female lone-parent families, 187,000, or 21.8%, and women’s average earnings have stagnated.
were low income, whereas the incidence of low In 2011 in the United States, full-time, year-round
income was 5.7% among children living in two- female workers earned 77 cents for every dollar
parent families (Statistics Canada, 2012c). earned by full-time, year-round male workers
In the United States, single mothers with children (DeNavas-Walt, Proctor, & Smith, 2012).
in poverty are particularly affected by major welfare In the early years of the 20th century, higher mor-
reform legislation, such as the Personal Responsibil- tality rates made it more common for children to live
ity and Work Opportunity Reconciliation Act with only one parent (Uhlenberg, 1996). As declining
(PRWORA) (Box 2-3). President Clinton claimed in death rates reduced the number of widowed single
his 1993 State of the Union Address that the 1996 parents, a counterbalancing increase in single-parent
law would “end welfare as we know it,” and the families occurred because of divorce. For example, at
changes embodied in PRWORA—time limits on the time of the 1960 Census, almost one-third of
welfare eligibility and mandatory job-training re- American single mothers living with children
quirements, for example—seemed far-reaching younger than 18 were widows (Bianchi, 1995). As di-
(Hays, 2003). Some argued that this legislation would vorce rates increased precipitously in the 1960s and
end crucial support for poor mothers and their chil- 1970s, most single-parent families were created
dren; several high-level government officials resigned through divorce or separation. Thus, at the end of
because of the law. Others heralded PRWORA as the 1970s, only 11% of American single mothers
the first step toward helping poor women gain con- were widowed and two-thirds were divorced or sep-
trol of their lives and making fathers take responsi- arated. In 1978, about one-fifth of single American
bility for their children. Many states had already mothers had never married but had a child and were
begun to experiment with similar reforms. The suc- raising that child on their own (Bianchi & Casper,
cess of this program is open to dispute because it has 2000). By 2011, 46.5% of single mothers had never
been and continues to be such a political issue. married (U.S. Census Bureau, 2011k).
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Family Demography: Continuity and Change in North American Families 53

BOX 2-3
Welfare Reform in the United States

Federal and state programs in the United States to aid Bureau estimated that in 2011 about 1 of every 10 chil-
low-income families have been transformed during the dren in the United States was not covered by any health
past two decades. The 1996 PRWORA was the legislative insurance (and one in five adults between ages 18 and
milestone at the federal level. 64 were uninsured) (DeNavas-Walt et al., 2012).
■ PRWORA replaced the Aid to Families With Dependent In 1996, Congress also made the following state-
Children program, an entitlement for poor families, with ments: (1) Marriage is the foundation of a successful
a program of block grants to the states called Temporary society. (2) Marriage is an essential institution of a suc-
Assistance to Needy Families (TANF). cessful society which promotes the interests of children.
■ It requires states to impose work requirements on at
To support healthy marriage, in conjunction with TANF,
least 80% of TANF recipients. the Deficit Reduction Act of 2005 was implemented pro-
■ It forbids payments to single mothers younger than 18
viding $150 million per year of funding to support healthy
unless they live with an adult or in an adult-supervised marriage and responsible fatherhood promotion. The goal
situation. of the Healthy Marriage Initiative (HMI) is to help couples,
■ It set limits of 60 months on TANF for any individual
“who have chosen marriage for themselves, gain greater
recipient (and 22 states have used their option to access to marriage education services, on a voluntary
impose shorter lifetime limits). basis, where they can acquire the skills and knowledge
■ It gives states more latitude to let TANF recipients earn
necessary to form and sustain a healthy marriage”
money or get child support payments without reduction (U.S. Department of Health and Human Services, 2012).
of benefits and to use block grants for child care. Key requirements of the law specify that HMI funds
may be used for competitive research and demonstra-
Welfare-reform proponents often supported efforts to tion projects to test promising approaches to encourage
“make work pay,” as well as to discourage long-term de- healthy marriages and promote involved, committed,
pendence on welfare. The Earned Income Tax Credit, for and responsible fatherhood by public and private entities
example, was expanded several times during the 1980s and also for providing technical assistance to states and
and 1990s and now provides twice as much money tribes:
to low-income families, whether single- or two-parent
families. Funding for child care was also expanded during ■ Applicants for funds must commit to consult with
the decade, though child care remains a problem for experts in domestic violence; applications must describe
low-income working families in most places. how programs will address issues of domestic violence
PRWORA accelerated a decline in welfare caseloads and ensure that participation is voluntary.
■ Healthy marriage promotion awards must be used for
throughout the country. Because of a concern that former
welfare recipients entering the workforce would lose in- eight specified activities, including marriage education,
surance coverage through Medicaid for their children, the marriage skills training, public advertising campaigns,
1997 Balanced Budget Act set up the new State Child high school education on the value of marriage, and
Health Insurance Program (SCHIP), providing federal marriage mentoring programs.
money to states in proportion to their low-income Not more than $50 million each year may be used
population and recent success in reducing the proportion for activities promoting fatherhood, such as counseling,
of uninsured children. mentoring, marriage education, enhancing relationship
Lack of health insurance remains an important concern skills, parenting, and activities to foster economic stability
for children in the United States, however. The Census (U.S. Department of Health and Human Services, 2012).

The remarkable increase in the number of single- births—the number of births per 1,000 unmarried
mother households with women who have never women—increased from 7.1 in 1940 to 47.6 in
married was driven by a dramatic shift to childbear- 2010. The nonmarital birth rate peaked in 1994 at
ing outside marriage. The number of births to 46.2, leveled out in the latter 1990s, and has in-
unmarried women grew from less than 90,000 creased slightly since the mid-2000s (Bianchi &
per year in 1940 to nearly 1.6 million per year in Casper, 2000; Martin et al., 2012). Births to unmar-
2010 (Martin et al., 2012). Less than 4% of all ried women have increased in Canada as well, from
births in 1940 were to unmarried mothers com- 12.8% in 1980 to 27.3% of all births in 2007 (U.S.
pared with 41% in 2010. The rate of nonmarital Census Bureau, 2012).
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54 Foundations in Family Health Care Nursing

The proportion of births that occur outside mar- responsible for and involved in all aspects of his
riage is even higher in some European countries children’s care. The ideal has been widely accepted
than in the United States and Canada. But unmar- throughout North American society; people today,
ried parents in European countries and Canada are as opposed to those in earlier times, believe that
more likely to be living together with their biolog- fathers should be highly involved in caregiving
ical children than are unmarried parents in the (Hernandez & Brandon, 2002). In the U.S. and
United States (Heuveline, Timberlake, & Fursten- Canada, although mothers still spend nearly twice
berg, 2003). In the United States, the tremendous as much time caring for children than fathers do,
variation in rates of unmarried childbearing among fathers are spending more time with their children
population groups suggests that there may be a con- and are doing more housework than in earlier
stellation of factors that determine whether women decades. In 1998, married fathers in the United
have children when they are not married. In 2010, States reported spending an average of 4 hours per
the percentage of births to unmarried mothers was day with their children, compared with 2.7 hours
the highest for blacks at 73%, followed by Native in 1965 (Bianchi, 2000). In 2010, in Canada, fathers
Americans (66%), Hispanics (53%), and white non- spent on average 24.4 hours per week (3.5 hours
Hispanics (29%). Asian and Pacific Islanders re- per day) taking care of children (Statistics Canada,
ported the lowest percentage at 17% (Martin et al., 2012f). These estimates vary by employment status
2012, Tables 13 and 14). Overall, 25% of all family of both parents and by the children’s age. Fathers
groups with children under 18 are maintained by spend more time caring for children when mothers
single mothers. The percentage of mother-only are employed and when children are young.
family groups is much higher for African American At the same time, other trends increasingly re-
families (52%) than for Hispanic (28%), white move fathers from their children’s lives. When the
non-Hispanic (19%), and Asian (12%) families mother and father are not married, for example, ties
(U.S. Census Bureau, 2011m). between fathers and their children often falter. Fa-
Single-mother families present challenges for thers’ involvement with children differs by marital
family health care nurses providing care to this vul- status and living arrangements. Among fathers re-
nerable group. Single mothers today are younger and siding with their children, biological married
less educated than they were a few decades ago. This fathers spend more time with their children, fol-
presents problems because these mothers have less lowed by fathers in cohabitating relationships. Step-
experience with the health care system and are likely fathers exhibit the lowest level of involvement
to have more difficulty reading directions, filling out among all resident fathers. Nonresidential fathers
forms, communicating effectively with doctors and exhibit the lowest involvement in child rearing.
nurses, and understanding their care instructions. In They also provide less financial support to their
the U.S., these mothers are also more likely to be children (Hofferth, Pleck, Stueve, Bianchi, & Sayer,
poor and uninsured, making it less likely they will 2002). Family demographer Frank Furstenberg
seek care and more likely they will not be able to pay (1998) used the label “good dads, bad dads” to de-
for it. Consequently, when the need arises, these scribe the parallel trends of increased commitment
women are more likely to resort to emergency rooms to children and child rearing on the part of some
for noncritical illnesses and injuries. Time is also in fathers at the same time that there seems to be less
short supply for single mothers. With the advent of connection to and responsibility for children on the
welfare reform in the United States, more of them are part of other fathers.
working, which conceivably reduces the time they Fathers’ involvement is associated with improved
used in the past to care for themselves and their chil- child well-being, including better cognitive devel-
dren (see Box 2-3). Moreover, although many of these opment, fewer behavioral problems, and better emo-
mothers can rely on their families for help, they are tional health. However, fathers’ involvement and
apt to have tenuous ties with their children’s fathers. child support significantly decrease when parents
separate, especially if the father or mother forms a
new family or if the custodial mother poses obstacles
for a father’s contact with his children (Carlson &
A new view of fatherhood emerged out of the fem- McLanahan, 2010). As a result, union disruption not
inist movement of the late 1960s and early 1970s. only hurts children’s cognitive and emotional well-
The new ideal father was a co-parent who was being, but also reduces children’s contact with
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Family Demography: Continuity and Change in North American Families 55

fathers, decreasing the parental and financial re- acceptance of cohabitation as a substitute for mar-
sources available to children (Amato & Dorius, riage, for example, may reduce the chance that a
2010). Nonetheless, when fathers re-partner and ac- premarital pregnancy will lead to marriage before
quire stepchildren, they usually assume new respon- the birth (Casper & Bianchi, 2002). Greater shares
sibilities and provide for their stepchildren, a fact of children today are born to a mother who is not
that is often overlooked when assessing fathers’ currently married than in previous decades. Some
involvement (Hernandez & Brandon, 2002). of those children are born to cohabitating parents
How many years do men spend as parents? De- and begin life in a household that includes both
mographer Rosalind King (1999) estimated the their biological parents. Data from the 2006–2010
number of years that American men and women will National Survey of Family Growth show that 58%
spend as parents of biological children or stepchil- of recent nonmarital births were to cohabitating
dren younger than 18 if the parenting patterns of the women (Martin et al., 2012). Cohabitation in-
late 1980s and early 1990s continue throughout creased for unmarried mothers in all race and ethnic
their lives; her estimations have not been refuted to groups, but especially among whites. Cohabitating
date. Almost two-thirds of the adult years will be couples account for up to 13% of all single-parent
“child-free” years in which the individual does not family groups. In 2011, 13% of white single parents
have biological children younger than 18 or respon- were actually cohabitating compared with 9% of
sibility for anyone else’s children. Men will spend, black, 13% of Asian, and 19% of Hispanic single
on average, about 20% of their adulthood living with parents (U.S. Census Bureau, 2011d). In 2011 in
and raising their biological children, whereas women Canada, 17% of all families consisted of common-
will spend more than 30% of their adult lives, on av- law couples, and among families with children
erage, raising biological children. Whereas women, under age 14, 14% were common-law families
regardless of race, spend nearly all of their parenting (Statistics Canada, 2012e).
years rearing their biological children, men are more
likely to live with stepchildren or a combination of
Same-Sex Couple Families
their own children and stepchildren. Among men in
the United States, white men will spend about twice An increasing number of same-sex couples are now
as much time living with their biological children as raising children. In the United States, nearly 17%
African American men. of same-sex couples had children in 2010 (author’s
One of the new aspects of the American family own calculations based on Lofquist et al., 2012). In
in the last 50 years has been an increase in the num- Canada, 9.4% of same-sex couples were raising chil-
ber of single fathers. Between 1950 and 2011, the dren in 2011 (Statistics Canada, 2012e). Same-sex
number of households with children that were couples, especially gay male couples, face consider-
maintained by an unmarried father increased from able obstacles and need to overcome negative public
229,000 to 2.2 million (U.S. Census Bureau, 2011c). attitudes to become parents (Biblarz & Savci, 2010).
During the 1980s and 1990s, the percentage of Female couples are more likely than male couples
single-father households nearly tripled for white to be parents (Statistics Canada, 2012e). Many
and Hispanic families and doubled for African same-sex couples bring children into their house-
American families (Casper & Bianchi, 2002). Re- holds from previous heterosexual relationships; oth-
cent demographic trends in fathering have changed ers become parents through the use of assisted
the context of family health care nursing. The reproductive technology and surrogacy, yet an in-
growth in single fatherhood and joint custody, to- creasing number of them become parents through
gether with the increased tendency for fathers to adoption as same-sex couples obtain legal adoption
perform household chores, means that family health rights (Biblarz & Savci, 2010; Greenfeld, 2007).
care nurses are more likely today than in decades Although some people have raised concerns
past to be interacting with the fathers of children. about the parenting styles of same-sex parents and
the potential negative effect for children’s out-
comes and well-being, recent research has found
Unmarried Parents Living Together
that, for the most part, the parental skills of same-
In the United States, changes in marriage and co- sex couples are comparable to if not better than
habitation tend to blur the distinction between one- those of heterosexual couples (Biblarz & Savci,
parent and two-parent families. The increasing 2010). This finding is partly explained by the fact
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56 Foundations in Family Health Care Nursing

that although many same-sex couples are very (11.7 million) lived in blended families in 2009.
eager to become parents, they face several obstacles Blended families were the least common among
that require them to invest more time, money, and Asian children (7%) and the most common among
effort to achieve this goal. Their higher initial in- black and Hispanic children (17% each). Although
vestments make them more likely to devote a great the number of children living in blended families
deal of time to their children when they finally has increased by almost 2 million since 1991, the
become parents (Biblarz & Savci, 2010). percentage increase has been negligible (from 15%
Research on children’s outcomes has focused on to 16%) (Furukawa, 1994; Kreider & Ellis, 2011a).
different dimensions of well-being, including psy- In 2011, the Census of Population in Canada iden-
chological well-being, emotional development, so- tified stepfamilies for the first time. Nearly 13% of
cial behavior, and school performance. Overall, couple families with children were stepfamilies, and
these studies have found that children of same-sex almost 10% of children aged 14 and under were
parents fare relatively as well, if not better, com- living in stepfamilies in 2011 (Statistics Canada,
pared with children raised by heterosexual couples. 2012g).
The gender of the child is an important moderat- Parental and financial responsibilities for biolog-
ing factor. Sons of same-sex couples are more likely ical parents are upheld by law, customs, roles, and
to experience disapproval from their peers and face rules that provide a cultural map of sorts for parents
greater homophobic teasing than girls; boys may to follow in raising their children. Because no such
be at greater risk of experiencing emotional dis- map is available for stepfamilies, stepparents’ roles,
tress. This effect seems to depend on the level of rules, and responsibilities must be defined, negoti-
social tolerance in their surrounding environments ated, and renegotiated by stepparents. Through
(Biblarz & Savci, 2010). these negotiations, many different types of step-
Nurses and health workers should be aware that families are formed, resulting in a variety of con-
same-sex couples often face particular challenges figurations and different patterns of everyday
to safeguarding their well-being and that of their living. The ambiguity surrounding roles in step-
children. Although children raised by same-sex families and the lack of a shared family history and
couples generally exhibit similar outcomes and lev- kinship system provide opportunities to build new
els of well-being, these children may be more sen- traditions and family rituals; however, they also
sitive to judgmental attitudes of individuals with open the door for greater conflict. Consider the
whom they interact, including health workers. following scenarios.
When asked by researchers, members of families
who are all related by either blood or partnership
(marriage or cohabitation) can very easily tell you
Stepfamilies are formed when parents bring to- and agree upon who is in their family. By contrast,
gether children from a previous union. By contrast, members within stepfamilies often do not share a
remarriages or cohabitating unions in which nei- common definition of who is included in their fam-
ther partner brings children into the marriage are ily. Common omissions include stepchildren, bio-
conceptualized and measured similarly to first mar- logical children not living in the household,
riages. The U.S. Census Bureau uses the term biological parents not living in the household, and
blended families to denote families with children that stepparents (Furstenberg & Cherlin, 1991). Even
are formed when remarriages occur or when chil- biological siblings can have different ideas regarding
dren living in a household share only one or no who they consider to be family members depending
biological parents. The presence of a stepparent, on the degree of closeness they feel toward steppar-
stepsibling, or half-sibling designates a family as ents, biological parents, biological siblings, half-
blended; these families can include adoptive chil- siblings, and stepsiblings, especially if the biological
dren who are not the biological child of either par- siblings are living in different households; a girl liv-
ent if there are other children present who are not ing with her biological mother and stepfather may
related to the adoptive child. In 2009, 13.3% of consider her brother living with his biological father
households with children under 18 were blended- and a stepmother as a separate family.
family households, numbering 5.3 million (Kreider Negotiations must occur with ex-spouses or ex-
& Ellis, 2011a). Almost 16% of U.S. children partners, as well as with former in-laws. Researchers
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Family Demography: Continuity and Change in North American Families 57

have found that the ex-spouse relationship can play authorization for medical procedures can be chal-
an important role in the well-being of stepfamilies lenging when legal obligations are unclear. Family
(Golish, 2003) and may affect the relationship be- nurses should take care to identify which parent(s)
tween the new stepparents, especially in the begin- have legal responsibility for medical decision mak-
ning of the relationship. Couples’ relationships ing. Health care workers should be aware that they
in stepfamilies and remarriages are informed and may also need to notify nonresidential parents
shaped by experiences in previous unions, leading when their children require medical attention as
to increased expectations in the remarriage. Remar- these parents may share the legal right to make
ried women expect and have more say in decision medical decisions.
making than women in first marriages. In stepfam-
ilies, the division of labor in the household is more
egalitarian between spouses, as are economic roles
and responsibilities (Allen, Baucom, Burnett, One moderating factor in children’s well-being in
Epstein, & Rankin-Esquer, 2001). single-parent families can be the presence of grand-
Step-relationships in particular are often weak parents in the home. Although the image of single-
or ambivalent, and stress arises around various is- parent families is usually that of a mother living on
sues such as perceptions of playing favorites, or her own and trying to meet the needs of her young
jealousy among biological children, of former child or children, many single mothers live with
spouses, and of stepchildren toward stepparents. their parents. For example, in the United States in
These tensions arise because in some families step- 2011, about 12% of children of single mothers
parents are not viewed by stepchildren as real par- lived in the homes of their grandparents compared
ents (Furstenberg & Cherlin, 1991). The level of with 8% of children of single fathers (U.S. Census
conflict also depends on the age of children, in- Bureau, 2011g). An additional 5.2% of children of
creasing as children approach adolescence. Unlike single mothers had a grandparent living with them
in biological families where the role of parent compared with 4.7% of children of single fathers.
emerges with the birth of the child (ascribed), step- This is a snapshot at one point in time, however. A
parent roles must be earned (achieved). As a result, much higher percentage of single mothers (36%)
discipline in stepfamilies is often a problem. Addi- live in their parents’ home at some point before their
tionally, it is more difficult to be a stepparent than children are grown. African American single moth-
a biological parent because new family cultures are ers with children at home are more likely than are
being developed. others to live with a parent at some time.
Like children growing up in single-parent fam- Several studies have shown that the presence
ilies, children with stepparents have lower levels of of grandparents has beneficial effects on chil-
well-being than children growing up with biologi- dren’s outcomes and can buffer some of the dis-
cal parents (Coleman, Ganong, & Fine, 2000). advantages of living in a single-parent family
Thus, it is not simply the presence of two parents, (DeLeire & Kalil, 2002). This beneficial effect,
but the presence of two biological parents that however, seems to be more pronounced among
seems to promote children’s healthy development. whites than among African Americans, probably
Despite these challenges, positive changes can because white grandparents in the United States
occur when stepfamilies are formed. For example, have more education and resources than black
a stepfather’s income can compensate for the neg- grandparents (Dunifon & Kowaleski-Jones, 2007).
ative economic slide that tends to occur for di- The involvement of grandparents in the lives of
vorced mothers, and a stepparent can alleviate the their children has even become an issue for court
demands of single parenting (Smock, Manning, & cases, as there have been several rulings in recent
Gupta, 1999). years on grandparents’ visitation rights. The 2000
Because stepfamilies comprise a significant pro- U.S. Census included a new set of questions on
portion of families with children, nurses are likely grandparents’ support of grandchildren. Children
to deal with parents whose roles and responsibili- whose parents cannot take care of them for one
ties are not well defined and with children who reason or another often live with their grandpar-
have behavioral problems, especially among re- ents. In 1970, 2.2 million, or 3.2% of all American
cently formed blended families. Obtaining legal children, lived in their grandparents’ households.
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58 Foundations in Family Health Care Nursing

By 2011, this number increased to nearly 5 million, multigenerational households, it is more common
or 6.6% of all American children (U.S. Census for adult children and grandchildren to move into
Bureau, 2011f). Since the Great Recession in a house that grandparents own or rent. In 2007 in
2008 the number of children living with grand- the United States, 64% of multigenerational house-
parents increased by 14%, from 4.3 million in holds were headed by grandparents (Florian &
2008 to nearly 5 million in 2011. In 2011 in Casper, 2011). Nearly 37% of all the grandparent-
Canada, 4.8% of children aged 0 to 14 resided maintained families were skipped generation, that
with at least one grandparent, up from 3.3% in is, grandparents living with their grandchildren
2001 (Statistics Canada, 2012e). In addition, in without the children’s parents (authors’ calculations
2010 in the United States, grandparents were the based on data from U.S. Census Bureau, 2011f).
regular child care providers for 15% of grade- Nearly 3.1% or 413,490 of all households in
schoolers and 23% of preschoolers (U.S. Census Canada contained a grandparent in 2011. Of these
Bureau, 2010a, 2010b). households, 53% also contained both parents, 32%
The prevalence of grandparent families is a re- contained a lone parent (mostly the mother), and
sult of demographic factors, socioeconomic con- 12% were skipped-generation households com-
ditions, and cultural norms. Increases in life prised of children residing with their grandparents
expectancy have expanded the supply of potential without a parent (Statistics Canada, 2012e).
kin support across generations, resulting in more Grandparents who own or rent homes that in-
multigenerational households. At the same time, clude grandchildren and adult children are younger,
changes in work and family life have increased par- healthier, and more likely to be in the labor force
ents’ need for child care, which, coupled with than are grandparents who live in a residence owned
pressing economic circumstances, has made multi- or rented by their adult children. Grandparents who
generational households a strategic symbiotic maintain multigenerational households are also bet-
arrangement, especially among single-mother, ter educated (more likely to have at least a high-
low-income, and immigrant families (Glick & Van school education) than are grandparents who live in
Hook, 2002). Grandparents often provide finan- their children’s homes (Casper & Bianchi, 2002).
cial, emotional, child care, and residential support Nevertheless, supporting grandchildren can drain
and, in turn, receive emotional and physical sup- grandparents’ resources. A recent study indicated
port (Bengtson, Giarrusso, Mabry, & Silverstein, that grandfathers who are primary caretakers of
2002). Nonetheless, after practical and economic grandchildren are at higher risk of experiencing
factors are taken into account, racial and ethnic poverty if they are in a skipped-generation house-
differences in the prevalence of grandparent hold, are ethnic minorities, or are not married
households remain. Strong kinship ties and family (Keene, Prokos, & Held, 2012).
norms also seem to explain the prevalence of The structure of grandparent households differs
grandparent households, especially among African by nativity. Although co-residential grandparent
American, Native American, Hispanic, and immi- families are more common among immigrant fam-
grant families (Florian & Casper, 2011; Haxton & ilies, immigrant grandparent families are less likely
Harknett, 2009). Thus, norms stressing familial to be maintained by grandparents and less likely to
obligations may also be an important factor ex- be skipped generation. Thus, while the flow of sup-
plaining differences in the formation of grandpar- port in native-born multigenerational families
ent families. more often runs from older to younger genera-
Emerging research reveals that grandparents tions, in immigrant grandparent families support
play an important role in multigenerational house- more often flows from adult children to their older
holds, which is at odds with the traditional image of parents (Florian & Casper, 2011).
grandparents as family members who themselves Parents who support both dependent children
require financial and personal support. Although and dependent parents have been referred to as the
early studies assumed that financial support flowed “sandwich” generation, because they provide eco-
from adult children to their parents, more recent nomic and emotional support for both the older
research suggests that the more common pattern is and younger generations. Although grandparents
for parents to give financial support to their adult in parent-maintained households tend to be older,
children (Bengtson, 2001; Bianchi et al., 2008). In in poorer health, and not as likely to be employed,
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Family Demography: Continuity and Change in North American Families 59

many are in good health and are, in fact, working SUMMARY

(Bryson & Casper, 1999). These findings suggest
that, at the very least, the burden of maintaining a Families change in response to economic conditions,
co-residential “sandwich family” household may be cultural change, and shifting demographics, such as
somewhat overstated in the popular press. Many the aging of the population and immigration. North
of the grandparents who are living in the houses of America has gone through a particularly tumultuous
their adult children are capable of contributing period in the last few decades, resulting in rapid
to the family income and helping with the supervi- changes in family structure, functions, and processes.
sion of children. Families have grown more diversified.
Many grandparents step in to assist their chil-
dren in times of crisis. Some provide financial ■ More single-mother families, single-father
assistance or child care, whereas others are the pri- families, same-sex parent families, and fami-
mary caregivers for their grandchildren. Although lies with both parents in the labor force exist
grandmothers comprise the majority of grandpar- today than in the past. This translates into
ent caregivers, a sizable number of grandfather less time for parents to take care of the health
caregivers exist who are likely to experience more needs of family members.
challenges than grandmothers as primary care- ■ Single mothers may find it particularly chal-

givers (Keene et al., 2012). lenging to meet the health care needs of their
The recent increase in the numbers of grand- families because they tend to have the least
parents raising their grandchildren is particularly time and money to do so.
salient to health care providers because both ■ More fathers are taking responsibility for

grandparents and grandchildren in this situation being primary caretakers of their children
often suffer significant health problems (Casper and will be more likely than in the past to be
& Bianchi, 2002). Researchers have documented the parent with whom nurses will interact.
high rates of asthma, weakened immune systems, ■ Changes in childbearing behaviors have also
poor eating and sleeping patterns, physical dis- altered family life.
abilities, and hyperactivity among grandchildren ■ Persistent levels of below replacement fertil-
being raised by their grandparents (Kelley, Whitley, ity in Canada have raised concerns about the
& Campos, 2011; Minkler & Odierna, 2001). future contraction of the population, which
Grandparents raising grandchildren tend to be in would reduce the tax base to support children
poorer health than their counterparts. They have and the growing number of senior citizens.
higher levels of stress, higher rates of anxiety and ■ As more couples delay childbearing, they are
depression, poorer self-rated health, and more more likely to seek assistance to conceive
multiple chronic health problems, especially if the from health care providers.
grandchildren exhibit behavioral problems ■ The growing number of same-sex couples
(Leder, Grinstead, & Torres, 2007). Other studies who aspire to become parents has further
suggest, however, that these negative outcomes increased the demand for assisted reproduc-
may not necessarily be a result of caring for tive technology.
grandchildren; instead, they may reflect grandpar- ■ Nurses should be aware that this is a stressful
ents’ preexisting health conditions and economic time in families’ lives, as more adults and
circumstances before they began to raise their children live in nontraditional family forms.
grandchildren (Hughes, Waite, LaPierre, & Luo, ■ Nurses also should be aware that the roles of
2007). It is important to keep in mind that, al- parents and responsibility for children in
though many of the grandparents who live in their these households may be ambiguous.
adult children’s homes are in good health, some ■ Many North American families adopt
of these grandparents require significant care. children. These children are likely to face a
Nurses should also be aware that there are also period of adjustment and are also more likely
adult children who provide care for their parents than other children to have special health
who are not living with them. Adults who provide care needs.
care for both generations are likely to face both ■ More grandparents are raising their grand-
time and money concerns. children, and these grandchildren may suffer
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60 Foundations in Family Health Care Nursing

from more health problems compared with Amato, P. R., & Dorius, C. (2010). Fathers, children, and divorce.
other children. In M. E. Lamb (Ed.), The role of the father in child development
(5th ed., pp. 177–200). Hoboken, NJ: John Wiley & Sons.
■ Many families maintained by grandparents
Assisted Human Reproduction Canada (AHRC). (2011). Making
are in poverty, and many of the grandparents a difference. AHRC annual report 2010–2011. Retrieved from
in these families suffer from poor health
themselves. Nurses will increasingly be likely Belle, S. H., & REACH II Investigators. (2006). Enhancing the
to provide care to grandparent families, and quality of life of dementia caregivers from different ethnic or
racial groups. Annals of Internal Medicine, 145(10), 727–738.
they should be aware of the unique health Bengtson, V. (2001). The Burgess Award lecture: Beyond the
and financial challenges these families face. nuclear family: The increasing importance of multigenera-
■ As mortality rates at older ages continue to tional bonds. Journal of Marriage and Family, 63(1), 1–16.
improve, and as baby boomers move into Bengtson, V. L., Giarrusso, R., Mabry, J. B., & Silverstein, M.
their retirement years, the proportions of the (2002). Solidarity, conflict, and ambivalence: Complementary
or competing perspectives on intergenerational relationships.
population of elderly persons will continue to Journal of Marriage and Family, 64, 568–576.
increase. This demographic shift will in- Bianchi, S. M. (1995). The changing demographic and socioeco-
crease the need for nurses who specialize in nomic characteristics of single-parent families. Marriage and
caring for elderly persons. Family Review, 20, 71–97.
■ More adults will have children and parents
Bianchi, S. M. (2000). Maternal employment and time with chil-
dren: Dramatic change or surprising continuity? Demography,
for whom they must care, increasing the 37(4), 401–414.
need for care in both directions, that of the Bianchi, S. M., & Casper, L. M. (2000). American families.
younger and the older. Population Bulletin, 55(4), 1–44. Retrieved from http://
■ Working with health care needs of both gen-
erations will be a challenge for health care Bianchi, S. M., Hotz, V. J., McGarry, K., & Seltzer, J. A. (2008).
Intergenerational ties: Alternative theories, empirical findings
professionals, especially nurses who are on and trends, and remaining challenges. In A. Booth, N.
the front line in most health care systems. Crouter, S. Bianchi, & J. Seltzer (Eds.), Intergenerational care-
■ Today, more North Americans come from giving (pp. 3–43). Washington, DC: Urban Institute Press.
other countries than in the past. Bianchi, S. M., Raley, S. B., & Casper, L. M. (2012). Changing
■ Health care providers will be serving a more
American families in the 21st century. In P. Noller & G. C.
Karantzas (Eds.), The Wiley-Blackwell handbook of couples and fam-
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■ Many of these individuals speak a language Biblarz, T. J., & Savci, E. (2010). Lesbian, gay, bisexual, and trans-
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■ Economics and family relationships remain Boivin, J., Bunting, L., Collins, J. A., & Nygren, K. G. (2007).
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■ Designing New Models for Explaining Family Change and
Suggested Readings Variation:
Baker, M. (Ed). (2009). Families: Changing trends in Canada ■ Federal Interagency Forum on Aging-Related Statistics:
(6th ed.). Toronto, Canada: McGraw-Hill Ryerson.
Bianchi, S. M., & Casper, L. M. (2005). Explanations of family ■ Federal Interagency Forum on Child and Family Statistics:
change: A family demographic perspective. In V. L. Bengtson,
A. C. Acock, K. R. Allen, P. Dilworth-Anderson, & D. M.
■ Fragile Families and Child Wellbeing Study: www.fragilefamilies.
Klein (Eds.), Sourcebook of family theory and research (pp. 93–117).
Thousand Oaks, CA: Sage.
Brown, S. L. (2004). Family structure and child well-being: The ■ Kaiser Commission on Medicaid and the Uninsured:
significance of parental cohabitation. Journal of Marriage and ■ Kids Count: The Annie E. Casey Foundation:
Family, 66(2), 351–367. kidscount
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■ National Center for Health Statistics, U.S. Department of Health ■ Population Reference Bureau:
and Human Services, Centers for Disease Control and Prevention: ■ Statistics Canada/Statistique Canada: ■ U.S. Census Bureau:
■ National Institute on Aging, National Institutes of Health: ■ Welfare, Children, & Families: A Three City Study:
■ National Center for Marriage and Family Research:
■ National Institute of Child Health and Human Development,
National Institutes of Health:
■ The National Longitudinal Study of Adolescent Health:
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Theoretical Foundations
for the Nursing of Families
Joanna Rowe Kaakinen, PhD, RN
Shirley May Harmon Hanson, PhD, PMHNP/ARNP, FAAN, CFLE, LMFT

Critical Concepts
■ Theories inform the practice of nursing. Practice informs theory and research. Theory, practice, and research are
interactive, and all three are critical to the profession of nursing and family care.
■ The major purpose of theory in family nursing is to provide knowledge and understanding that improves the quality
of nursing care of families.
■ By understanding theories and models, nurses are prepared to think more creatively and critically about how health
events affect family clients. Theories and models provide different ways of comprehending issues that may be
affecting families, and offer choices for action.
■ The theoretical/conceptual frameworks and models that provide the foundations for nursing of families have evolved
from three major traditions and disciplines: family social science, family therapy, and nursing.
■ No single theory, model, or conceptual framework adequately describes the complex relationships of health events
on family structure, function, and process.
■ Nurses who use an integrated theoretical approach build on the strengths of families in creative ways. Nurses
who use a singular theoretical approach to working with families limit the possibilities for families they serve. By
integrating several theories, nurses acquire different ways to conceptualize problems, thus enhancing thinking
about interventions.

By understanding theories and models, nurses are affecting families and, thereby, offer more choice
prepared to think creatively and critically about and options for nursing interventions.
how health events affect the family client. The re- Currently, no single theory, model, or concep-
ciprocal or interactive relationship between theory, tual framework adequately describes the complex
practice, and research is that each aspect informs relationships of family structure, function, and
the other, thereby expanding knowledge and nurs- process. Nor does one theoretical perspective give
ing interventions to support families. Theories and nurses a sufficiently broad base of knowledge and
models extend thinking to higher levels of under- understanding to guide assessment and interven-
standing problems and circumstances that may be tions with families. No one theoretical perspective
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68 Foundations in Family Health Care Nursing

is better, more comprehensive, or more correct RELATIONSHIP BETWEEN THEORY,

than another (Doane & Varcoe, 2005; Kaakinen &
Hanson, 2010). The goal for nurses is to have a
deep understanding of the stresses that families ex-
In nursing, the relationship of theory to practice
perience when their family clients have a health
constitutes a dynamic feedback loop rather than a
event and to support and implement family inter-
static linear progression. Theory, practice, and re-
ventions based on theoretical perspectives that best
search are mutually interdependent. Theory grows
match the needs identified by the family.
out of observations made in practice and is tested
Many theoretical approaches exist to under-
by research; then tested theory informs practice,
standing families. The purpose of this chapter is to
and practice, in turn, facilitates the further refine-
demonstrate how families who have members
ment and development of theory. Figure 3-1
experiencing a health event are conceptualized dif-
depicts the dynamic relationship between theory,
ferently depending on the theoretical perspective.
practice, and research.
In this chapter, nurses seek different data depending
Theories do not emerge all at once; they build
on which theory is being used, both to understand
slowly over time as data are gathered through prac-
the family experience and to determine the inter-
tice, observation, and analysis of evidence. Relating
ventions offered to the family to help bring them
together the various concepts that emerge from
back to a state of stability.
observation and evidence occurs through a pur-
poseful, thoughtful reasoning process. Inductive
reasoning is a process that moves from specific
pieces of information toward a general idea; it is
thinking about how the parts create the whole. De-
ductive reasoning goes in the opposite direction from
inductive reasoning. Deductive reasoning is where
the general ideas of a given theory generate more
specific questions about what filters back into the
cycle; it helps refine understanding of the theory
and how to apply the theory to practice (Smith &
Hamon, 2012; White & Klein, 2008).
Theories are designed to make sense of the
world, to show how one thing is related to another
and how together they make a meaningful pattern
that can predict the consequences of certain clus-
ters of characteristics or events. Theories are ab-
This chapter begins with a brief review of the stract, general ideas that are subject to rules of
components of a theory and how the components
contribute to the nursing of families. It then pres-
ents five theoretical approaches for working with THEORY
families, ranging from a broader to a more specific
■ Family Systems Theory Inductive PRACTICE Deductive
■ Developmental and Family Life Cycle Theory Reasoning Reasoning
■ Bioecological Theory
■ Chronic Illness Framework
■ Family Assessment and Intervention Model RESEARCH
The chapter utilizes a case study of a family with
FIGURE 3-1 Relationship between theory, practice, and
a member who is experiencing progressive multiple research. (Adapted from Smith, S. R., Hamon, R. R., Ingoldsby,
sclerosis (MS) to demonstrate these five different B. B., & Miller, J. E. [2008]. Exploring family theories [2nd ed.].
theoretical approaches to nursing care. New York, NY: Oxford University Press.)
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Theoretical Foundations for the Nursing of Families 69

organization. Theories provide a general frame- hypotheses. Theories are generally made up of sev-
work for understanding data in an organized way, eral propositions that emphasize the relationships
as well as showing us how to intervene. We live in among the concepts in that specific theory.
a time when tremendous amounts of information A hypothesis is a way of stating an expected rela-
are readily available and quickly accessible in mul- tionship between concepts or an expected proposi-
tiple forms. Therefore, theories provide ways to tion (Powers & Knapp, 2010). The concepts and
transform this huge volume of information into propositions in the hypothesis are derived from and
knowledge and to integrate/organize the informa- driven by the original theory. For example, using
tion to help us make better sense of our world the concepts of family and health, one could hy-
(White, 2005). Ideally, nursing theories represent pothesize that there is an interactive relationship
logical and intelligible patterns that make sense of between how a family is coping and the eventual
the observations nurses make in practice and en- health outcome of family members. In other words,
able nurses to predict what is likely to happen to the family’s ability to cope with stress affects the
clients (Polit & Beck, 2011). Theories can be used health of individual family members and, in turn,
as a level of evidence on which to base nursing the health of this individual family member influ-
practice (Fawcett & Desanto-Madeya, 2012). The ences the family’s ability to cope. This hypothesis
major function of theory in family nursing is may be tested by a research study that measures
to provide knowledge and understanding that family coping strategies and family members’ health
improves nursing services to families. over time and that uses statistical procedures to look
Most important, theories explain what is hap- at the relationships between the two concepts.
pening; they provide answers to “how” and “why” A conceptual model is a set of general propositions
questions, help to interpret and make sense of phe- that integrate concepts into meaningful configura-
nomena, and predict or point to what could happen tions or patterns (Fawcett & Desanto-Madeya,
in the future. All scientific theories use the same 2012). Conceptual models in nursing are based on
components: concepts, relationships, and propositions. the observations, insights, and deductions that com-
We will discuss hypotheses and conceptual models bine ideas from several fields of inquiry. Conceptual
as well. models provide a frame of reference and a coherent
Concepts, the building blocks of theory, are words way of thinking about nursing phenomena. A con-
that create mental images or abstract representa- ceptual model is more abstract and more compre-
tions of phenomena of study. Concepts, or the hensive than a theory. Like a conceptual model, a
major ideas expressed by a theory, may exist on a conceptual framework is a way of integrating con-
continuum from empirical (concrete) to abstract cepts into a meaningful pattern, but conceptual
(Powers & Knapp, 2010). The more concrete the frameworks are often less definitive than models.
concept, the easier it is to figure out when it applies They provide useful conceptual approaches or ways
or does not apply (White & Klein, 2008). For ex- in which to look at a problem or situation, rather
ample, one concept in Family Systems Theory is than a definite set of propositions.
that families have boundaries. A highly abstract In this chapter, the terms conceptual model or
aspect of this concept is that the boundary reflects framework and theory or theoretical framework are
the energy between the environment and the sys- often used interchangeably. In part, that is because
tem. A more concrete aspect of this concept is that no single theoretical base exists for the nursing of
families open or close their boundaries in times of families. Rather, nurses typically draw from many
stress. theoretical conceptual foundations using a more
Propositions are statements about the relationship pluralistic and eclectic approach. The interchange-
between two or more concepts (Powers & Knapp, able use of these various terms reflects the fact that
2010). A proposition might be a statement such as there is considerable overlap among ideas in
the following: Families as a whole influence the the various theoretical perspectives and conceptual
health of individual family members. The word models/frameworks and that many “streams of
influence links the two concepts of “families as a influence” are important for family nurses to incor-
whole” and “health of individual family members.” porate into practice. As might be expected, a
Propositions denote a relationship between the substantial amount of cross-fertilization among
subject and the object. Propositions may lead to disciplines has occurred, such as between social
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70 Foundations in Family Health Care Nursing

science and nursing, and concepts originating in about family phenomena; examples of such theo-
one theory or discipline have been translated into ries include the following: family function, the
similar concepts for use in another discipline. Cur- environment-family interchange, interactions and
rently, no one theoretical perspective gives nurses dynamics within the family, changes in the family
a sufficiently broad base of knowledge and under- over time, and the family’s reaction to health and
standing to guide assessment and interventions illness. Table 3-1 summarizes the basic family
with families. social science theories and provides some classic
references where these theories originate. It is
somewhat challenging to use the purist form of
THEORETICAL AND CONCEPTUAL family social science theories as a basis for nursing
FOUNDATIONS FOR THE NURSING assessment and intervention because of their ab-
OF FAMILIES stract nature. Despite this challenge, in recent
years, nursing and family scholars have made
Nursing is a scientific discipline; thus, nurses are strides in extrapolating and morphing these theo-
concerned about the relationships between ideas ries for use in clinical work (Fine & Fincham,
and data. Nurse scholars explain empirical observa- 2012; Kaakinen & Hanson, 2010).
tions by creating theories, which can be used as
evidence in evidence-based practice (Fawcett &
Garity, 2008). Nurse researchers investigate and Family Therapy Theories
test the models and relationships. Nurses in practice Family therapy theories are newer than and not as
use theories, models, and conceptual frameworks to well developed as family social science theories.
help clients achieve the best outcomes (Kaakinen & Table 3-2 lists these theories and the names of
Hanson, 2010). In nursing, evidence, in the form of some foundational scholars who first developed
theory, is used to explain and guide practice. The them. These theories emanate from a practice dis-
theoretical foundations, theories, and conceptual cipline of family therapy, rather than from an aca-
models that explain and guide the practice of nurs- demic discipline of family social science. Family
ing families have evolved from three major tradi- therapy theories were developed to work with trou-
tions and disciplines: family social science theories, bled families and, therefore, focus primarily on
family therapy theories, and nursing models and family pathology. Nevertheless, these conceptual
theories. Figure 3-2 shows the theoretical frame- models describe family dynamics and patterns that
works that influence the nursing of families. are found, to some extent, in all families. Because
these models are concerned with what can be done
Family Social Science Theories to facilitate change in “dysfunctional” families, they
are both descriptive and prescriptive. That is, they
Of the three sources of theory, family social science not only describe and explain observations made in
theories are the best developed and informative practice but also suggest treatment or intervention

Nursing Conceptual Frameworks

Finally, of the three types of theories, nursing con-
SCIENCE THEORIES ceptual frameworks are the least developed “theories”
FAMILY NURSING in relation to the nursing of families. Table 3-3 lists
several of the theories and theorists from within the
nursing profession. During the 1960s and 1970s,
nurses placed great emphasis on the development
of nursing models. Other than the Neuman Sys-
tems Model (Neuman & Fawcett, 2010) and the
Behavioral Systems Model for Nursing (Johnson,
FIGURE 3-2 Theoretical frameworks that influence the 1980), both of which were based on family social
nursing of families. science theories, the majority of the classic nursing
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Theoretical Foundations for the Nursing of Families 71

Table 3-1 Family Social Science Theories Used in Family Nursing Practice

Family Social Science Theory Summary

Structural Functional Theory

Artinian (1994) The focus is on families as an institution and how they function to maintain family
Friedman, Bowden, & Jones (2003) and social network.

Nye & Berardo (1981)

Symbolic Interaction Theory

Hill & Hansen (1960) The focus is on the interactions within families and the symbolic communication.
Nye (1976)
Rose (1962)
Turner (1970)

Developmental Theory and

Family Life Cycle Theory
Carter & McGoldrick (2005) The focus is on the life cycle of families and representing normative stages of
Duvall (1977) family development.

Duvall & Miller (1985)

Family Systems Theory

von Bertalanffy (1950, 1968) The focus is on the circular interactions among members of family systems, which
result in functional or dysfunctional outcomes.

Family Stress Theory

Hill (1949, 1965) The focus is on the analysis of how families experience and cope with stressful life
McCubbin & McCubbin (1993) events.

McCubbin & Patterson (1983)

Change Theory
Maturana (1978) The focus is on how families remain stable or change when there is change within
Maturana & Varela (1992) the family structure or from outside influences.

Watzlawick, Weakland, & Fisch (1974)

Wright & Leahey (2013)
Wright & Watson (1988)

Transition Theory
White (2005) The focus is on understanding and predicting the transitions families experience
White & Klein (2008) over time by combining Role Theory, Family Development Theory, and Life
Course Theory.

theorists from the 1970s focused on individual pa- approaches to nursing theory development (specific
tients and not on families as a unit of care/analysis. to the general) are now being advocated.
The nursing models, in large part, represent a Table 3-4 shows the differences between family
deductive approach to the development of nursing social science theories, family therapy theories, and
science (general to specific). Although they embody nursing models/theories as they inform the practice
an important part of our nursing heritage, these of nursing with families. The following case study
nursing conceptual frameworks and their deductive is used to demonstrate how the five different theo-
approach are viewed more critically today. As the retical approaches may inform a nurse’s work with
science of nursing has evolved, more inductive one particular family.
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72 Foundations in Family Health Care Nursing

Table 3-2 Family Therapy Theories Used in Family Nursing Practice

Family Therapy Theories Summary

Structural Family Therapy Theory
Minuchin (1974) This systems-oriented approach views the family as an open sociocultural system
Minuchin & Fishman (1981) that is continually faced with demands for change, both from within and from
outside the family. The focus is on the whole family system, its subsystems,
Minuchin, Rosman, & Baker (1978) boundaries, and coalitions, as well as family transactional patterns and covert rules.
Nichols (2004)

International Family Therapy Theory

Jackson (1965) This approach views the family as a system of interactive or interlocking behaviors
Satir (1982) or communication processing. Emphasis is on the here and now rather than on
the past. Key interventions focus on establishing clear, congruent communication
Watzlawick, Beavin, & Jackson (1967) and clarifying and changing family rules.

Family Systems Therapy Theory

Freeman (1992) This approach focuses on promoting differentiation of self from family and pro-
Kerr & Bowen (1988) moting differentiation of intellect from emotion. Family members are encouraged
to examine their processes to gain insight and understanding into their past and
Toman (1961) present. This therapy requires a long-term commitment.

Table 3-3 Nursing Theories and Models Used in Family Nursing Practice

Nursing Theories and Models Summary

Nightingale (1859) Family is described as having both positive and negative influences on the outcome of
family members. The family is seen as a supportive institution throughout the life span
for its individual family members.

Rogers’s Science of Unitary

Human Beings
Casey (1996) The family is viewed as a constant open system energy field that is ever-changing in its
Rogers (1970, 1986, 1990) interactions with the environment.

Roy’s Adaptation Model

Roy (1976) The family is seen as an adaptive system that has inputs, internal control, and feedback
Roy & Roberts (1981) processes and output. The strength of this model is understanding how families adapt
to health issues.

Johnson’s Behavioral
Systems Model for Nursing
Johnson (1980) The family is viewed as a behavioral system composed of a set of organized interactive
interdependent and integrated subsystems that adjust and adapt with internal and
external forces to maintain stability.

King’s Goal Attainment Theory

King (1981, 1983, 1987) The family is seen as the vehicle for transmitting values and norms of behavior across
the life span, which includes the role of a sick family member. Family is responsible for
addressing the health care function of the family. Family is seen as both an interpersonal
and a social system. The key component is the interaction between the nurse and the
family as client.
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Theoretical Foundations for the Nursing of Families 73

Table 3-3 Nursing Theories and Models Used in Family Nursing Practice—cont’d

Nursing Theories and Models Summary

Neuman’s Systems Model
Neuman (1983, 1995) The family is viewed as a system. The family’s primary goal is to maintain its stability by pre-
serving the integrity of its structure by opening and closing its boundaries. It is a fluid model
that depicts the family in motion and not a static view of family from one perspective.

Orem’s Self-Care Deficit

Gray (1996) The family is seen as the basic conditioning unit in which the individual learns culture,
Orem (1983a, 1983b, 1985) roles, and responsibilities. Specifically, family members learn how to act when one is ill.
The family’s self-care behavior evolves through interpersonal relationships, communication,
and culture that is unique to each family.

Parse’s Human Becoming

Parse (1992, 1998) The concept of family and who makes up the family is viewed as continually becoming
and evolving. The role of the nurse is to use therapeutic communication to invite family
members to uncover their meaning of the experience, to learn what the meaning of the
experience is for each other, and to discuss the meaning of the experience for the family
as a whole.

Friedemann’s Framework
of Systemic Organization
Friedemann (1995) The family is described as a social system that has the expressed goal of transmitting
culture to its members. The elements central to this theory are family stability, family
growth, family control, and family spirituality.

Denham’s Family Health

Denham (2003) Family health is viewed as a process over time of family member interactions and
health-related behaviors. Family health is described in relation to contextual, functional,
and structural domains. Dynamic family health routines are behavioral patterns that
reflect self-care, safety and prevention, mental health behaviors, family care, illness care,
and family caregiving.

Table 3-4 Family Social Science Theories, Family Therapy Theories, and Nursing Models/Theories

Family Social Family Nursing

Criteria Science Theories Therapy Theories Models/Theories
Purpose of theory Descriptive and explana- Descriptive and prescriptive Descriptive and prescriptive
tory (academic models); (practice models); to explain (practice models); to guide
to explain family function- family dysfunction and guide nursing assessment and
ing and dynamics. therapeutic actions. intervention efforts.
Discipline focus Interdisciplinary (although Marriage and family therapy; Nursing focus.
primarily sociological). family mental health; new
approaches focus on family
Target population Primarily “normal” families Primarily “troubled” families Primarily families with health
(normality-oriented). (pathology-oriented). and illness problems.

Source: Kaakinen, J. R., & Hanson, S. M. H. (2010). Theoretical foundations for nursing of families. In J. R. Kaakinen, V.
Gedaly-Duff, D. P. Coehlo, & S. M. H. Hanson (Eds.), Family health care nursing: Theory, practice and research
(4th ed.). Philadelphia, PA: F. A. Davis, with permission.
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74 Foundations in Family Health Care Nursing

age 39, but he is described as “a blessing.” Linda and

Family Case Study: Jones Family Robert are devout Baptists, but they did discuss abortion
in light of the fact that Linda’s illness could progress signifi-
Setting: Inpatient acute care hospital
cantly after the birth of Travis. Their faith and personal
Nursing Goal: Work with the family to assist them in beliefs did not support abortion. They made the decision
preparation for discharge that is planned to occur in the to continue with Linda’s pregnancy, knowing the risk that it
next 2 days. might exacerbate and speed up her MS. Linda had an
Family Members: uncomplicated pregnancy with Travis. She felt well until
The Jones family is a nuclear family. The Jones family 3 months postpartum with Travis when she noted a
genogram and ecomap are illustrated in Figures 3-3 and 3-4. significant relapse of her MS.
Over the last 4 years, Linda has experienced develop-
• Robert: 48 years old; father, software engineer, full-time ment of progressive relapsing MS, which is a progressive
employed. disease from onset with clear, acute relapses without full
• Linda: 43 years old; mother, stay-at-home homemaker, recovery after each relapse. The periods between her re-
has progressive multiple sclerosis, which recently has lapses are characterized by continuing progression of the
worsened significantly. disease. She now has secondary progressive multiple scle-
• Amy: 19 years old; oldest child, daughter, freshman at rosis because of her increased weakness. Robert and Linda
university in town 180 miles away. are having sexual issues with decreased libido and painful
• Katie: 13 years old: middle child, daughter, sixth grade, intercourse for Linda. Both are experiencing stress in their
usually a good student. marital roles and relationship.
• Travis: 4 years old: youngest child, son, just started Currently, Linda has had a serious relapse of her MS.
attending an all-day preschool because of his mother’s She is hospitalized for secondary pneumonia from aspi-
illness. ration. She has weakness in all limbs, left foot drag, and
Jones Family Story: increasing ataxia. Linda will be discharged with a wheel-
Linda was diagnosed with multiple sclerosis (MS) at age 30 chair (this aid is new as she has used a cane up until
when Katie was 3 months old. After she was diagnosed this admission). She has weakness of her neck muscles
with MS, Linda had a well-controlled, slow progression of and cannot hold her head steady for long periods. She
her illness. Travis was a surprise pregnancy for Linda at has difficulty swallowing, which probably caused her

Elise Tom Sally

70 yr 64 yr 63 yr

Healthy Full-time Full-time

employed employed
teacher, secretary
Robert high school Linda
Full-time Multiple sclerosis;
48 yr 43 yr
software progressive and
engineer relapse
Difficulty swallowing
Amy Katie Travis Requires
19 yr 13 yr 4 yr supplemental O2
Uses wheelchair
Freshman at Sixth grade Preschool, just
university 180 Healthy moved to full day
miles away Usually a good Healthy
Healthy student, now
showing some
difficulty noted
by teachers
FIGURE 3-3 Jones family genogram.
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Theoretical Foundations for the Nursing of Families 75

Travis’s P.E.
Hospital social
school teacher
Katie’s middle
school teacher MS support

Robert’s work


Family Woman’s
insurance church group

Neurology Linda’s
RN case parents
Neurology grandmother,
team Elise

Weak relationship

Strong relationship

Tense relationship
Direction of
energy flow

FIGURE 3-4 Jones family ecomap.

aspiration. She has numbness and tingling of her legs worsens. Robert works for a company that offers family
and feet. She has severe pain with flexion of her neck. leave, but without pay.
Her vision is blurred. She experiences vertigo at times
Family Members:
and has periodic tinnitus. Constipation is a constant
Robert reports being continuously tired from caring for his
problem, together with urinary retention that causes
wife and children, as well as working full-time. He asked the
periodic urinary tract infections.
doctor for medication to help him sleep and decrease his
Health Insurance: anxiety. He said he is afraid that he may not hear Linda in
Robert receives health insurance through his work that cov- the night when she needs help. He is open to his mother
ers the whole family. Hospitalizations are covered 80/20, moving in to help care for Linda and the children. He began
so they have to pay 20% of their bills out of pocket. Al- counseling sessions with the pastor in their church.
though Robert is employed full-time, this cost adds heavily Amy is a freshman at a university that is 180 miles
to the financial burden of the family. Robert has shared away in a different town. Her mother is proud of Amy
with the nurses that he does not know whether he should going to college on a full scholarship. Amy does well in
take his last week of vacation when his wife comes home, her coursework but travels home weekends to help the
or whether he should save it for a time when her condition (continued)
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76 Foundations in Family Health Care Nursing

family and her mother. Amy is considering giving up her Travis just started going to preschool 2 months ago for
scholarship to transfer home to attend the local commu- full days because of his mother’s illness. This transition to
nity college. She has not told her parents about this preschool has been difficult for Travis because he had been
idea yet. home full-time with Linda until her disease worsened. He is
Katie is in the sixth grade. She is typically a good stu- healthy and developmentally on target for his age.
dent, but her latest report card showed that she dropped Linda’s parents live in the same town. Her parents,
a letter grade in most of her classes. Katie is quiet. She Tom and Sally, both work full-time and are not able to
stopped having friends over to her home about 6 months help. Robert’s widowed mother, Elise, lives by herself in
ago when her mother began to have more ataxia and slur- her own home about 30 minutes out of town and has
ring of speech. Linda used to be very involved in Katie’s offered to move into the Jones’ home to help care for
school but is no longer involved because of her illness. Linda and the family.
Katie has been involved in Girl Scouts and the youth group
Discharge Plans: Linda will be discharged home in 2 days.
at church.

THEORETICAL PERSPECTIVES One of the major assumptions of Family Sys-

tems Theory is that family system features are de-
AND APPLICATION TO FAMILIES signed to maintain stability, although these features
may be adaptive or maladaptive. At the same time,
The case of the Jones family is used throughout the
families change constantly in response to stresses
rest of this chapter to demonstrate how assess-
and strains from both the internal and external en-
ments, interventions, and options for care vary
vironments. Family systems increase in complexity
based on the particular theoretical perspective
over time and increase their ability to adapt and to
chosen by nurses caring for this family.
change (Smith & Hamon, 2012; White & Klein,
2008). The family systems theoretical perspective
Family Systems Theory encourages nurses to see individual clients as
participating members of a larger family system.
Family Systems Theory has been the most influential
Figure 3-5 depicts a mobile showing how family
of all the family social science frameworks (Kaakinen
systems work. Any change in one member of the
& Hanson, 2010; Wright & Leahey, 2013). Much
family affects all members of the family. As it
of the understanding of how a family is a system de-
applies to the Jones family, nurses who are using
rives from physics and biology perspectives that or-
this perspective would assess the impact of Linda’s
ganisms are complex, organized, and interactive
illness on the entire family, as well as the effects of
systems (Bowen, 1978; von Bertalanffy, 1950, 1968).
family functioning on Linda. The goal of nurses is
Nursing theorists who have expanded the concept
to help maintain or restore the stability of the fam-
of systems theory include Hanson (2001), Johnson
ily, to help family members achieve the highest
(1980), Neuman (1995), Neuman and Fawcett
level of functioning that they can. Therefore,
(2010), Parker and Smith (2010), Walker (2005),
emphasis should be on the whole, rather than on
and Wilkerson and Loveland-Cherry (2005).
any given individual. Some of the concepts of sys-
The Family Systems Theory is an approach
tems theory that help nurses working with families
that allows nurses to understand and assess fami-
are explained in the following sections.
lies as an organized whole and/or as individuals
within family units who form an interactive and
interdependent system (Kaakinen & Hanson, Concept 1: All Parts of the System
2010). Family Systems Theory is constructed Are Interconnected
of concepts and propositions that provide a What influences one part of the system influences
framework for thinking about the family as a all parts of the system. When an individual in a
system. Typically, in family nursing, we look family experiences a health event, all members are
at three-generational family systems (Goldenberg affected because they are connected. The effect
& Goldenberg, 2012). on each family member varies in intensity and
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Theoretical Foundations for the Nursing of Families 77

whole affected by this unexpected (nonnormative)

family health event. The individuals in this family
may, at times, wonder what will happen to them as
a family (whole) when Linda dies.
One way of visualizing the family as a whole is
to think of how the Jones family has built the con-
cept of the “Jones Family Easter.” Even though
Linda always decorates the house and bakes sev-
eral special dishes for the family for this holiday,
this year she has been too ill to decorate or cook
for Easter. The family as a whole feels stressed by
the loss of routine and ritual as it represents a
FIGURE 3-5 Mobile depicting family system.
change in their family tradition and beliefs. Thus,
the family loss is larger than individual loss of this
quality. In the Jones case study, all members of the
Jones family are touched when Linda’s health Concept 3: All Systems Have Some Form
condition changes, requiring her to be hospital- of Boundaries or Borders Between the
ized. Linda takes on the role of a sick person and System and Its Environment
must give up some of her typical at-home mother Families control the in-flow of information and
roles; she is physically ill in the hospital. She feels people coming into its family system to protect in-
guilty about not being at home for her family. dividual family members or the family as a whole.
Robert is affected because he has to assume the Boundaries are physical or abstract imaginary lines
care of Katie and Travis. These tasks require get- that families use as barriers or filters to control the
ting them ready for school, transporting them to impact of stressors on the family system (Smith &
school and other events, and making lunches. Hamon, 2012; White & Klein, 2008). Family
Katie gives up some after-school activities to help boundaries include levels of permeability in that
Travis when he gets home from preschool. Travis they can be closed, flexible, or too open to infor-
misses the food his mother prepared for him, his mation, people, or other forms of resources. Some
afternoon alone time with his mother when they families have closed boundaries as exemplified by
read a story, and being tucked into bed at night statements such as, “We as a family pull together
with songs and a back rub. Amy, who is a fresh- and don’t need help from others,” or “We take care
man in college, finds it difficult to concentrate of our own.” For example, if the Jones family were
while reading and studying for her college classes. to have a closed boundary, they would not want to
The formal and informal roles of all these family meet with the social worker or, if they did, they
members are affected by Linda’s hospitalization. would reject the idea of a home-health aide and
What affects Linda affects all the members of the respite care.
Jones family in multiple ways. Some families have flexible boundaries, which they
control and selectively open or close to gain bal-
Concept 2: The Whole Is More Than ance or adapt to the situation. For example, the
the Sum of Its Parts Jones family welcomes a visit from the pastor but
The family as a whole is composed of more than the turns down visits from some of the women in
individual lives of family members. It goes beyond Linda’s Bible study group. Some families have too
parents and children as separate entities. Families open boundaries in which they are not discriminating
are not just relationships between the parent-child about who knows their family situation or the num-
but are all relationships seen together. As we look ber of people from whom they seek help. Open
at the Jones family, it is a nuclear family—mother, boundaries can invite chaos and unbalance if the
father, and three children. They are a family system family is not selective in the quantity or quality of
that is experiencing the stress of a chronically ill resources. If the Jones family were to have truly
mother who is deteriorating over time; each of them open boundaries, it may reach out to the larger com-
is individually affected, but so is the family as a munity for resources and have different church
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78 Foundations in Family Health Care Nursing

members come stay with the children every ■ The last time your condition worsened,
evening. The permeability of boundaries resides on what was the least help to your family?
a continuum and varies from family to family. (See Concept 2.)
■ Who outside of your immediate family do
Concept 4: Systems Can Be Further you see as being a potential person to help
Organized Into Subsystems your family during the next week when you
In addition to conceptualizing the family as a go home? (See Concept 3.)
whole, nurses can think about the subsystems of the ■ How do you feel your family would react to
family, which may include husband to wife, mother having a home-health aide come to help you
to child, father to child, child to child, grandparents twice a week? (See Concept 3.)
to parents, grandparents to grandchildren, and so ■ Are there some friends, church members,
forth. These subsystems take into account the three or neighbors who might be able to help with
dimensions of families discussed in Chapter 1: some of the everyday management issues,
structure, function (including roles), and processes such as carpooling to school, or providing
(interconnection and dynamics). By understanding some after-school care for Travis so Katie
these three dimensions, family nurses can stream- could go to her after-school activities?
line interventions to achieve specific family out- (See Concepts 3 and 4.)
comes. For example, the Jones family has the ■ What are your thoughts about how the
following subsystems: parents, siblings, parent- children will react to having Grandma Elise
child, a daughter subsystem, an in-law subsystem, here to help the family? (See Concept 4.)
and a grandparent subsystem. The nurse may work
to decrease family stress by focusing on the marital Interventions by family nurses must address in-
spouse subsystem to help Linda and Robert con- dividuals, subsystems within the family, and the
tinue couple time, or the nurse may focus on the whole family all at the same time. One strategy
sibling subsystem of Katie and Travis and their would be to assess family process and functioning
after-school activities. and then offer intervention strategies to assist the
family in its everyday functioning. Nurses could ask
Application of Family Systems Theory the following types of questions about functioning:
to the Jones Family
■ Linda and Robert, from what you have told
The focus of the nurses’ practice from this perspec-
me, it appears that your oldest daughter,
tive is family as the client. Nurses work to help
Amy, has been able to help take on some of
families maintain and regain stability. Assessment
the parental jobs in the family by being the
questions of family members are focused on the
errand runner, chauffeur, and grocery shop-
family as a whole. While planning for Linda’s dis-
per. Now that Amy is off to college, which
charge that is scheduled in the next couple of days,
of your family roles will need to be covered
a nurse would ask questions such as the following
by someone else for a while when you and
to explore with Linda or with Linda and Robert:
Linda first come home: cooking, laundry,
■ Who are members of your family? (See chauffeur, cleaning the house?
Concept 1.) ■ Because you both shared with me that your
■ How do you see your family being involved family likes to go bowling on family night
in your care once you go home? (See out, how do you envision how Linda being in
Concept 1.) a wheelchair might affect family night out?
■ Who in your family will experience the most ■ Robert and Linda, have the two of you dis-
difficulty coping with the changes, especially cussed legal durable power of attorney for
now that you will be using a wheelchair? health care so Robert can make health care
(See Concept 1.) decisions when the time comes that Linda
■ How are the members of your family may not be able to do this for herself? Linda,
meeting their personal needs at this time? who would you prefer to make health care
(See Concept 1.) decisions for you, should you not be able to
■ The last time your condition worsened, what do so? Let’s discuss what those health care
helped your family the most? (See Concept 2.) decisions might involve.
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Theoretical Foundations for the Nursing of Families 79

■ Tell me about your personal/sexual relation- Families are seen as a system in that what happens
ship that you, Linda, are experiencing now at one level has powerful ramifications at other lev-
that you are more disabled. els of the system. Families are seen as the basic
social unit of society and as the optimal level of
The goal of using a family systems perspective
is to help the family reach stability by building on
The family developmental theories are specifi-
their strengths as a family, using knowledge of the
cally geared to understanding families and not in-
family as a social system, and understanding how
dividuals (Smith & Hamon, 2013; White & Klein,
the family is an interconnected whole that is adapt-
2008). Families, like individuals, are in constant
ing to the changes brought about by the health
movement and change throughout time—the fam-
event of a given family member.
ily life cycle. Family developmental theorists who
Strengths and Weaknesses of Family inform the nursing of families include Duvall
Systems Theory (1977); Duvall and Miller (1985); and McGoldrick,
The strengths of the general systems framework Carter, and Garcia-Preto (2010). The original
are that this theory covers a large array of phe- work of Duvall (1977), and later Duvall and Miller
nomena and views the family and its subsystems (1985), examined how families were affected or
within the context of its suprasystems (the larger changed cognitively, socially, emotionally, spiritu-
community in which it is embedded). Moreover, it ally, and physically when all members experienced
is an interactional and holistic theory that looks at developmental changes. The relationships among
processes within the family, rather than at the con- family members are affected by changes in individ-
tent and relationships between the members. The uals, and changes in the family as a whole affected
family is viewed as a whole, not as merely a sum of the individuals within the family. These theorists
its parts. Another strength of this approach is that recognized that families are stressed at common
it is an excellent data-gathering method and assess- and predictable stages of change and transition and
ment strategy, such as using a family genogram to need to undergo adjustment to regain family
gather a snapshot of the family as a whole or other stability. This early theoretical work was primarily
family system assessment instruments discussed in based on the experiences of white Anglo middle-
Chapter 4. class nuclear families, with a married couple,
Systems theory also has its limitations (Smith & children, and extended family.
Hamon, 2012). Because this theoretical orientation McGoldrick et al. (2010) expanded on the orig-
is so global and abstract, it may not be specific inal Developmental and Family Life Cycle Theory
enough for beginners to define family nursing in- because they recognized the dramatically chang-
terventions. It is important for family nurses to be ing landscape of family structure, functions, and
able to understand conceptually how important the processes that was making it increasingly difficult
family as a whole is to the practice of family nurs- to determine normal predictable patterns of change
ing. As health care systems continue to emphasize in families. They replaced the concept of “nuclear
the autonomy of the individual, it takes time and family” with “immediate family,” which takes into
practice to develop ways to deeply understand how consideration all family structures, such as stepfam-
a family, as a whole, is greater than the members ilies, gay families, and divorced families. Instead of
of the family. addressing the legal aspects of being a married cou-
ple, they viewed the concept of couple relationships
and commitment as a focal point for family bonds.
Developmental and Family Life Cycle
Theory Concept 1: Families Develop and Change
Developmental Theory provides a framework for Over Time
nurses to understand normal family changes and According to Family Developmental Theory, fam-
experiences over the members’ lifetimes; the the- ily interactions among family members change
ory assesses and evaluates both individuals and over time in relation to structure, function (roles),
families as a whole. Developmental stages for in- and processes. The stresses created by these
dividuals have been detailed by psychologists and changes in family systems are somewhat pre-
sociologists, such as Erikson, Piaget, and Bandura. dictable for different stages of family development.
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80 Foundations in Family Health Care Nursing

The first way to view family development is family undergoing a divorce and describes the
to look at predictable stresses and changes as they developmental tasks the family deals with at dif-
relate to the age of the family members and ferent stages.
the social norms the individuals experience According to this theory, families have a pre-
throughout their development. The classic tradi- dictable natural history. The first stage involves the
tional work of Duvall (1977) and Duvall and simple husband-wife pairing, and the family group
Miller (1985) identified overall family tasks that becomes more complex over time with the addition
need to be accomplished for each stage of family of new members. When the younger generation
development, as related to the developmental tra- leaves home to take jobs or marry, the original fam-
jectory of the individual family members. It starts ily group becomes less complex again.
with couples getting married and ends with one The second way to view family development is
member of the couple dying. Refer to Table 3-5 to assess the predictable stresses and changes in
for a detailed list of the traditional family life families based on the stage of family development
cycle stages and developmental tasks. McGoldrick and how long the family is in that stage. For ex-
et al. (2010) expanded the traditional develop- ample, suppose each of the following couples have
mental and family life cycle theory to address made a choice to be childless: a newly married
changes in the family that undergoes a divorce. couple, a couple who have been married for
Table 3-6 outlines the emotional process of a 3 years, and a couple who have been married for

Table 3-5 Traditional Family Life Cycle Stages and Developmental Tasks

Stages of Family Life Cycle Family Developmental Tasks

Married couple Establishing relationship as a married couple.
Blending of individual needs, developing conflict-and-resolution approaches,
communication patterns, and intimacy patterns.
Childbearing families with infants Adjusting to pregnancy and then infant.
Adjusting to new roles, mother and father.
Maintaining couple bond and intimacy.
Families with preschool children Understanding normal growth and development.
If more than one child in family, adjusting to different temperaments and styles
of children.
Coping with energy depletion.
Maintaining couple bond and intimacy.
Families with school-age children Working out authority and socialization roles with school.
Supporting child in outside interests and needs.
Determining disciplinary actions and family rules and roles.
Families with adolescents Allowing adolescents to establish their own identities but still be part of family.
Thinking about the future, education, jobs, working.
Increasing roles of adolescents in family, cooking, repairs, and power base.
Families with young adults: launching After member moves out, reallocating roles, space, power, and communication.
Maintaining supportive home base.
Maintaining parental couple intimacy and relationship.
Middle-aged parents Refocusing on marriage relationship.
Ensuring security after retirement.
Maintaining kinship ties.
Aging families Adjusting to retirement, grandparent roles, death of spouse, and living alone.
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Theoretical Foundations for the Nursing of Families 81

Table 3-6 Family Life Cycle for Divorcing Families

Emotional Process of Transition:

Phase Prerequisite Attitude Developmental Issues
The decision to divorce Acceptance of inability to resolve marital Acceptance of one’s own part in the failure
tensions sufficiently to continue of the marriage.
Planning the breakup of Supporting viable arrangements for all a. Working cooperatively on problems of
the system parts of the system. custody, visitation, and finances.
b. Dealing with extended family about the
Separation a. Willingness to continue cooperative a. Mourning loss of intact family.
co-parental relationship and joint financial b. Restructuring marital and parent-child
support of children. relationships and finances; adaptation to
b. Work on resolution of attachment to living apart.
spouse. c. Realignment of relationships with
extended family; staying connected with
spouse’s extended family.
The divorce More work on emotional divorce: a. Mourning loss of intact family.
overcoming hurt, anger, guilt, among b. Retrieval of hopes, dreams, expectations
other emotions. from the marriage.
c. Staying connected with extended

Postdivorce Family
Single parent (custodial Willingness to maintain financial responsi- a. Making flexible visitation arrangements
household or primary bilities, continue parental contact with with ex-spouse and family.
residence) ex-spouse, and support contact of chil- b. Rebuilding own financial resources.
dren with ex-spouse and his or her family.
c. Rebuilding own social network.
Single parent Willingness to maintain financial a. Finding ways to continue effective
(noncustodial) responsibilities and parental contact with parenting.
ex-spouse, and to support custodial b. Maintaining financial responsibilities to
parent’s relationship with children. ex-spouse and children.
c. Rebuilding own social network.

Source: Adapted from Carter, B., & McGoldrick, M. (2005). The divorce cycle: A major variation in the American
family life cycle. In B. Carter & M. McGoldrick (Eds.), The expanded family life cycle: Individual, family, and social
perspectives (3rd ed.). New York, NY: Allyn & Bacon.

15 years (White & Klein, 2008). The stresses each considered to be greatest at the transition points as
couple experiences from this decision would be families adapt to achieve stability, redefine their
different. concept of family in light of the changes, and re-
align relationships as a result of the changes
Concept 2: Families Experience Transitions (McGoldrick et al., 2010). For example, marriage
From One Stage to Another changes the status of all family members, creates
Disequilibrium occurs in the family during the new relationships for family members, and joins
transitional periods from one stage of development two different complex family systems.
to the next stage. When transitions occur, families Family developmental theorists explore whether
experience changes in kinship structures, family families make these transitions “on time” or “off
roles, social roles, and interaction. Family stress is time” according to cultural and social expectations
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82 Foundations in Family Health Care Nursing

(Smith & Hamon, 2012; White & Klein, 2008). For Today, the Developmental and Family Life
example, it is “off time” for a couple in their forties Cycle Theory remains useful as long as it is viewed
to have their first child. It is still considered “on generally for use with families, despite all the cur-
time” in North America to have a couple be married rent variations of families. McGoldrick et al. (2010)
before the birth of a child, but that norm may be recently expanded the Family Life Cycle to incor-
changing given the increased numbers of babies porate the changing family patterns and broaden
born to couples who are not married but cohabitate. the view of both development and the family.
Even though some family developmental needs
and tasks must be performed at each stage of the Application of Developmental and Family
family life cycle, developmental tasks are general Life Cycle Theory to the Jones Family
goals, rather than specific jobs that must be com-
In conducting family assessments using the devel-
pleted at that time. Achievement of family devel-
opmental model, nurses begin by determining the
opmental tasks enables individuals within families
family structure and where this family falls in the
to realize their own individual tasks. According to
family life cycle stages. Using the developmental
family developmental theory, every family is
tasks outlined in the developmental model, the
unique in its composition and in the complexity
nurse has a ready guide to anticipate stresses the
of its expectations of members at different ages
family may be experiencing or to assess the devel-
and in different roles. Families, like individuals,
opmental tasks that are not being accomplished.
are influenced by their history and traditions and
Family assessment would also entail determining
by the social context in which they live. Further-
whether the family is experiencing a “normative”
more, families change and develop in different
or “nonnormative” event in the family life cycle.
ways because their internal/external demands and
According to Duvall and Miller (1985), the
situations differ. Families may also arrive at simi-
Jones family is in the Families With Young Adults:
lar developmental levels using different processes.
Launching Phase because Amy left home and is now
Despite their differences, however, families have
a freshman at a college. She is living away from
enough in common to make it possible to chart
home for the first time. Regardless of the fact that
family development over the life span in a way
the Jones family is experiencing a nonnormative
that applies to most, if not all families (Friedman,
event (unexpected, developmental stressor) because
Bowden, & Jones, 2003). Families experience
Linda, the mother, is now in the hospital, the fam-
stress when they transition from one stage to the
ily is also experiencing the normative or expected
next. The predictable changes that are based on
challenges for a family when the oldest child leaves
these family developmental steps are called nor-
home. This is a good example of where major in-
mative changes. When changes occur in families
dividual and whole family events coincide and pres-
out of sequence, “off time,” or are caused by a dif-
ent challenges for families. Questions to explore
ferent family event, such as illness, they are called
with the family might include the following:
In contrast with the Duvall (1977) and later 1. How has the family addressed the realloca-
Duvall and Miller’s (1985) traditional develop- tion of family household physical space since
mental approach, Carter and McGoldrick (1989) Amy left for school? (For example, the allo-
and McGoldrick et al. (2010) built on this work cation of bedrooms or the arrangement of
by approaching family development from the per- space within the bedroom if Katie and Amy
spective of family life cycle stages. They explored shared the bedroom).
what happens within families when family mem- 2. How has Amy developed as an indirect
bers enter or exit their family group; they focus caregiver (such as calling home to chat with
on specific family experiences, such as disruption dad and see how he is doing, talking with
in family relationships, roles, processes, and fam- the siblings and teasing or supporting their
ily structure. Examples of a family member leav- efforts, or sharing with parents her school
ing would be divorce, illness, a miscarriage, or life to reduce their worry about her
death of a family member. Examples of family adjustment)?
members entering would include birth, adoption, 3. How have family roles changed since Amy
marriage, or other formal union. left for school? What roles did Amy perform
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Theoretical Foundations for the Nursing of Families 83

for the family that someone else needs to original eight-stage model was based on a nuclear
pick up now? For example, who will per- family, assumed an intact marriage throughout the
form such roles as chauffeur, grocery shop- life cycle of the family, and was organized around
per, errand runner, and babysitter now the oldest child’s developmental needs. It did not
that Linda is not able and Amy is gone? take into account divorce, death of a spouse, remar-
4. How has the power structure of the family riage, unmarried parents, childless couples, or co-
shifted now that Katie is more responsible habitating or gay and lesbian couples. It normalized
for the care of Travis? one type of family and invalidated others (Smith &
5. How has the parents’ couple time changed Hamon, 2012). Today’s families vary widely in
since Amy went off to college? their makeup and in their roles. The traditional
view of families moving in a linear direction from
With the developmental approach, nursing
getting married, tracking children from preschool
interventions may include helping the family to un-
to launching, middle-aged parents, and aging fam-
derstand individual and family developmental tasks.
ilies is no longer so clear-cut and applicable. Carter
Interventions could also include helping the family
and McGoldrick (1989, 2005), Carter (2005), and
understand the normalcy of disequilibrium during
McGoldrick et al. (2010) expanded the family
these transitional periods. Another intervention is
developmental model to include stresses in the re-
to help the family mitigate these transitions by cap-
married family. As family structures continue to
italizing on family rituals. Family rituals serve to
change in response to the culture and ecologic sys-
decrease the anxiety of changes in that they help
tem, trajectories of families likely will not fit within
link the family to other family members and to the
the traditional developmental framework (White
larger community (Imber-Black, 2005).
& Klein, 2008).
Family nurses must recognize that every family
must accomplish both individual and family devel-
opmental tasks for every stage of the Developmental Bioecological Systems Theory
and Family Life Cycle. Events at one stage of the
Urie Bronfenbrenner was one of the world’s lead-
cycle have powerful effects at other stages. Helping
ing scholars in the field of developmental psychol-
families adjust and adapt to these transitions is an
ogy (Bronfenbrenner, 1972a, 1972b, 1979, 1981,
important role for family nurses. It is important for
1986, 1997; Bronfenbrenner & Morris, 1998). He
nurses to keep in mind the needs and requirements
contributed greatly to the ecological theory of
of both the family as a whole and the individuals
human development, which concentrated on the
who make up the family.
interaction and interdependence of humans—as
biological and social entities—with the environ-
Strengths and Weaknesses of the ment. Originally this idea was called the Human
Developmental and Family Life Cycle Ecology Theory, then it was changed to Ecological
A major strength of the developmental approach is Systems Theory, and it finally evolved into the
that it provides a systematic framework for predict- Bioecological Systems Theory (Bronfenbrenner &
ing what a family may be experiencing at any stage Lerner, 2004). The Bioecological System is the
in the family life cycle. Family nurses can assess a combination of children’s biological disposition
family’s stage of development, the extent to which and environmental forces coming together to
the family has achieved the tasks associated with shape the development of human beings. This
that stage of family development, and problems theory combines both Developmental Theory
that may or may not exist. It is a superb theoretical and Systems Theory to understand individual and
approach for assisting nurses who are working with family growth.
families on health promotion. Family strengths and Before Bronfenbrenner, child psychologists
available resources are easier to identify because studied children, sociologists examined families,
they are based on assisting families to achieve anthropologists analyzed society, economists scru-
developmental milestones. tinized the economic framework, and political sci-
A primary criticism of family development the- entists focused on political structures. Through
ory is that it best describes the trajectory of intact, Bronfenbrenner’s groundbreaking work in “human
two-parent, heterosexual nuclear families. The ecology,” environments from the family to larger
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84 Foundations in Family Health Care Nursing

economic/political structures have come to be influences on the family from systems at different
viewed as part of the life course from childhood levels of engagement.
through adulthood. This “bioecological” approach Microsystems are the settings in which individuals/
to human development crosses over barriers among families experience and create day-to-day reality.
the social sciences and builds bridges among the They are the places people inhabit, the people with
disciplines, allowing for better understanding to whom they live, and the things they do together.
emerge about key elements in the larger social In this level, people fulfill their roles in families,
structure that are vital for optimal human develop- with peers, in schools, and in neighborhoods where
ment (both individual and family) (Boemmel & they are in the most direct interaction with agents
Briscoe, 2001). around them.
The human ecology framework brings together Mesosystems are the relationships among major
other diverse influences. From evolutionary theory microsystems in which persons or families actively
and genetics comes the view that humans develop participate, such as families and schools, families
as individual biological organisms with capacities and religion, and families to peers. For example,
limited by genetic endowment (ontogenetic develop- how does the interaction between families and
ment) that lead to hereditary familial characteristics. school affect families? Can the relationship
From population genetics comes the perspective between families and their religious/spiritual com-
that populations change by means of natural selec- munities be used to help families?
tion. For the individual, this means that individuals/ Exosystems are external environments that influ-
families demonstrate their fitness by adapting to ence individuals and families indirectly. The person
ever-changing environments. From ecological the- may not be an active participant within these sys-
ories come the notion that human and family de- tems, but the system has an effect on the persons/
velopment is “contextualized” and “interactional” families. For example, a parent’s job experience
(White & Klein, 2008, p. 247). All of this leads to affects family life, which, in turn, affects the chil-
the never-ending debate related to the dual nature dren (parent’s job’s travel requirements, job
of humans as constructions of both biology and stress, salary). Furthermore, governmental funding
culture, hence the argument nature versus nurture. to other microsystems environments—schools, li-
Although this debate has never been resolved, sci- braries, parks, health care, and day care—affect the
entists have moved beyond debate to the realization experiences of children and families.
that the development of most human traits depends Macrosystems are the broad cultural attitudes, ide-
on a nature/nurture interaction rather than on one ologies, or belief systems that influence institutional
versus the other (White & Klein, 2008). Thus, environments within a particular culture/subculture
Bronfenbrenner moved his own theory and ideas in which individuals/families live. Examples include
from the concept and terminology of ecology (en- the Judeo-Christian ethic, democracy, ethnicity,
vironment) to bioecology (both genetics and soci- and societal values. Mesosystems and exosystems
ety) as a way of embracing two developmental are set within macrosystems, and together they
origins for this theory. His Bioecological Systems are the “blueprints” for the ecology of human and
Theory emphasizes the interaction of both the family development.
biological/genetics (ontologic/nature) and the so- Chronosystems refer to time-related contexts where
cial context (society) characteristics of development changes occur over time and have an effect on the
(Smith & Hamon, 2012; White & Klein, 2008). other four levels/systems of development mentioned
The human bioecological perspective consists of earlier. Chronosystems include the patterning of
a framework of four locational/spatial contexts and environmental events and transitions over the life
one time-related context (Bengtson, Acock, Allen, course of individuals/families. These effects are cre-
Dilworth-Anderson, & Klein, 2005). A primary fea- ated by time or critical periods in development and
ture of this theory is the premise that individual and are influenced by sociohistorical conditions, such as
family development is contextual over time. Accord- parental divorce, unexpected death of a parent, or a
ing to Bronfenbrenner, individual development is war. Individuals/families have no control over the
affected by five types or levels of environmental sys- evolution of such external systems over time.
tems (Figure 3-6) (Emory University, 2008). Family Within each one of these levels are roles,
Bioecological Theory describes the interactions and norms, and rules that shape the environment.
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Theoretical Foundations for the Nursing of Families 85

ns or environment
in perso over
h a nges time
toms of one’s culture, su
n d c us b cu
s, a ltur
aw e, o
gy, l rs
olo oc
Extended Family s

B ro s






of Neighbors

., p

School Neighborhood

play area


l divo


Mass Family Day-care Legal
media center services

synagogue Peers

Doctor’s office board

st e

Community health


welfare services

torical Conditions

FIGURE 3-6 Bioecological Systems Theory Model.

Bronfenbrenner’s model of human/family devel- parents, teachers, and society. All relationships
opment acknowledges that people develop not in among humans/families and their environment are
isolation, but rather in relation to their larger en- bidirectional or interactional. The environment in-
vironment: families, home, schools, communities, fluences us as individuals or families, but, in turn,
and society. All of these interactive, ever-changing, individuals/families influence what happens in their
and multilevel environments over time are key to own environments. This kind of interaction is also
understanding human/family development. basic to family systems theory.
Bronfenbrenner uses the term bidirectional to In the bioecological framework, what happens
describe the influential interactions that take place outside family units is as important as what hap-
between children and their relationships with pens inside individual members and family units.
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86 Foundations in Family Health Care Nursing

Developing families are on center stage as an ac- macrosystem shows that this community is largely
tive force shaping their social experiences for them- white, with only 10% of residents from ethnic
selves. The ecological perspective views children/ backgrounds. Most people in the community em-
families and their environments as mutually shap- brace a Christian ethic.
ing systems, each changing and adapting over time The value system includes a family focus and a
(again, a systems perspective). The bioecological strong work ethic. Many of the people prefer the
approach addresses both opportunities and risks. Democratic Party. In terms of the time-related
Opportunities mean that the environment offers contexts of the chronosystem, a few things are no-
families material, emotional, and social encourage- table. These time-related events put more stress on
ment compatible with their needs and capacities. the family than usual nonnormative events. Linda’s
Risks to family development are composed of direct disease process with MS has exacerbated in recent
threats or the absence of opportunities. times, placing additional strain on the family sys-
tem. Robert’s own dad died in the past year, leaving
Application of the Bioecological Systems him extra responsibility for his widowed mother in
Theory to the Jones Family addition to his responsibility for his own children
Assessment consists of looking at all levels of the and now ill wife. The economy in the country and
system when interviewing the family in a health region is going through a recession, leading people
care setting. Assessment of the microsystem reveals to feel some fear about their economic futures.
that the Jones family consists of five members: two Robert had hoped that his wife could go to work
parents and three children. They live in a two-story part-time when their youngest child went to
home with four bedrooms in an older suburban school, but that no longer seems to be a possibility.
section of the town. Mother Linda had been a full- The family assessment would include how the fam-
time homemaker before experiencing health prob- ily at each of the earlier-mentioned levels is influ-
lems related to her diagnosis of MS. The mesosystem enced by the changes brought about by Linda’s
assessment for the family consists of identifying the progressing debilitative disease and recent hospi-
schools the children attend, neighborhood/friends, talization. The family is experiencing disturbance
extended family, and religious affiliation. The old- at many of these levels.
est daughter is a college student who travels home Interventions include the following possibilities.
on weekends to help the family. The second daugh- In general, nurses can also look for additional sys-
ter is in a local middle school and can walk back tems with which the family could interact to help
and forth to her school. The youngest child, a boy, support family functioning during this family ill-
attends an all-day preschool and is transported by ness event. Nurses could make home visits to assess
his parents or other parents from the preschool. the living arrangements of the family and to deter-
The family has attended a Protestant church in the mine how the home could be changed to accom-
neighborhood. The family lives in a house in an modate a wheelchair/walker. The nurses should
older established neighborhood, and has made talk with the parents about their relationship to the
friends through the schools, church, and neighbor- schools, church, and extended family support sys-
hood contacts. Part of the extended family (grand- tems. The parents might be advised to inform the
parents) live nearby, and all of the family members school(s), church, workplace, and grandparents of
get together for the holidays; neither parent has what is happening to their family. The nurses could
siblings who live nearby. The exosystem assessment make suggestions relative to Travis’s current be-
shows that father Robert works 40 hours a week for havior with having to go to all-day preschool. The
an industrial plant at the edge of town, and he nurses also could explore with the family the larger
drives back and forth daily. The father has some external environment, including community re-
job stress, because he is in a middle-management sources (e.g., Multiple Sclerosis Society, visiting
position. His salary is average for middle-class fam- nurse service, or counseling services). The nurses
ilies in the United States. State and county funding should contact the medical doctor(s) and discharge
to the area schools, libraries, and recreational facil- planning nurse at the hospital to obtain informa-
ities are always a struggle in this community. The tion to interpret the diagnosis, prognosis, and treat-
town has physicians/clinics of all specialties and has ment of MS to the family. The nurses might talk
one community hospital. An assessment of the to the family about how their faith can be of help
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Theoretical Foundations for the Nursing of Families 87

during these tough times and what their primary Chronic Illness Framework
concerns are as a family. The nurses should get in
touch with the social workers at the hospital to co- The Chronic Illness Framework was proposed by
ordinate care and social well-being strategies for Rolland (1987, 1994) to help foster understanding
the posthospitalization period, as well as in the of how chronic illness affects the family. Chronic
future. Strategies may involve application to social illness is a complex concept that has vast implica-
security for the disabled. A family care planning tions for the individual and the family. Rolland’s
meeting should be set up to involve as many care- conceptual framework has evolved over time and
takers and stakeholders as possible. helps nurses think about multiple factors of the ill-
Evaluation of the interventions would consist ness and how these influence family functioning.
of follow-up with the family through periodic This framework, sometimes called the Family Sys-
home visits and telephone contact. The nurses tems and Chronic Illness Framework (Rolland,
would be interested in how the family is adapting 1987), has three major elements:
to its situation, how the father is dealing with the ■ Illness types
extra responsibility, how the children are coping, ■ Time phases of the illness
and the physical and mental health of the mother. ■ Family functioning
Because MS is a chronic progressive relapsing dis-
order, a plan would be put into place for periodic The illness types include the following aspects
evaluations that might involve changing the plan of chronic illness: onset of the illness, the course
of care. of the disease, the outcome of the illness, and the
degree of incapacitation of the family member.
Strengths and Weaknesses of The aspect of time addresses how issues facing
the Bioecological Systems Theory families and individuals vary depending on the
The strength of the bioecological perspective is that timing in the course of the illness, such as initial
it represents a comprehensive and holistic view of diagnosis, long chronic illness day-to-day adjust-
human/family development—a bio/psycho/socio/ ment phase, or terminal phase. All of these factors
cultural/spiritual approach to the understanding of influence the third major concept of family func-
how humans and families develop and adapt to the tioning. Family functioning includes the demands
larger society. It includes both the nature (biological) of managing the illness and the family strengths
and nurture (environmental contexts) aspects of and vulnerabilities. All of these aspects of the
growth and development for both individuals and Chronic Illness Framework are detailed in the fol-
families. It directs our attention to factors that lowing section. Figure 3-7 depicts the different
occur within, as well as to the layered influences of factors that influence how the family experiences
factors that occur outside individuals and families. the chronic illness of a family member. The over-
The bioecological perspective provides a valuable arching factor for families living with chronic ill-
complement to other theories that may offer ness is the degree of uncertainty about how the
greater insight into how each aspect of the holistic illness will present and affect the family. According
approach affects individuals and families over time. to the Chronic Illness Framework, it is possible to
The strength of this theory is also part of the have at a minimum 24 different configurations of
weakness of this approach. The different systems the factors that influence chronic illness and family
show nurses what to think about that may affect the systems (Rolland, 1987).
family, but the direction of how the family adapts is
not specifically delineated in this theory. In other Illness Types
words, the bio/psycho/socio/cultural/spiritual as- Onset of Illness: Gradual or Acute
pects of human/family growth and development are When chronic illness has an acute onset (e.g.,
not detailed enough to define how individuals/ a spinal cord injury, a traumatic brain injury, or
families can accomplish or adapt to these contextual an amputation), the family reacts by rapid mobi-
changes over time. Aspects of the theory require lization of crisis mode strategies to manage the
further delineation and testing, that is, the influence situation. These strategies include short-term
of biological and cognitive processes and how they role flexibility, accessing previously used problem-
interact with the environment. solving approaches in other crises, and the ability
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88 Foundations in Family Health Care Nursing

Chronic Illness Framework

(Rolland, 1987)

Illness Types

Incapacitating Progressive Gradual

Non-incapacitating Constant Acute

Fatal Relapsing



Family Functioning Time Phases

Demands of Family strengths Initial/crisis Mid Terminal

illness and vulnerabilities

FIGURE 3-7 Family systems and illness model.

to use outside resources. As the acute phase of a develop and family caregiving tasks evolve over
chronic condition morphs into a chronic illness—or time. Examples of a progressive chronic illness are
if a chronic illness has a gradual onset, such as amyotrophic lateral sclerosis (ALS), Huntington’s
multiple sclerosis, Parkinson’s disease, or renal disease, and Parkinson’s disease.
failure—the family adaptation occurs over a pro- Chronic illness is considered constant when,
longed period of time. after the initial chaos and stress caused by the acute
Course of Illness: Progressive, Constant, illness/injury, it evolves into a semipermanent
or Relapsing/Episodic change in condition that is stable and somewhat
The issues families manage are affected by the predictable. The potential for family stress and
course of the illness. Chronic disease, however, is exhaustion are present, but to a lesser degree than
seldom a pure typology and over time it often in a progressive chronic illness. Examples of a con-
changes from one course to another. When indi- stant chronic illness are spinal cord injuries, cere-
vidual family members have a progressive chronic brovascular stroke, and myocardial infarction.
illness, the disability occurs in a stepwise fashion. With a relapsing/episodic chronic illness, fam-
It requires families to make gradual changes in ilies alternate between stable low symptomology
their roles to adapt to the losses and needs of the periods and periods of exacerbation with flare-up.
family member as the illness progresses in severity. Families are strained by both the frequency of the
The families must address perpetual symptoms, transition between stable and unstable crisis
which requires continual adaptation mixed with modes of functioning and the ongoing uncer-
minimal periods of relief. Thus, families usually tainty of when the remission and exacerbation
experience exhaustion from the demands of the will occur. The uncertainty and unpredictability
illness. As the disease progresses, new family roles of relapsing is very taxing on families. Examples
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Theoretical Foundations for the Nursing of Families 89

of relapsing/episodic chronic illness are multiple (3) accept the diagnosis (Danielson, Hamel-Bissell,
sclerosis, bipolar disorder, schizophrenia, and lupus. & Winstead-Fry, 1993). All diagnoses have the po-
Outcome: Trajectory of Illness tential to create stress. The diagnostic process cre-
The trajectory of the illness and the possible out- ates stress and uncertainty in families. Families
come affect family functioning. Stress is constant vary in their ability to seek resources or informa-
and adaptation strained when the chronic illness has tion and to understand the ramifications of the
a fatal outcome that results in a shortened life span, diagnosis. For some families, the diagnosis is un-
such as metastatic cancers, ALS, Huntington’s expected and can put the family in a crisis mode.
disease, or cystic fibrosis. Other chronic illnesses For other families, the diagnosis is confirmation of
do not shorten the individual’s life span, so they their observations and concerns and so may result
do not generate the same amount of family adjust- in relief. Families may or may not accept the diag-
ment as other outcomes. Types of chronic illness nosis. Some families may deny the diagnosis, and
that do not shorten a person’s life span are arthri- others will question the diagnosis and seek other
tis, chronic fatigue syndrome, and gluten intoler- opinions. Once a medical diagnosis is given to
ance. Some chronic illnesses both shorten the life families, the diagnosis becomes public knowledge,
span of the individual and have the potential for which means that everyone who knows the diag-
sudden death. Examples of these types of chronic nosis has a reaction and response. Families may
illness include congestive heart failure and auto- choose to keep the information within their family
nomic dysreflexia with a high spinal cord injury. unit or be discriminating about whom they tell.
These types of chronic illness present with a dif- Nurses have a central role in providing informa-
ferent set of family stressors and adaption needs tion to families with new diagnoses and helping
than either of the two other possible outcomes or them navigate the health care system. Family
trajectories. education is critical to the health outcomes, specif-
Outcome: Incapacitation ically integrating the medical treatment plan into
The extent and kind of incapacitation of the illness family life and family roles.
places different stressors on the family and the in- Mid–Time Phase
dividual living with chronic illness. Incapacitation The mid–time phase is considered the “long haul”
can present in a variety of ways, such as cognitive of chronic illness (Rolland, 1987, 2005a). Rolland
(Alzheimer’s disease, Parkinson’s disease), energy (2005a) outlined the salient issues in this phase:
production or expenditure (congestive heart failure, (1) pacing and avoiding burnout, (2) minimizing
chronic obstructive pulmonary disease), impaired relationship skew between the patient and other
mobility (stroke, multiple sclerosis, cerebral palsy), family members, (3) sustaining autonomy for
disfigurement (amputation, scars), or social stigma all members of the family, (4) preserving or
(mental health disorders or HIV). redesigning individual and family development
goals within the constraints of the illness, and
Time Phases (5) sustaining intimacy in the face of threatened
The stress responses and needs of the family loss. According to Danielson, Hamel-Bissell, and
change depending on the time phase of the illness. Winstead-Fry (1993), this time phase also includes
The needs of the family when a chronic illness is the following challenges: (1) accept the treatment
newly diagnosed are different than when a person plan, (2) reorganize family roles, and (3) maintain
adjusts and lives with the illness over time. The a positive relationship with health care providers.
needs change again when ill family members enter Once families accept the diagnosis, they move into
the terminal phase of their chronic illness. Specific what Danielson et al. (1993) called “illness career,”
family stressors or needs for each time phase are which is a way that families adapt and adjust to the
outlined below. illness on a day-by-day basis. The major challenge
Initial/Crisis Time Phase of the family is to redefine what is a normal bal-
When family members are first diagnosed with a anced family life while also facing uncertainty
chronic illness they must (1) establish a positive about the future (Rolland, 2005a, 2005b). During
working relationship with health care providers, this phase, families are constantly adjusting to the
(2) gather information about the diagnosis, and situation caused by the illness. Families vary in
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90 Foundations in Family Health Care Nursing

their ability to adjust to the illness situation—the presented earlier in the chapter, the demands of the
more problems adjusting, the more stress families illness can take multiple forms, depending on the
will experience. Family role stress, role strain, and illness type and the time phases of the illness. As
role overload can occur when the family lives with each family is unique in its strengths and vulnerabil-
illness over a long period. ities, the ways in which families adapt to the chal-
Family tasks in this phase are to redefine normal, lenge of chronic illness are vast and too numerous
adjust to social stigma or altered relationships to list, which reinforces the opening statements of
caused by the disability or illness, continue to main- this chapter that nurses who bring knowledge of a
tain positive relationships with the health care variety of models, theories, and conceptual frame-
team, and successfully grieve the loss caused by the works to their practice tailor their practice to the
disability or chronic condition. The family must family needs by building on the strength of families
adjust continually to the remission and exacerba- in creative ways.
tions of the illness. One of the major tasks is to bal-
Application of the Chronic Illness
ance the needs of the family and the needs of ill
family members (Danielson et al., 1993).
Framework to the Jones Family
Families must adapt to the demands of the The Jones family is living with, adjusting to, and
chronic condition; thus, a whole body of informa- stressed and influenced by Linda’s chronic illness
tion has evolved around family coping and family of multiple sclerosis (MS). The course of MS is a
adaptation with medical regimens. How do families gradual onset of symptoms. Linda was diagnosed
promote the recovery of ill members while preserv- after the birth of her second child, Katie; therefore,
ing their energy to nurture other family members the Jones family has been living with her chronic
and perform other family functions? An example of illness for 13 years. The course of illness for Linda is
an appropriate intervention would be to help fam- typical of many individuals with MS. For the first
ilies find respite care for family caregivers so that 10 years, or in the Jones’ case 13 years, of the dis-
caregivers do not “burn out.” The family relation- ease, the most common type of MS is relapsing MS
ship with the health care provider(s) is a critical (RMS), which is characterized by exacerbation
component of this phase. Families expect that they (relapses and attacks) followed by partial recovery
will be active members of the treatment team. periods (remission) and no disease progression be-
Terminal Time Phase tween exacerbations. For most people with MS,
The nursing tasks in the terminal time phase con- after this initial course of disease, the presentation
sist of working with the family through the dying changes to progressive. At this point in time,
of the family member, through the grieving Linda’s illness has morphed to secondary progres-
process, to integrating the loss into the family and sive MS (SPMS), which is characterized by a
family life. Nurses can work with families to change steadily worsening disease course with or without
focus from managing the illness to comfort care occasional exacerbations, minor partial recoveries,
strategies and working on the concept of “letting or plateaus until death. Approximately 50% of
go” (Rolland, 2005a). During this time, an impor- people with RMS will convert to SPMS within
tant nursing role is to help families with the cascade 10 years (Lewis, Dirksen, Heitkemper, Bucher, &
of decisions that occur in the terminal phase. Each Camera, 2011). The Jones family remains in the
family member will respond differently to the loss, mid–time phase of the illness trajectory, but the
and the family will be forever changed by the loss. change in the course of Linda’s illness brings
The loss requires the family to adjust and adapt with it increased incapacitation and an unpredictable
to the finality and to develop or generate a different outcome.
sense of identity of family without the person The Jones family is constantly adjusting and
(see Chapter 10). adapting to the course of Linda’s illness and in-
creasing incapacitation. The family is exhausted
Family Functioning with managing this change; solutions that have
Families, as a whole, experience health events. worked for this family in the past are not working
When family members become ill, it triggers a now. The family roles need to be supported, rede-
stress response in the family to adapt to the needs fined, or renegotiated. Each of the members is ex-
of the individual and the family member. As periencing role stress and strain. Linda is having
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Theoretical Foundations for the Nursing of Families 91

to “let go” of more of her mothering role and ac- Family Assessment and Intervention
tions. Her self-concept regarding her illness has Model
been changed. Robert is having role overload with
all the changes in his life. The intimacy needs of The Family Assessment and Intervention Model,
the couple are stressed by these changes. Amy is originally developed by Berkey and Hanson
thinking of staying home and not going to college (1991), is based on Neuman’s Health Care Sys-
in another town. Katie is now a struggling student. tems Model (Hanson, 2001; Hanson & Mischke,
Travis is a full-day student in a preschool. Grand- 1996; Kaakinen & Hanson, 2010). Neuman’s
mother, Elise, will no longer be living independ- model and theoretical constructs are based on
ently as she moves into the Jones family home to systems theory and were extended and modified
assume new roles as caretaker to the children and to focus on the family rather than on the individ-
Linda. All the role changes, and seeing Linda get ual (Neuman & Fawcett, 2010). Figure 3-8 de-
worse or more incapacitated, creates uncertainty picts the Family Assessment and Intervention
about the future for each member and the family Model.
as a whole. Each family member experiences un- According to the Family Assessment and Inter-
certainty differently based on age, family roles, vention Model, families are viewed as a dynamic,
role expectations, and the developmental needs of open system interacting with their environment.
each person. One of the roles for families is to help buffer their
Family functioning is of central concern for the members, or protect the family as a whole, from
family nurse as he helps Linda and the family learn perceived threats to the family system. The core of
to adapt to new treatment and regimen manage- the family system comprises basic family structure,
ment issues and establish a new normal day-to-day function, processes, and energy/strength resources.
long-haul balance. One aspect of family function- This basic family structure must be protected at all
ing the nurse can help with revolves around family costs, or the family ceases to exist. The family de-
roles. The nurse can assist by exploring options for velops normal lines of defense as an adapting mech-
care and potential future decisions the family may anism and abstract flexible protective lines of
face as Linda’s health continues to decline and the defense when the system is threatened by signifi-
time phase changes to terminal. cant stressors. Family systems are vulnerable to
tensions produced when stressors in the form
Strengths and Weaknesses of the Chronic of problems or concerns penetrate the family’s lines
Illness Framework of defenses. Families also have lines of resistance to
The strength of this descriptive framework is that help prevent penetration into the basic family core.
it outlines how multiple factors of a chronic illness The lines of defense and resistance depicted in the
can be grouped in a variety of ways that affect model (see Fig. 3-8) demonstrate how unexpected/
family functioning. Rolland’s (1987, 1994) con- unwanted health status changes can affect the basic
ceptual framework depicts the complexity of family unit or core.
chronic illness and the diversity of potential family Families are subject to imbalance from normal
responses to chronic illness. It may appear at first homeostasis when stressors (e.g., physical or mental
glance that families have similar circumstances health problems) penetrate families’ flexible and
given the same chronic illness, but on closer as- normal lines of defense. Furthermore, the stressors
sessment it becomes clear that families’ experi- can challenge the families’ lines of resistance, which
ences of the different components of this have been put in place to maintain stability and to
framework result in different family stressors and prevent penetration of the basic family defense sys-
strengths. tem. In other words, health events cause families to
The weakness of this model is the same as the react to stressors created by changes in the health
strengths in that the complexity of chronic illness is status of a family member. Families vary in their
not predictive. Because this framework depicts how response to the stressors and in their ability to
the individual’s illness progresses from more of a cope, depending on how deeply the stressors pen-
medical model, it is easy for nurses to focus only on etrate the basic family unit and how capable or ex-
that part of the framework and not think about the perienced the family is in adapting to maintain its
overarching aspect of the family as a whole. stability.
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92 Foundations in Family Health Care Nursing

Area 1: Wellness-health promotion activities:

problem identification and family factors at line of defense and resistance

o rs Stre
ess sso
Str rs

ble line of defense

Area 3: Restoration of family stability and family functions at levels of prevention/intervention


Area 2: Family's reaction and instability at lines of defense and resistance

mal line defense
No r
of resistance
n/interv ion level

rvention level
ervention level

Basic family structure,

function, process,

Lines of

and energy resources





le lin













c Te


es ors
so ess
rs Str

FIGURE 3-8 Family Assessment and Intervention Model.

Reconstitution or adaptation is the work the (3) restoration of family stability and family func-
family undertakes to preserve or restore family sta- tioning at levels of prevention and intervention.
bility after stressors penetrate the family lines of The Family Assessment and Intervention Model
defense and resistance. This process alters the focuses specifically on what causes family stress and
whole of the family. The model addresses three how families react to this stress. One critical con-
areas: (1) wellness–health promotion activities— cept is to build on the family’s strengths by helping
problem identification and family factors at lines of the family identify its problem-solving strategies.
defense and resistance, (2) family reaction and in- The basic assumptions of this family-focused
stability at lines of defense and resistance, and model are listed in Box 3-1.
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Theoretical Foundations for the Nursing of Families 93

BOX 3-1
Basic Assumptions for Family Assessment and Intervention Model

■ Although each family has a unique family system, all ■ When the flexible line of defense is no longer capable
families have a common basic structure that is a com- of protecting the family or family system against the
posite of common, known factors or innate characteris- environmental stressor, the stressor is said to break
tics within a normal given range of response. through the normal line of defense.
■ Family wellness is on a continuum of available energy ■ Families have an internal resistance factor called the line
to support the family system in its optimal state. of resistance that functions to stabilize and return the
■ The family, in both a state of wellness or illness, is a family to its usual wellness state (normal line of de-
dynamic composite of interrelationships of variables fense), or possibly to a higher level of stability after an
(physiological, psychological, sociocultural, developmental, environmental stressor reaction.
and spiritual). ■ Primary prevention is general knowledge that is applied
■ A myriad of environmental stressors can affect the fam- in family assessment and intervention for identification
ily. Each stressor differs in its potential for disturbing the and mitigation of risk factors associated with environ-
family’s stability level or normal line of defense. The mental stressors to prevent possible reaction.
specific family interrelationships (physiological, psycho- ■ Secondary prevention is symptomatology after reaction
logical, sociocultural, developmental, and spiritual) af- to stressors, appropriate ranking of intervention priori-
fect the degree to which a family is protected by its ties, and treatment to reduce their noxious effects.
flexible lines of defense against possible reactions to ■ Tertiary prevention is the adjusting processes that take
the stressors. place as reconstitution begins and maintenance factors
■ Families evolve a normal range of response to the envi- move the client back in the circular manner toward
ronment, which is called a normal line of defense. The primary prevention.
normal line of defense is flexible or accordion-like as it ■ The family is in a dynamic, constant energy exchange
moves to protect the family. with the environment.

Adapted from Berkey, K. M., & Hanson, S. M. (1991). Pocket guide to family assessment and intervention. St. Louis,
MO: Mosby–Year Book.

complete the FS3I, or the entire family can sit

Family Systems Stressor-Strength Inventory together and complete the assessment. The nurse
Berkey and Hanson (1991) developed an assess- meets with family members and interviews them to
ment, intervention, and measurement tool, the clarify their perceived general stressors, specific
Family Systems Stressor-Strength Inventory (FS3I), stressors, and family strengths as identified by the
to help guide nurses working with families who family members.
are undergoing stressful health events and to After the interview, the nurse completes the
build on the strengths of the family. The FS3I is quantitative summary and enters each respondent’s
divided into three sections: (1) family systems score on the graph. Recording individual scores on
stressor—general, (2) family stressors—specific, the graph allows for a comparison of the family re-
and (3) family system strengths. The tool helps sponses and visually shows the variability among
nurses assess family stability by gathering infor- family members’ perceptions of general and specific
mation on family stressors and strengths. The as- health stressors. The nurse synthesizes the inter-
sessment of general, overall stressors is followed view information gleaned from all the family par-
by an assessment of specific issues or problems, ticipants on the qualitative summary. Together, the
such as birth of first child, automobile accident, nurse and family develop a family care plan with in-
or family divorce. The tool helps to identify fam- tervention strategies tailored to the individual fam-
ily strengths to help determine potential or actual ily needs and built on the strengths of the family.
problem-solving abilities of the family system. A major benefit of using the FS3I for family as-
Examples of family strengths could include sup- sessment and intervention planning is that both
portive extended family, health insurance, and quantitative and qualitative data are used to deter-
availability of family counseling. mine the level of prevention and intervention
The FS3I is intended for use with multiple fam- needed: primary, secondary, or tertiary (Pender,
ily members. Individual members of the family can Murdaugh, & Parsons, 2006). Primary prevention
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94 Foundations in Family Health Care Nursing

focuses on moving the individual and family to- Family; Figure 3-10, which presents an FS3I quan-
ward a state of improved health or toward health- titative summary of family system stressors, general
promotion activities. Primary interventions include and specific, for the Jones family; Figure 3-11,
providing families with information about their which lists FS3I family and clinician perception
strengths, supporting their coping and functioning scores of the Jones family; Figure 3-12, which is an
capabilities, and encouraging movement toward FS3I qualitative summary, family and clinician, of
health through family education. Secondary inter- the Jones family; and Figure 3-13, which provides
ventions attain system stability after stressors or an FS3I family care plan for the Jones family.
problems have invaded the family core. Secondary The qualitative summary, family and clinician
interventions include helping the family to handle form in Figure 3-12, serves as the groundwork for
its problems, helping family members to find and the family care plan. This form synthesizes infor-
use appropriate treatment, and intervening in mation pertaining to general stressors, specific
crises. Tertiary prevention is designed to maintain stressors, family strengths, and the overall func-
system stability through intervention strategies that tioning and physical and mental health of the fam-
are initiated after treatment has been completed. ily members. The nurse completed this form using
Coordination of care after discharge from the hos- her assessment skills with information obtained
pital and postdischarge rehabilitation services are from the verbal exchange and the FS3I.
examples of tertiary prevention. The family members and the nurse perceived
The Family Assessment and Intervention Model that the chronic and debilitating diagnosis of MS
focuses on the family as client. The Family Systems was the major general stressor. Linda’s specific
Stressor-Strength Inventory (FS3I) was developed to stressors included her growing inability to func-
provide a concrete, focused assessment and interven- tion as a wife and mother; her physical problems,
tion instrument that helps families identify current such as increasing physical weakness, swallowing
family stressors and strengths and that assists nurses challenges, pain, vision impairment, vertigo/tinnitus,
and families in planning interventions to meet family constipation, urinary infections; and her mental
needs. The model and inventory represent a nursing health issues, such as guilt, anxiety, and depression.
model made for nursing care of families. An updated Specific stressors for Robert included his worry
blank copy of the instrument, with instructions for about Linda’s health; loss of his life’s partner in
administration and a scoring guide, can be found in taking care of the family, household maintenance,
Appendix A. A summary of a completed instrument and raising children; fear of the unknown future
applied to the case study follows. and health outcomes; loss of sexual expression with
his wife; and financial worries. The strengths of
Application of the Family Assessment and the family were seen as communication between
Intervention Model With the Jones Family the couple, religious faith, the social support net-
The FS3I was used to assess stressors (problems) work of extended family, and the availability of
and strengths (resources) that the Jones family had good health providers. The overall family func-
to cope with their situation. Robert and Linda were tioning was considered to be as good as could be
interviewed together by the nurse, but each person expected under the circumstances. Where the
completed a separate FS3I. Scores were tallied mother’s physical health was compromised, the
using the scoring guide for the FS3I. Amy was away father’s physical health was good. Both Linda
attending college, and Katie and Travis were too and Robert expressed mental health concerns.
young to complete the assessment instrument. Overall, the nurse perceived that this family
The general stressors were viewed similarly by had the strengths it needed to deal with both the
both Robert and Linda, and these stressors were general and specific stressors. After completing a
assessed as more serious by the nurse than by the genogram (Fig. 3-3) and ecomap (Fig. 3-4) of this
couple. Robert, Linda, and the nurse concurred family unit, the nurse concluded that the family
that the general stress level was high. The specific was being supported by community/family re-
stressors were perceived slightly differently by sources. These social support systems are impor-
Robert and Linda. The following figures summa- tant factors in coping with stress, and the nurse
rize information gained from the Jones family: concluded that this family could use assistance in
Figure 3-9, which applies the FS3I to the Jones utilizing these resources.
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Theoretical Foundations for the Nursing of Families 95

The Family Systems Stressor-Strength Inventory (FS I) is an assessment and measurement instrument
intended for use with families (see Chapter 14). It focuses on identifying stressful situations occurring in
families and the strengths families use to maintain healthy family functioning. Each family member is asked
to complete the instrument on an individual form before an interview with the clinician. Questions can be
read to members unable to read.
After completion of the instrument, the clinician evaluates the family on each of the stressful situations
(general and specific) and the strengths they possess. This evaluation is recorded on the family member form.
The clinician records the individual family member’s score and the clinician perception score on the
Quantitative Summary. A different color code is used for each family member. The clinician also completes
the Qualitative Summary, synthesizing the information gleaned from all participants. Clinicians can use
the Family Care Plan to prioritize diagnoses, set goals, develop prevention and intervention activities, and
evaluate outcomes.
Family Name Jones Date April 18, 2009
Family Member(s) Completing Assessment Robert and Linda
Ethnic Background(s) “American all mixed up”
Religious Background(s) Protestant
Referral Source Neurologist For Linda
Interviewer Meredith Rowe, RN
Family Relationship Education
Members in Family Age Marital Status (highest degree) Occupation

1. Robert Father 48 yr Married MS Software engineer

2. Linda Mother 43 yr Married Home maker
3. Amy Daughter 19 yr Single
4. Katie Daughter 13 yr Single
5. Travis Son 4 yr Single
Family’s current reasons for seeking assistance:
Linda MS is progressing family feels stressed.

FIGURE 3-9 Family System Stressor-Strength Inventory: Jones family. (Source: Hanson, S. M. H.
[2001]. Family health care nursing: Theory, practice, and research [2nd ed.]. Philadelphia, PA: F. A. Davis, with

The family care plan for the Jones family was activities—primary/secondary/tertiary, and outcome/
developed by the nurse in concert with the family evaluation/replanning proposed for this family.
members who completed the FS3I (see Fig. 3-13). The goal of this family care plan was to achieve a
The family care plan addresses the diagnosis restoration of optimum health that could provide
of general and specific family systems stressors homeostasis and stability for this family, as well
and family systems strengths that support the as more positive health outcomes than the family
family care plan and the goals of the family could reach at the beginning of their health
and the clinician(s): interventions/prevention challenges. The outcome/evaluation/replanning
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96 Foundations in Family Health Care Nursing

DIRECTIONS: Graph the scores from each family member inventory by placing an “X” at the appropriate location. (Use first name
initial for each different entry and different color code for each family member.)



5.0 5.0

4.8 4.8 X√1

4.6 4.6
4.4 4.4
X√1 X√2
4.2 4.2

4.0 X√2 4.0

3.8 3.8

3.6 3.6

3.4 3.4

3.2 3.2

3.0 3.0

2.8 2.8

2.6 2.6

2.4 2.4

2.2 2.2

2.0 2.0

1.8 1.8

1.6 1.6

1.4 1.4

1.2 1.2

1.0 1.0

*PRIMARY Prevention/Intervention Mode: Flexible Line 1.0-2.3 √1 = Robert

*SECONDARY Prevention/Intervention Mode: Normal Line 2.4-3.6
*TERTIARY Prevention/Intervention Mode: Resistance Lines 3.7-5.0 √2 = Linda
*Breakdowns of numerical scores for stressor penetration are suggested values.

FIGURE 3-10 Quantitative summary of family systems stressors, general and specific: Jones family.
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Theoretical Foundations for the Nursing of Families 97

DIRECTIONS: Graph the scores from the inventory by placing an “X” at the appropriate location and connect with a line. (Use first name
initial for each different entry and different color code for each family member.)






4.4 X




3.4 √1













*PRIMARY Prevention/Intervention Mode: Flexible Line 1.0-2.3 √1 = Robert

*SECONDARY Prevention/Intervention Mode: Normal Line 2.4-3.6
*TERTIARY Prevention/Intervention Mode: Resistance Lines 3.7-5.0 √2 = Linda
*Breakdowns of numerical scores for stressor penetration are suggested values.

FIGURE 3-11 Family and clinician perception scores: Jones family.

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98 Foundations in Family Health Care Nursing

Summarize general stressors and remarks of family and clinician. Prioritize stressors according to importance
to family members.
The major general stressor of the family is the DX of MS and the impact of the progressive disabling illness on the entire

A. Summarize specific stressors and remarks of family and clinician.

Linda’s specific stressors: growing disability to function as wife/mother,
physical signs of impairment and guilt, anxiety, and depression. Robert’s
specific stressors: loss of fully functional wife, fear of unknown; loss
of sexual expression and finances.

B. Summarize differences (if discrepancies exist) between how family members and clinicians view effects
of stressful situation on family.
Each family member has some different stressors, but share in common the
fears, anxiety, helplessness, sadness over their losses due to Linda’s
condition. Nurse views general and specific stressors higher than family
rates them.

C. Summarize overall family functioning.

Functioning as best as can be expected. Physical health in question. Mental
health standing up so far. Family addressing issues one by one.

D. Summarize overall significant physical health status for family members.

Mother’s physical health compromised. Father’s physical health is okay.

E. Summarize overall significant mental health status for family members.

Mother is frustrated and anxious. Expressed guilt, which makes her
depressed. Father is also frustrated and worried about Linda, the children,
and finances.

Summarize family systems strengths and family and clinician remarks that facilitate family health and stability.
Couple communication, religious faith, social support of extended family and
believe they have competent caring health care providers.

FIGURE 3-12 Qualitative summary, family and clinician: Jones family.

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Theoretical Foundations for the Nursing of Families 99

Prevention/Intervention Mode

Diagnosis: General Family Systems Goals for Family Primary, Secondary, Prevention/ Outcomes Evaluation
and Specific Family Strengths Supporting and Clinician or Tertiary Intervention Activities and Replanning
System Stressors Family Care Plan

Dx of MS Couple Restoration of Support of family Couple receives Evaluation to be done

weakness of communication, stability and changes, connect counseling, pain once plan
swallowing, pain, religious faith, homeostasis at family with MS and symptom implemented.
vision impairment, social support of each level of family support management;
vertigo/tinnitus, extended family, progressive group, locate involve social
constipation, good medical care. chronic illness. part-time family worker to look at
urinary infections, helper for home, community agencies
guilt/anxiety, coordinate with to offer assistance.
depression, sexual other medical
dysfunction, over- groups involved,
load for caregiver set up rehabilitation,
father. and physical

FIGURE 3-13 Family care plan: Jones family.

section of the family care plan remains blank for practice, and research, and explained crucial as-
now because it is dependent on feedback from the pects of theory. The chapter then explored five
interventions proposed for the family, as well as theories and models for the nursing care of fami-
the physical and mental health status of the entire lies and applied the theories to the case study in
family. the chapter:

Strengths and Weaknesses ■ Family Systems Theory

■ Developmental and Family Life Cycle Theory
The strength of the FS3I approach is that both
■ Bioecological Theory
quantitative and qualitative data are used to deter-
■ Chronic Illness Framework
mine the level of prevention and intervention
■ Family Assessment and Intervention Model
needed: primary, secondary, or tertiary. The in-
strument is brief, is easy to administer, and yields The chapter revealed how nurses can practice
data to compare one family member with another family nursing differently with the Jones family ac-
member and one family with another family. The cording to the different theoretical perspectives.
weakness of this model and instrument is that they The following points highlight critical concepts
focus only on family strengths and stressors rather that are addressed in this chapter:
than all the dimensions of the family as a unit. This
■ No single theory, model, or conceptual
model and instrument hold much promise for nurs-
framework adequately describes the complex
ing assessment of families, but more work needs to
relationships of family.
be done on this approach. See Box 3-2 for a com-
■ No one theoretical perspective gives nurses
parison of the approaches.
a sufficiently broad base of knowledge and
understanding to guide assessment and
SUMMARY interventions with all families.
■ No one theoretical perspective is better,
By understanding theories and models, nurses are more comprehensive, or more correct than
better prepared to think creatively and critically another.
about how health events affect the family. This ■ Nurses who draw from multiple theories
chapter introduced nurses to the concept of theory- are more effective in tailoring their nursing
guided, evidence-based family nursing practice. practice and family interventions. Using
It presented the relationship between theory, multiple theories substantially increases the
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100 Foundations in Family Health Care Nursing

BOX 3-2
Comparison of Theories as They Apply to the Jones Family

Family Systems Theory Intervention Examples

Conceptual ■ Conduct family interview to determine where family is

Family is viewed as a whole. What happens to the family in terms of cognitive, social, emotional, spiritual, and
as a whole affects each individual family member, and physical development.
what happens to individuals affects the totality of the fam- ■ A family genogram and ecomap should be completed.

ily unit. Focus is on the circular interactions among mem- ■ Determine the normative and nonnormative events that

bers of the family system, resulting in functional or have occurred to the family as a whole or to individuals
dysfunctional outcomes. within the family.
■ Analyze how an individual’s growth and developmental
milestones may affect the family developmental trajectory.
The family may be assessed together or individually.
Assessment questions relate to the interaction between Strengths
the individual and the family, and the interaction between Focus is on the family as a whole. The theory provides a
the family and the community in which the family lives. framework for predicting what a family will experience at
any given stage in the family life cycle so that nurses can
Intervention Examples
offer anticipatory guidance.
■ Complete a family genogram to understand patterns
and relationships over several generations over time. Weaknesses
■ Complete family ecomap to see how individuals/family The traditional linear family life cycle is no longer the
relate to the community around them. norm. Modern families vary widely in their structure and
■ Collect data about the family as a whole and about roles. Divorce, remarriage, gay parents, and never-married
individual family members. parents have changed the traditional trajectory of growth
■ Conduct care-planning sessions that include family and developmental milestones. The theory does not
members. focus on how the family adapts to the transitions from
one stage to the other; rather, it simply predicts what
transitions will occur.
Focus is on family as a whole or its subsystems, or both. It
is a generally understood and accepted theory in society. Application to Jones Family
The Jones family is in the stages of “families with adoles-
cents” and “launching young adults.” The nonnormative
Theory is broad and general. It does not give definitive health condition of the mother is changing the predictable
prescriptions for interventions. normative course of development for the individuals and
Application to Jones Family for the family as a whole. These health events will change
All members of the Jones family are affected by the the cognitive, social, emotional, spiritual, and physical de-
mother’s progressive chronic health condition and velopment as the family shifts to integrate new roles into
changes. Family structure, functions, and processes of the their lives as family members.
family are influenced, changing family roles and dynamics. Bioecological Systems Theory
Everyone in the family has his or her own concerns and Conceptual
needs attention from health care professionals.
Bioecological systems theory combines children’s biologi-
Family Developmental and Life Cycle Theory cal disposition and environmental forces that come to-
Conceptual gether to shape the development of human beings. This
Family is viewed as a whole over time. All families go theory has a basis in both developmental theory and sys-
through similar developmental processes starting with the tems theory to understand individual and family growth.
birth of the first child to death of the parents. Focus is on It combines the influence of both genetics and environ-
the life cycle of families and represents normative stages ment from the individual and family with the larger eco-
of family development. nomic/political structure over time. The basic premise is
that individual and family development are contextual
Assessment over time. The different levels of the theory that apply to
The family may be assessed together or individually. As- the family at any one point in time vary depending on
sessment questions relate to the normative predictable what is happening at that time. Therefore, the interaction
events that occur in family life over time. It also includes of the systems vary over time as the situation changes.
nonnormative, unexpected events.
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Theoretical Foundations for the Nursing of Families 101

BOX 3-2
Basic Assumptions for Family Assessment and Intervention Model—cont’d

Assessment has a chronic illness. The areas of inquiry that inform this
Assess all levels of the larger ecological system when model are onset of the chronic illness, course of illness,
interviewing the family. Determine the microsystem, outcome or trajectory of the chronic illness, outcome rela-
mesosystem, exosystem, macrosystem, and chronosys- tive to degree of incapacitation from the illness, time
tem of the individual and of the family as a whole. phase of the illness, and family functioning.
Intervention Examples Assessment
■ Conduct a family interview to determine the family’s sta- In this framework, it is important first to analyze the vari-
tus in relationship to four locational/spatial contexts and ous aspects of the specific type of chronic illness. Each
one time-related context. aspect presents a different type of stress or challenge for
■ A family genogram and ecomap should be completed. the family based on the particular chronic illness. The last
■ Determine how individuals are doing in relationship to aspect of the framework, family function, requires the
their entire environment, which includes immediate family nurse to explore how the specific chronic illness
family, extended family, home, school, and community. affects this specific family based on the demands of the
■ Analyze the family in its smaller and larger contextual illness and the family strengths and vulnerabilities.
aspects. Intervention Examples
Strengths ■ Complete a family genogram and ecomap.

Focus is on a holistic approach to human/family develop- ■ Implement a plan of care to help facilitate family adap-

ment. A bio/psycho/socio/cultural/spiritual approach to tation and coping strategies.

understanding how individuals and families develop and ■ Work with families by building on the family strengths to

change/adapt over time in their society is a more com- adjust family roles to help the family with managing the
plete approach. stressors identified in this specific chronic illness for this
specific family.
This holistic approach is not specific enough to define
contextual changes over time. Nor can the larger context The Chronic Illness Framework is designed to support
in which individuals/families are embedded be predicted family-centered nursing care. Focus is on family strengths
or controlled. and vulnerabilities through identified predictable stressors
experienced by families who are in that aspect of the
Application to Jones Family chronic illness. Anticipatory guidance can be provided as
■ Microsystem: The Jones family consists of school-age the chronic illness may progress through typical trajecto-
children living at home. The parental roles have been ries or times phases.
traditional until recent health events.
■ Mesosystem: Family has much interaction with schools,
church, and extended family. The model is not specific enough to identify precise ways
■ Exosystem: Family influenced by father’s work at the fac-
families adapt; rather, it is more of a guideline to typical
tory and other institutions in the community. stressors and coping tasks that may happen when a fam-
■ Macrosystem: Family consistent with community culture,
ily member develops a chronic illness.
attitudes, and beliefs. Their community is largely Cau- Application to Jones Family
casian, middle class, and Christian. The Jones family is struggling to adapt during the rocky
■ Chronosystem: At this time in the illness story of the chronic illness phase. As the mother’s illness has changed
Jones family with the mother’s illness changing, the from being episodic to progressive in nature, the family is
family situation changes and moves between stability stressed with adapting to the mother losing ambulation
and crisis. and needing more physical support than in the past. The
Chronic Illness Framework family is in a constant state of stress as it adjusts to the
new patterns, regimens, and roles. The family is grieving
as Linda becomes more disabled.
This is a conceptual framework and not a theory. There-
fore, each aspect of the framework represents several Family Assessment and Intervention Model
fields of inquiry relative to chronic illness. The framework Conceptual
has been built and data have been organized to provide a Families are viewed as dynamic, open systems in interac-
coherent way of thinking about families when a member tion with their environment. A major role of family is to

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102 Foundations in Family Health Care Nursing

BOX 3-2
Basic Assumptions for Family Assessment and Intervention Model—cont’d

help protect itself from events such as illness that may Strengths
threaten the family’s inner core. The inner core of the The model and instrument provide a structured approach
family consists of family structure, function, process, and to family assessment and intervention based on both
energy/strength resources and must be protected or the quantitative and qualitative data. These data help deter-
family ceases to exist. Adaptation is the work the family mine the primary, secondary, and tertiary levels of preven-
undertakes to preserve/restore family stability. This model tion and intervention. The focus on family strengths is
evolved out of nursing and builds on general systems unique to this model and approach.
theory, stress theory, and change theory.
Assessment This model is used specifically when families enter
Family may be assessed together, but all individuals the health care system. It is applicable when health
are asked to complete the measurement instrument. The problems have come up that cause stressors. Although
Family Systems Stressor-Strength Inventory (FS3I) the model per se is applicable to all families in terms
is administered to determine general family stressors, spe- of life stressors and strengths, the administration of
cific family stressors, and family system strengths. The the FS3I is specific to only these two aspects of the
stressors that affect the balance of the family strengths are health events.
analyzed to assist the family to achieve stability.
Application to Jones Family
Intervention Examples The adults in this family were interviewed together,
■ The FS3I is completed by all adult individuals in the with each person completing the FS3I. General stressors
family. Scores are derived from the measurement scales and specific stressors were rated similarly by each
and then analyzed. Health care providers meet with member of the couple. The nurse also rated her per-
families to review results and provide different interven- ceptions of the family stressors and strengths. Overall
tion strategies based on the specific stressors, how the family physical and mental functioning were also rated.
family is coping, and what strengths are brought to the The nurse concluded that this family had the strengths
situation. it needed to deal with both the general and specific
■ A family genogram and ecomap should be completed. stressors.

likelihood that the family will be able to

achieve stability and health as a family unit.
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Family Nursing Assessment
and Intervention
Joanna Rowe Kaakinen, PhD, RN
Aaron Tabacco, BSN, RN, Doctoral Candidate

Critical Concepts
■ Families are complex social systems with which nurses interact in many ways and in many different contexts; the use
of a logical systematic family nursing assessment approach is important.
■ In the context of family nursing, the creative nurse thinker must be aware of possibilities, be able to recognize the
new and the unusual, be able to decipher unique and complex situations, and be inventive in designing an approach
to family care.
■ Nurses determine through which theoretical and practice lens(es) to analyze the family event.
■ Knowledge about family structures, functions, and processes inform nurses in their efforts to optimize and provide in-
dividualized nursing care, tailored to the uniqueness of every family system.
■ Nurses begin family assessment from the moment of contact or referral.
■ Family stories are narratives that nurses construct in framing, contextualizing, educating, communicating, and provid-
ing interpretations of their family clients’ needs as they exercise clinical judgment in their work.
■ Interacting with families as clients requires knowledge of family assessment and intervention models, as well as
skilled communication techniques so that the interaction will be effective and efficient for all parties.
■ The family genogram and ecomap are both assessment data-gathering instruments. The therapeutic interaction that
occurs with the family while diagramming a genogram or ecomap is itself a powerful intervention.
■ Families’ beliefs about health and illness, about nurses and other health care providers, and about themselves are es-
sential for nurses to explore in order to craft effective approaches to family interventions and promote health literacy.
■ Families determine the level of nurses’ involvement in their health and illness journeys, and nurses seek to tailor their
work and approach accordingly.
■ Nurses and families who work together and build on family strengths are in the best position to determine and priori-
tize specific family needs; develop realistic outcomes; and design, evaluate, and modify a plan of action that has a
high probability of being implemented by the family.
■ The final step in working with families should always be for nurses to engage in critical, creative, and concurrent re-
flection about the family, their work with the family, and professional self-reflection of their practice.

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106 Foundations in Family Health Care Nursing

Families are complex social systems. Therefore, the introduction to three family assessment and inter-
use of logical, systematic approaches to assess and vention models that were developed by nurses.
intervene with family clients is essential for several
reasons: (1) to ensure that the needs of the family
are met, (2) to uncover any gaps in the family plan FAMILY NURSING ASSESSMENT
of action, and (3) to offer multiple supports and re-
sources to the family. Nurses use a variety of as- Central to the delivery of safe and effective family
sessment models to collect information about nursing care is the nurse’s ability to make accurate
families. In concert with the family, this informa- assessments, identify health problems, and tailor
tion is used to develop the interventions families plans of care. Each step of working with families,
use to manage their current health event. Some as- whether applied to individuals within the family or
sessment and intervention instruments are based the family as a whole, requires a thoughtful, delib-
on theoretical models, and some are developed erate reasoning process. Nurses decide what data
using a psychometric approach to instrument de- to collect and how, when, and where those data are
velopment. Built on the traditional nursing process collected. Nurses determine the relevance of each
as visualized by Doenges, Moorhouse, and Murr new piece of information and how it fits into the
(2013) (Fig. 4-1) and combined with the Outcome emerging family story. Before moving forward,
Present State Testing Model (Pesut & Herman, nurses decide whether they have obtained sufficient
1999), this chapter presents a dynamic systematic information on problem and strength identifica-
critical reasoning method to conducting a family as- tion, or whether gaps exist that require additional
sessment and tailoring interventions to meet family data gathering.
needs (Fig. 4-2) and applies it to a case study. The Nurses must always be aware that “common” in-
chapter explores assessment strategies, including terpretations of data may not be the “correct” in-
how to select assessment instruments, determine terpretation in any given situation, and that
the need for interpreters, assess for health literacy, commonly expected signs and symptoms may not
diagram family genograms, and develop family appear in every case or in the same data pattern
ecomaps. Intervention strategies follow assessment presentation. The ability of nurses to be open to
strategies to assist nurses and families in shared de- the unexpected and to be alert to unusual or differ-
cision making. The chapter concludes with a brief ent responses is critical to determining the primary

Pl Pl Pl

an an an



nin nin nin




g g g













dia sing

dia sing

dia sing








Assessment Assessment

FIGURE 4-1 Nursing process model.

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Family Nursing Assessment and Intervention 107

Over Time

De De
ns fa sig s fa sig
ily tio m
ily n on m
ily n
m en ily ti
Fa terv pla m en pla
n Fa terv n
in in


Nurse Nurse

Reflection Reflection




fam lyze

fam lyze





Assess Assess
family story family story

FIGURE 4-2 Family nursing assessment model.

needs confronting the family. Nurses should be working well, does a new care plan need to
able to perceive that which is not obvious and to be put into place, or does the nurse/family
understand how this family story is similar to or relationship need to end?
different from other family stories. ■ Nurse reflection: Nurses engage in critical,
The family nursing assessment includes the fol- creative, and concurrent reflection about them-
lowing steps: selves and their own family experiences, the
family client, and their work with the family.
■ Assessment of the family story: The nurse
gathers data from a variety of sources to see
the whole picture of the family experience. Engaging Families in Care
■ Analysis of family story: The nurse clusters
the data into meaningful patterns to see how Background and First Contact
the family is managing the health event. The Nurses encounter families in diverse health care
family needs are prioritized using a Family settings for many different kinds of problems and
Reasoning Web. circumstances. Every family has a story about how
■ Design of a family plan of care: Together, the the potential or actual health event influences its
nurse and family determine the best plan of individual members, family functioning, and man-
care for the family to manage the situation. agement of the health event. Nurses are charged
■ Family intervention: Together, the nurse and with gathering, sifting, organizing, and analyzing
family implement the plan of care incorporat- the data to craft a clear view of the family’s story.
ing the most family-focused, cost-effective, Nurses filter data gathered in the story through dif-
and efficient interventions that assist the fam- ferent views or approaches, which affects how they
ily to achieve the best possible outcomes. think about the family as a whole and each individ-
■ Family evaluation: Together, the nurse and ual family member. For example, a family who is
family determine whether the outcomes are faced with a new diagnosis of a chronic illness
being reached, are being partially reached, would have different needs than a family who is
or need to be redesigned. Is the care plan faced with a member dying of an end-stage chronic
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108 Foundations in Family Health Care Nursing

illness. Nurses might use different strategies if the

BOX 4-1
patient is in the acute hospital setting, is in an as-
sisted living center, or is living at home. Sources of Pre-encounter Family Data
The underlying theoretical approach used by the
■ Referral source: includes data that indicated a problem
nurses working with families influences how they ask for this family, as well as demographic information
questions and collect family data. For example, if the ■ Family: includes family members’ views of the prob-
family is worried about how their 2-year-old child lem, surprise that the referral was made, reluctance to
will react to a new baby, such as in the Bono family set up the meeting, avoidance in setting up the ap-
case study presented later in this chapter, the nurse pointment
may elect to base the assessment and interventions ■ Previous records: in the health care systems or that are

on a family systems theoretical view, or the devel- sent by having the client sign a release for information
opmental family life cycle theoretical view. Refer to form, such as process logs, charts, phone logs, or
Chapter 3 for a detailed discussion of working with school records
families from different theoretical perspectives.
Data collection, which is the first part of assess-
ment, involves both subjective and objective family ■ Specific medical information about the
information that is obtained through direct obser- family member with the health problem
■ Strategies that have been used previously
vation, examination, or in consultation with other
■ Insurance sources for the family
health care providers. In all cases, family assess-
■ Family problems identified by other health
ment begins from the first moment that the family
is referred to the nurse. Following are some cir- providers
■ Family demographic data, when available,
cumstances in which a family is referred to a nurse:
such as the number of people and ages of
■ A family is referred by the hospital to a home family members or basic cultural background
health agency for wound care on the feet of a information
client with diabetes. ■ The need for an interpreter
■ A couple seeks advice for managing their
busy life with three children as the mother Before contacting the family to arrange for the
returns home from the hospital following an initial appointment, the nurse decides whether the
unplanned cesarean section. most appropriate place to conduct the appointment
■ A family calls the Visiting Nurse Association
is in the family’s home or the clinic/office. The type
to request assistance in providing care to a of agency where the nurse works may dictate this
family member with increasing dementia. decision. Advantages and disadvantages of a home
■ A school nurse is asked by the school psy-
setting and a clinic setting are listed in Table 4-1.
chologist to conduct a family assessment with Contacting the family for the appointment pro-
a family who is suspected of child neglect. vides valuable information about the family. It is im-
■ A physician requests a family assessment with
perative that the nurse be confident and organized
a child who has nonorganic failure to thrive. when making the initial contact. Information that
■ A family with a member with critical care
is important for the nurse to note is whether the
needs is asked to make decisions about life-sus- family acts surprised that the referral was made,
taining treatments in the intensive care unit. shows reluctance in setting up a meeting, or ex-
presses openness about working together. The fam-
Making Community-Based Appointments ily also gathers important information about the
nurse during the initial interaction. For example,
As soon as a family is identified, the nurse begins
family members will notice whether the nurse takes
to collect data about the family story. Sources of
time to talk with them, uses a lot of words they do
data that can be collected before contacting a fam-
not understand, or appears organized and open to
ily for a home or clinic appointment are listed in
working with the family. To facilitate the best pos-
Box 4-1. Specifically, the nurse needs to know the
sible outcomes in engaging families for the first
following information:
time to learn about their health and illness story,
■ The reason for the referral or requested visit effective nurses consider the family and its needs
■ The family knowledge of the visit or referral as central to starting a successful collaboration.
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Family Nursing Assessment and Intervention 109

Table 4-1 Advantages and Disadvantages of Home Visits Versus Clinic Visits

Home Visit Clinic Visit

• Opportunity to see the everyday family environment. • Conducting the family appointment in the office or clinic al-
• Observe typical family interactions because the family lows for easier access to consultants.
members are likely to feel more relaxed in their physical • The family situation may be so strained that a more formal,
space. less personal setting will facilitate discussions of emotion-
• More family members may be able to attend the meeting. ally charged issues.
• Emphasizes that the problem is the responsibility of the
whole family and not one family member.
• Home may be the only sanctuary or safe place for the • May reinforce a possible culture gap between the family
family or its members to be away from the scrutiny of others. and the nurse.
Therefore, conducting the meeting in the home would invade
or violate this sanctuary and bring the clinical perspective into
this safe world.
• The nurse must be highly skilled in communication, specifically
setting limits and guiding the interaction, or the visit may have
a more social tone and not be efficient or productive.

This relationship of trust begins from the moment illnesses who experience poor symptom manage-
of first contact with families. As a guide, Box 4-2 ment, nurses in acute care settings often feel there
outlines steps to follow when making an appoint- is little time to engage families effectively. Lack of
ment with a family. time, in fact, has been identified by nurses as the
primary barrier to engaging families, though there
Family Assessments in Acute Care Settings are many other barriers as well, including nurse
Nurses in acute care settings encounter families of bias, safety concerns, and negative nurse attitudes
their individual patients on a daily basis. The de- about working with families (Duran, Oman, Abel,
gree to which nurses feel comfortable and to which Koziel, & Szymanski, 2007; Gurses & Carayon,
they demonstrate clinical competence engaging 2007; Svavarsdottir, 2008). It is critical that nurses
families varies widely. Because cost (which is con- gain skill and comfort with families in acute care
strained) determines length of stay, and because of settings as families are the primary caregivers fol-
the increasing population of people with chronic lowing the discharge of their family members.
Families need the help of nurses in order to learn
how to provide effective postdischarge care tasks;
BOX 4-2 engage in shared decision making with health care
Setting Up Family Appointments
providers; understand the current health status of
their ill family member; balance admission and
■ Introduce yourself. postdischarge family life demands; assist families
■ State the purpose of the requested meeting, including during critical events such as resuscitation; and
who referred the family to the agency. solve ethical dilemmas that arise in the care of their
■ Do not apologize for the meeting. loved one. With this extensive list of needs, it is es-
■ Be factual about the need for the meeting but do not sential that nurses in acute care settings intention-
provide details. ally and effectively engage families.
■ Offer several possible times for the meeting, including
Nurses in acute care settings encounter a num-
late afternoon or evening.
ber of challenges, including caring for several
■ Let the family select the most convenient time that
allows the majority of family members to attend.
acutely ill persons simultaneously, managing the
■ Offer services of an interpreter, if required.
informational needs of interdisciplinary providers,
■ Confirm date, time, place, and directions. and coping with a host of distractions that often
keep nurses away from the bedside. Therefore,
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110 Foundations in Family Health Care Nursing

nurses seeking to engage families, complete family If a qualified medical interpreter cannot come to
assessments, and implement family interventions the meeting in the family home, the nurse should
must be highly efficient and creative. A number of plan to use a speaker phone so that the professional
specific strategies and tools must be used to accom- interpreter can be involved in the conversation with
plish a meaningful and effective experience. For an the family. One of the problems with using an in-
in-depth discussion of acute care family nursing terpreter on the phone is that interpreters do not
needs, refer to Chapter 14. have the advantage of seeing the family members
in person and cannot observe nonverbal commu-
Using Interpreters With Families nication (Bethell, Simpson, & Read, 2006; Gray
It is critical for the nurse to determine whether an et al., 2011; Herndon & Joyce, 2004). Also, the
interpreter is needed during the family meeting, be- nurse should be aware that using a telephone inter-
cause the number of families who do not speak Eng- preter introduces another outside person into the
lish is increasing. For 55.4 million Americans, family setting, which may be perceived as imper-
English is not the primary language spoken in the sonal by the family (Bethell et al., 2006).
home, and 13.6 million of these people speak English
poorly or not at all (U.S. Census Bureau, 2010). Lan- Family-Centered Meetings and Care
guage barriers have been found to complicate many Conferences
aspects of patient care, including comprehension and Family-centered care (FCC) principles should be
adherence to plans of care. Furthermore, language applied in all interactions between nurses and fam-
barriers have been found to contribute to adverse ilies or other health care providers. According to
health outcomes, compromised quality of care, the Institute for Patient and Family Centered Care
avoidable expenses, dissatisfied families, and in- (IPFCC) (2013), the core principles of FCC are re-
creased potential for medical mistakes (Flores, Abreu, spect and dignity, information sharing, participa-
Barone, Bachur, & Lin, 2012; Schenker, Wang, tion, and collaboration. The goal of FCC is to
Selig, Ng, & Fernandez, 2007). Thus, it is essential increase the mutual benefit of health care provision
that nurses who are not bilingual use interpreters for all parties, with a focus on improving the satis-
when working with non–English-speaking families. faction and outcomes of health care for families
The types of interpreters that nurses solicit to (IPFCC, 2013). By utilizing these principles in all
help work with families have the potential to influ- aspects of the family nursing approach from assess-
ence the quality of the information exchanged and ment through intervention and evaluation, nurses
the family’s ability to follow the suggested plan of can facilitate exchanges of shared expertise, which
action. One of the most common types of inter- lead to better holistic health outcomes.
preters used are bilingual family members or During the initial interaction with families, it is
friends, called ad hoc family interpreters. The prob- critical for nurses to introduce themselves to the
lems with using family members as interpreters are family, meet all the family members present, learn
that they have been found to buffer information, about the family members not present, clearly state
alter the meaning of the content, or make the de- the purpose for working with the family, outline
cision for the person for whom they are interpret- what will happen during this session, and indicate
ing (Flores et al., 2012; Ledger, 2002). The ad hoc the length of time the meeting will last. Taking
family member interpreter also has been found to these actions demonstrates respect for family mem-
lack important language skills, especially when it bers and their unique story. To continue with this
comes to medical interpretation (Flores et al., 2012; precedent, the nurse needs to develop a systematic
Khwaja et al., 2006; Ledger, 2002). If the ad hoc plan for the first and all following family meetings.
family member interpreter is a child, the informa- This focus on respect, dignity, and collaboration in
tion that is being discussed may be frightening or initial meetings helps to establish relationships that
the topic may be too personal and sensitive are therapeutic; effective, satisfying partnerships
(Ledger, 2002). Using ad hoc family interpreters between nurses and families are critical as they
also raises confidentially issues (Gray, Hilder, & work together toward health-related goals.
Donaldson, 2011). Therefore, it is not ideal for Nurses who use a therapeutic approach to
nurses to use a family member for interpretation, family meetings have found that their focus on
especially if another choice is available. family-centered care increased, and that their
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Family Nursing Assessment and Intervention 111

communication skills with families became more FAMILY NURSING ASSESSMENT

fluid with experience (Harrison, 2010; Martinez,
D’Artois, & Rennick, 2007). When nurses use
therapeutic communication skills with families, the
Nurses practice family nursing using a variety of
families report feeling a stronger rapport with the
tools. The following three family assessment
nurse, an increased frequency of communication
models have been developed by family nurses.
between families and the nurse occurs, and families
The Family Assessment and Intervention Model
perceive these nurses to be more competent
and the FS3I were developed by Berkey-Mischke
(Harrison, 2010; Martinez et al., 2007).
and Hanson (1991). Friedman developed the
Conducting family meetings not only requires
Friedman Family Assessment Model (Friedman
skilled communication strategies but also requires
et al., 2003). The Calgary Family Assessment
knowledge of family assessment and intervention
Model (CFAM) and Calgary Family Intervention
models. Nurses use a variety of data collection and
Model (CFIM) were developed by Wright and
assessment instruments to help gather information
Leahey (2013). These three approaches vary in
in a systematic and efficient manner. Therefore, it
purpose, unit of analysis, and level of data col-
is important that the instruments be carefully se-
lected. Table 4-2 has a detailed comparison of the
lected so they are family friendly and render infor-
essential components of these three family assess-
mation pertinent to the purpose of working with
ment models.
the family.

Table 4-2 Comparison of Family Assessment Models Developed by Family Nurses

Name of model Family Assessment and In- Friedman Family Assess- Calgary Family Assessment
tervention Model and the ment Model and Intervention Model
Family System Stressor-
Strength Inventory (FS3I)
Citation Berkey-Mischke & Hanson Friedman, Bowden, & Jones Wright & Leahey (2013)
(1991) (2003)
Hanson (2001)
Purpose Concrete, focused measure- Concrete, global family as- Conceptual model and mul-
ment instrument that helps sessment interview guide tidimensional approach to
families identify current that looks primarily at fami- families that looks at the fit
family stressors and builds lies in the larger community among family functioning,
interventions based on in which they are embedded affective, and behavioral
family strengths aspects
Theoretical underpinnings Systems: Developmental Systems:
Family systems Structural-functional Cybernetics Communica-
Neuman systems Family stress-coping tion Change Theory
Model: Environmental
Stress-coping theory
Quantitative: Qualitative: Qualitative:
Level of data collected
Ordinal and interval Nominal Nominal
Inpatient Outpatient Outpatient
Settings in which primarily
Outpatient Community Community
Family as context Family as client Family as system
Units of analysis
Family as client Family as component
Family as system of society
Family as component
of society

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112 Foundations in Family Health Care Nursing

Table 4-2 Comparison of Family Assessment Models Developed by Family Nurses—cont’d

Strengths Short Comprehensive list of areas Conceptually sound

Easy to administer to assess family
Yields data to compare
one family member with
another family member
Assess and measure
focused presenting
Weaknesses Narrow variable Large quantities of data Not concrete enough to be
that may not relate to the useful as a guideline unless
problem the provider has studied this
No quantitative data model and approach in detail

Family Assessment and Intervention instructions for administration and a scoring guide,
can be found in Appendix A.
Nurses can assess family stability by gathering in-
The Family Assessment and Intervention Model, formation on family stressors and strengths. The
originally developed by Berkey-Mischke and Hanson nurse and family work together to assess the family’s
(1991), is presented in greater detail in Chapter 3, general, overall stressors, and then specific family
but is worth exploring in this context as well. The problems. Identified family strengths give an indi-
Family Assessment Intervention Model is based on cation of the potential and actual problem-solving
Neuman’s health care systems model (Kaakinen & abilities of the family system. A plus to the FS3I ap-
Hanson, 2005). proach is that both quantitative and qualitative data
According to the Family Assessment and Inter- are used to determine the level of prevention and
vention Model, families are subject to tensions intervention needed. The family is actively involved
when stressed. The family’s reaction depends on in the discussions and decisions. Moreover, this as-
how deeply the stressor penetrates the family unit sessment and intervention approach focuses on
and how capable the family is of adapting to main- family stressors and strengths, and provides a theo-
tain its stability. The lines of resistance protect the retical structure for family nursing.
family’s basic structure, which includes the family’s
functions and energy resources. The family core
contains the patterns of family interactions and
Friedman Family Assessment Model
strengths. The basic family structure must be pro- The Friedman Family Assessment Model (Friedman
tected at all costs or the family ceases to exist. Re- et al., 2003) is based on the structural-functional
constitution or adaptation is the work the family framework and developmental and systems theory.
undertakes to preserve or restore family stability. This assessment model takes a macroscopic approach
This model addresses three areas: (1) health pro- to family assessment by viewing families as subsystems
motion, wellness activities, problem identification, of the wider society, which includes institutions de-
and family factors at lines of defense and resistance; voted to religion, education, and health. Family is
(2) family reaction and instability at lines of defense considered an open social system and this model fo-
and resistance; and (3) restoration of family stability cuses on family’s structure, functions (activities and
and family functioning at levels of prevention and purposes), and relationships with other social systems.
intervention. The Friedman model is commonly used when the
The FS3I is the assessment and intervention tool family-in-community is the setting for care (e.g., in
that accompanies the Family Assessment and In- community and public health nursing). This approach
tervention Model. The FS3I is divided into three enables family nurses to assess the family system as a
sections: (1) family systems stressors—general; (2) whole, as a subunit of the society, and as an interac-
family stressors—specific; and (3) family system tional system. Box 4-3 delineates the general assump-
strengths. An updated copy of the instrument, with tions of this model (Friedman et al., 2003, p. 100).
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Family Nursing Assessment and Intervention 113

BOX 4-3 stage and history of the family, (3) environmental

data, (4) family structure (i.e., role structure, family
Underlying Assumptions of Friedman’s values, communication patterns, power structure),
Family Assessment Model
(5) family functions (i.e., affective functions, social-
■ A family is a social system with functional require- ization functions, health care functions), and
ments. (6) family stress and coping. Each category has sev-
■ A family is a small group possessing certain generic eral subcategories (Friedman et al., 2003).
features common to all small groups. Friedman’s assessment was developed to provide
■ The family as a social system accomplishes functions guidelines for family nurses who are interviewing
that serve the individual and society. a family. The guidelines categorize family informa-
■ Individuals act in accordance with a set of internalized tion according to structure and function. Fried-
norms and values that are learned primarily through man’s Family Assessment Form exists in both a
long form and a short form. The long form is quite
Source: Friedman, M. M., Bowden, V. R., & Jones, E. G. (2003).
extensive (13 pages), and it may not be possible to
Family nursing: Research, theory & practice (5th ed.). Upper collect all of the data in one visit. Moreover, all the
Saddle River, NJ: Prentice Hall/Pearson Education. categories of information listed in the guidelines
may not be pertinent for every family. Like other
Structure refers to how a family is organized and approaches, this model has its strengths and weak-
how the parts relate to each other and to the whole. nesses. One problem with this approach is that it
The four basic structural dimensions are role sys- can generate large quantities of data with no clear
tems, value systems, communication networks, and direction as to how to use all of the information in
power structure. These dimensions are interrelated diagnosis, planning, and intervention. The strength
and interactive, and they may differ in single-par- of this approach is that it addresses a comprehen-
ent and two-parent families. For example, a single sive list of areas to assess the family, and that a short
mother may be the head of the family, but she may assessment form has been developed to highlight
not necessarily take on the authoritarian role that critical areas of family functioning. The short form,
a traditional man might in a two-parent family. In which is included in Appendix B, outlines the types
turn, the value systems, communication networks, of questions the nurse can ask.
and power structures may be quite different in the
single-parent and two-parent families as a result of Calgary Family Assessment Model
these structural differences.
The CFAM by Wright and Leahey (2013) blends
Function refers to how families go about meet-
nursing and family therapy concepts that are
ing the needs of individuals and meeting the pur-
grounded in systems theory, cybernetics, commu-
poses of the broader society. In other words, family
nication theory, change theory, and a biology of
functions are what a family does. The functions of
recognition. The following concepts from general
the family historically are discussed in Chapter 1,
systems theory and family systems theory make up
but the following specific family functions are con-
the theoretical framework for this model (Wright
sidered in this approach:
& Leahy, 2013, pp. 21–44):
■ Pass on culture, religion, ethnicity.
■ A family system is part of a larger suprasys-
■ Socialize young people for the next genera-
tem and is also composed of many subsys-
tion (e.g., to be good citizens, to be able to
cope in society through education).
■ The family as a whole is greater than the sum
■ Exist for sexual satisfaction and reproduction.
of its parts.
■ Provide economic security.
■ A change in one family member affects all
■ Serve as a protective mechanism for family
family members.
members against outside forces.
■ The family is able to create a balance be-
■ Provide closer human contact and relations.
tween change and stability.
The Friedman Family Assessment Model form ■ Family members’ behaviors are best under-
consists of six broad categories of interview ques- stood from a perspective of circular rather
tions: (1) identification data, (2) developmental than linear causality.
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114 Foundations in Family Health Care Nursing

Cybernetics is the science of communication ■ Change can be the result of a myriad of

and control theory; therefore, it differs from sys- causes.
tems theory. Systems theory helps change the focus
Figure 4-3 shows the branching diagram of the
of one’s conceptual lens from parts to wholes. By
CFAM (Wright & Leahey, 2013, p. 48). The as-
contrast, cybernetics changes the focus from sub-
sessment questions that accompany the model are
stance to form. Wright and Leahey (2013) pull two
organized into three major categories: (1) struc-
useful concepts from cybernetics theory:
tural, (2) developmental, and (3) functional. Nurses
■ Families possess self-regulating ability. examine a family’s structural components to answer
■ Feedback processes can simultaneously occur these questions: Who is in the family? What is the
at several system levels with families. connection between family members? What is the
family’s context? Structure includes family compo-
Communication theory in this model is based on
sition, sex, sexual orientation, rank order, subsys-
the work of Watzlawick and colleagues (Watzlawick,
tems, and the boundaries of the family system.
Weakland, & Fisch, 1967, 1974). Communication
Aside from interview and observation, strategies
represents the way that individuals interact with
recommended to assess structure include the
one another. Concepts derived from communica-
genogram and the ecomap.
tion theory used in the CFAM are as follows
The second major assessment category in the
(Wright & Leahey, 2013):
Calgary approach is family development, which in-
■ All nonverbal communication is meaningful. cludes assessment of family stages, tasks, and at-
■ All communication has two major channels tachments. For example, nurses may ask, “Where
for transmission: digital (verbal) and analogi- is the family in the family life cycle?” Understand-
cal (nonverbal). ing the stage of the family enables nurses to assess
■ A dyadic relationship has varying degrees of and intervene in a more purposeful, specific, and
symmetry (similarity) and complementarity meaningful way. There are no actual instruments
(divergence, contrast, or complementary for assessing development, but nurses can use de-
characteristics). velopmental tasks as guidelines.
■ All communication has two levels: content The third area for assessment in the CFAM is
and relationship. family functioning. Family functioning reflects how
individuals actually behave in relation to one an-
Helping families to change is at the very core of
other, or the “here-and-now aspect of a family’s
family nursing interventions. Families need a bal-
life” (Wright & Leahey, 2013, p. 116). Aspects of
ance between change and stability. Change is re-
family functioning include activities of daily life,
quired to make things better, and stability is required
such as eating, sleeping, meal preparation, and
to maintain some semblance of order. A number of
health care, as well as emotional communication,
concepts from change theory are important to this
verbal and nonverbal communication, communica-
family nursing approach (Wright & Leahey, 2013):
tion patterns (the way communication and re-
■ Change is dependent on the perception of sponses are passed back and forth between
the problem. members), problem solving, roles, influence and
■ Change is determined by structure. power, beliefs, and alliances and coalitions. Wright
■ Change is dependent on context. and Leahey indicate that nurses may assess in all
■ Change is dependent on co-evolving goals three areas for a macroview of the family, or they
for treatment. can use any part of the approach for a microassess-
■ Understanding alone does not lead to change. ment. Wright and Leahey (2013) developed a com-
■ Change does not necessarily occur equally in panion model to the CFAM, the CFIM. This
all family members. intervention model provides concrete strategies by
■ Facilitating change is the nurse’s responsibility. which nurses can promote, improve, and sustain
■ Change occurs by means of a “fit” or meshing effective family functioning in the cognitive, affec-
between the therapeutic offerings (interven- tive, and behavioral domains. The strength of the
tions of the nurse) and the bio-psycho- Calgary Assessment and Intervention Model is that
social-spiritual structures of family members. it is a conceptually sound model that incorporates
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Family Nursing Assessment and Intervention 115

Family composition
Sexual orientation
Internal Rank order
Extended family
Structural External
Larger systems
Context Social class
Religion and/or spirituality


Developmental Tasks


Instrumental Activities of daily living

Emotional communication
Functional Verbal communication
Nonverbal communication
Expressive Circular communication
Influence and power
FIGURE 4-3 Calgary assessment model diagram. (From Wright L. M., & Leahey, M. [2009]. Nurses and
families: A guide to family assessment and intervention [5th ed.]. Philadelphia, PA: F. A. Davis, with permission.)

multiple theoretical aspects into working with fam- that Sobo (2004) designed to assess the family’s per-
ilies. The strength of this approach is also its weak- spective on shared decision making. Other times,
ness in that unless you are intimately knowledgeable more comprehensive family assessment instruments
with the model and the interventions, it is difficult are necessary, such as the Family Systems Stressor-
to implement in acute care settings. Strength Inventory (FS3I) (Berkey-Mischke &
Hanson, 1991; Hanson, 2001; Kaakinen, Hanson,
& Denham, 2010). The FS3I is an instrument
Family Assessment Instruments designed by nurses to provide quantitative and qual-
itative data pertinent to family stressors, family
Because there are approximately 1,000 family-
strengths, and intervention strategies (see Appendix
focused instruments that have been developed and
A). To select the most appropriate assessment in-
used in assessing family-related variables (Touliatos,
strument, be sure the instrument has the following
Perlmutter, & Straus, 2001), the selection of the ap-
propriate instrument can be complex. Sometimes,
a simple questionnaire or instrument can be com- ■ Written in uncomplicated language at a fifth-
pleted in just a few minutes. One such example is grade level
the Patient/Parent Information and Involvement ■ Only 10 to 15 minutes in length
Assessment Tool (PINT), which is an instrument ■ Relatively easy to score
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116 Foundations in Family Health Care Nursing

■ Offers valid data on which to base decisions This diagram offers a rich source of information
■ Sensitive to sex, race, social class, and ethnic for planning intervention strategies because it dis-
background plays the family visually and graphically in a way
Regardless of which assessment/measurement in- that provides a quick overview of family complexi-
strument is used, families should always be informed ties. Family genograms help both nurses and fam-
of how the information gathered through the instru- ilies to see and think systematically about families
ments will be used by the health care providers. and the impact of the health event on family struc-
Two other family data-gathering instruments ture, function, and processes.
that should be used in working with families are the The three-generational family genogram had its
family genogram and the family ecomap. Both are origin in Family Systems Theory (Bowen, 1985;
short, easy instruments and processes that supply Bowen & Kerr, 1988). According to family systems,
essential family data and engage the family in ther- people are organized into family systems by gener-
apeutic conversation. ation, age, sex, or other similar features. How a
person fits into his or her family structure influ-
Family Genogram and Family Ecomap ences its functioning, relational patterns, and what
Genograms and ecomaps provide care providers type of family he or she will carry forward into the
with visual diagrams of the current family story and next generation. Bowen incorporated Toman’s
situation (Harrison & Neufeld, 2009; Kaakinen, (1976) ideas about the importance of sex and birth
2010). The information gathered from both the order in shaping sibling relationships and charac-
genogram and ecomap help guide the family plan teristics. Furthermore, families repeat themselves
of action and the selection of intervention strate- over generations in a phenomenon called the trans-
gies (Ray & Street, 2005). One of the major bene- mission of family patterns (Bowen, 1985). What hap-
fits of working with families with these two pens in one generation repeats itself in the next
instruments is that family members can feel and vi- generation; thus, many of the same strengths and
sualize the amount of energy they are expending to problems get played out from generation to gen-
manage the situation, which in itself is therapeutic eration. These include psychosocial and physical
for the family (Harrison & Neufeld, 2009; Holts- and mental health issues.
lander, 2005; Rempel, Neufeld, & Kushner, 2007). Nurses establish therapeutic relationships with
The use of genograms and ecomaps among nurses families through the process of asking questions
and other disciplines is growing and these useful tools while collecting family data. Families become more
are being applied in a number of practice and re- engaged in their current situation during this inter-
search contexts. Genograms, used historically in the action as their family story unfolds. Both the nurse
context of genetic prediction and counseling, have and the family can see the “big picture” historically
been applied alongside ecomaps as primary assess- on the vertical axis of the genogram and horizontally
ment and decision-making tools in acute centers across the family (McGoldrick et al., 2008). This ap-
(Leahey & Svavarsdottir, 2009; Svavarsdottir, 2008). proach can help families see connectedness, and help
Examples of how other providers have applied the identify potential and missing support people.
use of these tools include enhancing health promo- The diagramming of family genograms must ad-
tion (Cascado-Kehoe & Kehoe, 2008); increasing here to specific rules and symbols to ensure that all
provider cultural competence and spiritual assess- parties involved have the same understanding and
ment of families (Hodge & Limb, 2010); and assess- interpretations. It is important not to confuse family
ment of child social support systems (Baumgartner, genograms with a family genetic pedigree. A family
Burnett, DiCarlo, & Buchanan, 2012). It is clear that pedigree is specific to genetic assessments (see
generating and annotating visual data in these dia- Chapter 7), whereas a genogram has broader uses
grammatic forms will be increasingly useful to nurses for family health care practitioners. Olsen, Dudley-
caring for families in many settings and contexts. Brown, and McMullen (2004) have suggested, how-
Family Genogram ever, that given the advancement of genomics in
The family genogram is a format for drawing a fam- driving health care, nursing should consider blend-
ily tree that records information about family ing pedigrees with genograms and ecomaps as a way
members and their relationships over at least three to offer a more comprehensive holistic nursing care
generations (McGoldrick, Gerson, & Petry, 2008). perspective. Creative blended models built upon
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Family Nursing Assessment and Intervention 117

these ideas are emerging in practice with innovative their relationships function to aid in the recovery
applications such as the use of color coding for en- of the ill family member. A suggested format for
hancing multimodal understanding of children and conducting a concise, focused family genogram in-
families (Driessnack, 2009). terview is outlined in Box 4-4. Most families are co-
Figure 4-4 provides a basic genogram from operative and interested in completing their
which a nurse can start diagramming family mem- genogram, which becomes a part of their ongoing
bers over the first, second, and third generations health care record. The genogram does not have
(McGoldrick, Gerson, & Schellenberger, 1999). to be completed at one sitting. As the same or a dif-
Figure 4-5 depicts the genogram symbols used to ferent nurse continues to work with a family, data
describe basic family membership and structure, can be added to the genogram over time in a con-
family interaction patterns, and other family infor- tinuing process. Families should be given a copy of
mation of particular importance, such as health sta- their own genogram.
tus, substance abuse, obesity, smoking, and mental Family Ecomap
health comorbidities (McGoldrick et al., 2008). The A family ecomap provides information about systems
health history of all family members (e.g., morbid- outside of the immediate nuclear family that are
ity, mortality, and onset of illness) is important in- sources of social support or that are stressors to the
formation for family nurses and can be the focus of family (Olsen et al., 2004). The ecomap is a visual
analysis of the family genogram. An example of a representation of the family unit in relation to the
family genogram developed from one interview is larger community in which it is embedded (Kaaki-
contained in the Bono family case study below. nen, 2010). It is a visual representation of the rela-
The structure of the interview for gathering the tionship between an individual family and the
genogram information is based on the reasons why world around it (McGoldrick et al., 2008). The
the nurse is working with the family. For example, ecomap is thus an overview of the family in its cur-
if the context of creating a genogram is that of ob- rent context, picturing the important connections
taining a health history aimed at uncovering family among the nuclear family, the extended family, and
patterns of illness, the nurse may wish to explore the community around it.
more fully the health history of each generational The blank ecomap form consists of a large circle
family member. If, on the other hand, the context with smaller circles around it (Fig. 4-6). A simpli-
of the nursing care is determining the nature of so- fied version of the family is placed in the center of
cial relationships and roles among family members the larger circle to complete the ecomap. This cir-
to craft an acute care plan of discharge, the nurse cle marks the boundary between the family and its
may wish to focus the interview more closely on extended external environment. The smaller outer
determining who is directly in the home and how circles represent significant people, agencies, or

FIGURE 4-4 Basic genogram format.

3921_Ch04_105-136 05/06/14 10:58 AM Page 118

Male Female Pet Therapy or Family Household shown by circling members living together
Institutional Secret (couple living with their dog after launching children)

Has Lived in
Immigration 2+ Cultures
Gay Lesbian Bisexual

Transgender People Ed 62 63 Judy

Location &
Man to Woman Annual
woman to man Income
Death Sam 27 Dog
1941–2001 Boston
Birth Date Age $100,000
41 82 72 identified patient (IP)
symbol has double line spouses
23 X and age
and is written lower 24 Jolie
at death in written
above inside symbol, death above than siblings smaller &
symbol symbol date above* birth date lower

*When multiple deceased generators are included, use an X only for untimely death. Adopted Child/Foster Child

Sexual Relationship Committed

Marriage Secret Affair Living Together Relationship

use an 94 A 99
m 1970 LT 95 LT 95
arrow to 10
show family
into which child moved Adopted at 5
Marital Reconciliation
Marital Separation After Separation Divorce Reconciliation After Divorce Donor
m 70, s 95 s 95–96 m 70, s 95, d 97 d 98, remar 00

Divorce and Remarriage

m 95 m 80, s 85–86 d 90, remar 93, rediv 94 d 98, remar 00

lesbian couple’s
Children daughter
list in birth order beginning with the oldest on left with egg of one
partner and
LW 98–99 A 97 97 sperm donor
92 94 95 99 01 03 04 05
13 11 10
Biological Foster Adopted Information Miscarriage Abortion Twins Identical Pregnancy
child child child unknown twins
Interactional Patterns Between People Addiction, Physical or Mental Illness or Other Problem
Physical or Physical or psychological
Focused on Close Fused Hostile psychological illness illness in remission
Substance abuse In recovery from gay couple’s
Close-hostile Caretaker Distant Cutoff substance abuse daughter
substance abuse In recovery from mental conceived
Focused on Positive Spiritual Cutoff or physical problems and with sperm of one
negatively relationship connection repaired Physical or from substance abuse partner and
or affinity psychological illness Language difficulty (person egg donor,
does not speak dominant carried by
Smoker Obesity language of the country) surrogate mother
Physical abuse Sexual abuse Emotional abuse S O

FIGURE 4-5 Genogram symbols. (From Genograms: Assessment and Intervention, Second Edition by Monica McGoldrick,
Randy Gerson, and Sylria Shellenberger. Copyright © 1999 by Monica McGoldrick and Sylvia Shellenberger. Copyright © 1985 by
Monica McGoldrick and Randy Gerson. Used by permission of W. W. Norton & Company, Inc.)
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Family Nursing Assessment and Intervention 119

BOX 4-4 institutions with which the family interacts. Lines

are drawn between the circles and the family mem-
Family Genogram Interview Data Collection bers to depict the nature and quality of the rela-
1. Identify who is in the immediate family.
tionships, and to show what kinds of energy and
2. Identify the person who has the health problem. resources are moving in and out of the immediate
3. Identify all the people who live with the immediate family. Straight lines show strong or close relation-
family. ships; the more pronounced the line or greater the
4. Determine how all the people are related. number of lines, the stronger the relationship is.
5. Gather the following information on each family Straight lines with slashes denote stressful relation-
member. ships, and broken lines show tenuous or distant re-
■ Age lationships. Arrows reveal the direction of the flow
■ Sex of energy and resources between individuals, and
■ Correct spelling of name
between the family and the environment. Ecomaps
■ Health problems
not only portray the present situation but also can
■ Occupation
■ Dates of relationships: marriage, separation, divorce,
be used to set goals, for example, to increase con-
living together, living together/committed nections and exchanges with individuals and agen-
■ Dates and age of death
cies in the community. See the Bono family case
6. Seek the same information for all family members study later in this chapter for an example of a com-
across each generation for consistency and to reveal pleted ecomap.
patterns of health and illness. The value of using a genogram and ecomap in
7. Add any information relative to the situation, such as family nursing practice is expansive. By creating
geographical location and interaction patterns. a visual picture of the system in which the family


Place basic genogram of

the immediate family in the
Extended center of the ecomap circle
family or Work


Strong relationship

Weak relationship

Tense relationship
Direction of
energy flow
FIGURE 4-6 Blank ecomap.
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120 Foundations in Family Health Care Nursing

exists, families are more able to envision alternative because of shame or embarrassment (Bass, 2005;
solutions and possible social support networks (Ray Dreger & Tremback, 2002; Osborn et al., 2007).
& Street, 2005; Yanicki, 2005). In addition, the When nurses design written material for the
process of this data collection itself helps to expose family, the following common elements make it
a clearer picture of the supportive or unsupportive easier to understand from a health literacy per-
family relationships that are going on in a family spective (Bass, 2005; Peters, Dieckmann, Dixon,
system (Neufeld, Harrison, Hughes, & Stewart, Hibbard, & Mertz, 2007):
2007). This information will enhance understand-
■ All written information should be in at least
ing of the family’s social network with their care-
14-point font using high-contrast Arial or
givers (Ray & Street, 2005).
sans serif print with plenty of blank space on
Family Health Literacy glossy paper.
■ Uppercase and lowercase letters should be
Health literacy is the ability to use health infor-
mation to make informed decisions through the
■ Information is most easily seen when using
comprehension of reading material, documents,
black ink on white paper. Use short sen-
and numbers. Functional health literacy incorpo-
tences with bullets or lists no longer than
rates all of these elements, but it also implies that
seven items (Peters et al., 2007).
the client (family) has the ability to act on health
care decisions. Concepts of health literacy include Written information presented at the third-
the comprehension of medical words, the ability grade reading level will reach the largest audience,
to follow medical instructions, and the under- but it may be necessary to write at the fifth-grade
standing of the consequences when instructions level to retain the meaning of the content (Mayer
are not followed (Speros, 2005). Nurses who & Rushton, 2002; Peters et al., 2007). Using mul-
understand the concept of health literacy will ac- tiple forms of communication, including visual
tively seek to collect ongoing assessment data aids, will help families retain the information (Bass,
about the learning needs of family members in 2005; Dreger & Tremback, 2002; Osborn et al.,
their meetings, interviews, or conferences. This 2007).
data about the family members’ abilities and pref- Nurses need to approach assessment of the fam-
erences for learning will help guide the nurse to ily health literacy with sensitivity and understand-
provide education, materials, and other supports, ing. It is a crucial element to take into consideration
such as videos or Web sites, that are accessible to during the analysis of the family story and in the de-
the family. velopment of the family action plan.
Through interactions with the family and when
completing the genogram and ecomap, nurses have
the opportunity to determine whether there is an ANALYSIS OF THE FAMILY STORY
issue of health literacy for any member of the fam-
ily. Health literacy is an important measure for One of the challenges of data collection is organ-
health care practitioners because lower health lit- izing the individual pieces of information so that
eracy is strongly associated with poor health out- the “big picture” or whole family story can be un-
comes (Berkman, Sheridan, Donahue, Halpern, & derstood and analyzed. To understand the family
Crotty, 2011; Sentell & Halpin, 2006; Speros, picture, the nurse must consolidate the data that
2005). Health literacy plays a primary role in peo- were collected into meaningful patterns or cate-
ple’s ability to gain knowledge, make decisions, and gories so as to visualize the relationships between
take actions that result in positive health outcomes and among the patterns of how the family is man-
(Berkman et al., 2011; DeWalt, Boone, & Pignone, aging the situation. Diagramming the family and
2007; Speros, 2005), especially when managing a the relationships between the data groups assists
chronic illness (Gazmararian, Williams, Peel, & identifying the most pressing issues or problems for
Baker, 2003). Assessment is particularly important the family. If the family and nurse focus on solving
when low literacy or low language proficiency ex- these major family problems, the outcome will have
ists, because such individuals are more likely to at- a ripple effect by positively influencing the other
tempt to hide their inability to read or understand areas of family functioning.
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Family Nursing Assessment and Intervention 121

The Family Reasoning Web (Fig. 4-7) is an Once the data have been placed into the cate-
organizational tool to help analyze the family gories of the Family Reasoning Web template, the
story, by clustering individual pieces of data into nurse assigns a family nursing diagnosis to each cat-
meaningful family categories. The components of egory. “A nursing diagnosis is defined as a clinical
the Family Reasoning Web have been pulled from judgment about individuals, families, or community
various theoretical concepts, such as Family responses to actual or potential health problems/life
Structure and Function Theory, Family Develop- processes. Nursing diagnoses link information to
mental Theory, Family Stress Theory, and family care planning. Nursing diagnoses provide the basis
health promotion models. This systematic ap- for selecting nursing interventions to help achieve
proach to collecting and analyzing information outcomes for which nurses are accountable”
helps structure the information collection process (Doenges et al., 2013, p. 11). The case study below
to ensure inclusion of important pieces of infor- presents more information on nursing diagnoses.
mation. The categories of the Family Reasoning The North American Nurses Diagnosis Associ-
Web are as follows: ation (NANDA) (2007) is the most global nursing
classification system. NANDA nursing diagnoses
1. Family routines of daily living (i.e., sleep-
that are specific to families are listed in Box 4-5. If
ing, meals, child care, exercise)
the pattern of family data in the specific category
2. Family communication
in the Family Reasoning Web does not match one
3. Family supports and resources
of the NANDA nursing diagnoses, nurses are en-
4. Family roles
couraged to create a family nursing diagnosis that
5. Family beliefs
captures the family problem. Nursing diagnosis
6. Family developmental stage
manuals are extremely important resources for
7. Family health knowledge
nurses because family nursing diagnoses are read-
8. Family environment
ily linked with both the Nursing Intervention
9. Family stress management
Classification (NIC) (Bulechek, Butcher, Dochter-
10. Family culture
man, & Wagner, 2013) and Nursing Outcomes
11. Family spirituality
Classification (NOC) (Moorhead, Johnson, Maas,

Family Family stress

culture management


Family routines Family diagnosis

Family health
of daily living,
(e.g., meals, sleep,
exercise, child)

Family developmental
communication stage

Family social Family

supports and beliefs
resources Family
FIGURE 4-7 Family Reasoning
Web template.
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122 Foundations in Family Health Care Nursing

BOX 4-5 Table 4-3 Selected Family-Centered Diagnoses

From Diagnostic and Statistical Manual
NANDA Nursing Diagnoses Relevant to of Mental Disorders, Fifth Edition
Family Nursing
V61.9 Relational problem related to a mental disorder
■ Risk for impaired parent/infant/child attachment or general medical condition
■ Caregiver role strain V61.20 Parent-child relational problem
■ Risk for caregiver role strain
V61.10 Partner relational problem
■ Parental role conflict
■ Compromised family coping
V61.8 Sibling relational problem
■ Disabled family coping V71.02 Child or adolescent antisocial behavior
■ Readiness for enhanced family coping V62.82 Bereavement
■ Dysfunctional family processes: alcoholism
V62.3 Academic problem
■ Readiness for enhanced family processes
■ Interrupted family processes
V62.4 Acculturation problem
■ Readiness for enhanced parenting V62.89 Phase-of-life problem
■ Impaired parenting
■ Risk for impaired parenting Source: American Psychiatric Association. (2013). Diagnostic
■ Relocation stress syndrome
and statistical manual of mental disorders (DSM-5)
(5th ed.). Washington, DC: Author.
■ Ineffective role performance
■ Ineffective family therapeutic regimen management

Table 4-4 Selected Family-Centered Diagnoses

Source: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2013).
From ICD-9-CM
Nursing diagnosis manual: Planning, individualizing, and doc-
umenting client care (3rd ed.). Philadelphia, PA: F. A. Davis, 313.3 Relationship problems
with permission.
313.8 Emotional disturbances of childhood or
V61.0 Family disruption
& Swanson, 2012) data sets. These resources pro-
vide many new ideas for family interventions and V25.09 Family planning advice
suggest focused family outcomes that can be ex- V61.9 Family problem
plored with families. 94.41 Group therapy
Other diagnostic classification systems that can 94.42 Family therapy
be used to identify problems include the Omaha
System–Community Health Classification System Source: American Medical Association. (2013). International
(Martin, 2004), the Diagnostic and Statistical Manual classification of diseases: Clinical modifications (IDC-9-CM).
Dover, DE: Author.
of Mental Disorders, Fifth Edition (DSM-5; American
Psychiatric Association, 2013), and the International
Classification of Diseases: Clinical Modifications, Ninth greatly involves the focus on the domains of activity
Edition (ICD-9-CM; American Medical Associa- and participation and the environmental context of
tion, 2012). See Tables 4-3 and 4-4, respectively, family life. Given that nurses’ primary focus with
for examples of selected family diagnoses from the individuals and families is the functional aspect of
DSM and ICD-9-CM sources. health in daily life, this system of categorizing and
A rapidly growing system of diagnostic language coding functional outcomes of health is com-
relevant to nursing in North America is that of the pelling. The ICF and ICF-CY approaches are
World Health Organization ICD companions, being used with expanded focus in Europe and
the International Classification of Functioning Canada particularly (Florin, Björvell, Ehnfors, &
(ICF) and its related child and youth version Ehrenberg, 2012; Raggi, Leonardi, Cabello, &
(ICF-CY) (World Health Organization, 2013). Bickenbach, 2010).
This broad schema of classification focuses on After the categories have been assigned and a
making diagnostic statements of health impact in family nursing diagnosis determined, the next step
four domains: body structure, body function, activ- in analyzing the family story is for the nurse and
ity and participation, and environment (World family to work together to determine the relation-
Health Organization, 2013). Family nursing practice ships between the categories. Arrows are drawn
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Family Nursing Assessment and Intervention 123

between the family categories showing the direc- hours, and even discussions with/among family
tion of influence if the data in one category influ- members. Families have expressed fears of alienat-
ence the data in another category. The important ing health care providers (Taylor, 2006), thus com-
family problems or issues surface by systematically promising their loved ones’ care. All of this may
working through all of the relationships because interfere with nurses being able to be effective fam-
they are the ones that have the most arrows indi- ily advocates (Leske, 2002).
cating the strongest relationships to all other areas Health care providers underestimate the extent
of family functioning. The step reveals the primary that families want to be involved in the care of and
family problems. decision making about loved ones (Bruera, Sweeny,
Another dimension of the family story that is of Calder, Palmer, & Benisch-Tolly, 2001; Pierce &
importance to nurses is the dimension of beliefs. Hicks, 2001). Although most families prefer a shared
Family and family member beliefs about health, ill- decision-making approach (de Haes, 2006; Schat-
ness, health care providers, and even their own tner et al., 2006; Whitmer et al., 2005), families vary
roles and processes are of great importance for relative to the amount of information they want and
nurses to assess in planning to provide optimal care. their role in the decision-making process (Sobo,
The Beliefs and Illness Model by Wright and Bell 2004). The amount of information families seek or
(2009) suggests that nurses should assess families’ need changes over the course of the health event, the
beliefs in a number of areas, specifically, family stage of the illness, and the likelihood of a cure
structure, roles, communication, and decision- (Butow, Maclean, Dunn, Tattersall, & Boyer, 1997).
making authority; beliefs about health and illness An option grid is one strategy for implementation
(how they are defined, why they occur, how they of shared decision making (Elwyn et al., 2012). An
are managed); and beliefs about health care option grid is developed by the family nurse keeping
providers (their intentions, motivations, and health literacy principles at the fifth-grade level.
knowledge and the meaning of their presence and Elwyn et al. specifically developed the grid format as
actions to the families and their health or illness ex- a decision-making paper worksheet addressing com-
perience). Individuals and families often behave mon therapeutic approaches to specific health con-
based upon their beliefs and thus any attempt for ditions where patients and families could view the
nurses to engage families in health promotion, benefits or drawbacks associated with different pos-
health literacy, or health intervention in any setting sible treatment decisions. On the worksheet, the
requires an exploration of these key areas. After most relevant, frequently asked questions about a
verifying all of these findings with the family, the specific condition make up the rows of the grid, and
next step is to work with the family to understand the specific options available for the decision make
their preferences for decision making and design a up the columns. Patients are given the paper grid and
family plan of care accordingly. talked through the options available to them with
their provider. For example, see Box 4-6, an option
grid that a nurse could design to help parents deter-
Shared Decision Making
mine respite placement for their 12-year-old daugh-
Family nurses should explore how involved the ter who is medically fragile with severe cerebral palsy.
family would like to be in the decision-making This specific tool shows promise for nurses working
processes. Universal needs of families include con- with families because not only does it represent the
sistency, clarity, comprehensive information, and principles of family-centered care in practice, but also
involvement in shared decision making with the because families often have difficulties understanding
health care provider (Salmond, 2008; Schattner, their options and the potential benefits or conse-
Bronstein, & Jellin, 2006; Whitmer, Hughes, quences associated with their choices.
Hurst, & Young, 2005). Nurses, consciously and Another approach to shared decision making is
otherwise, affect the family stress level by control- to use the Patient/Parent Involvement Informa-
ling how much (and how quickly) they involve the tion Assessment Tool (PINT) developed by Sobo
family in the care of their family members (Corlett (2004). The PINT is a self-administered survey
& Twycross, 2006). Nurses control how much in- that can be kept in the medical record to facilitate
formation they share with families, how much they and target information for communication be-
involve the family in the daily routine, visiting tween the health care team and the family. In the
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124 Foundations in Family Health Care Nursing

BOX 4-6
Example of Option Grid

The following is an example of an option grid for helping a family to decide about 1-week respite placement for their
12-year-old medically fragile child:
Option 1: Home Option 2: Grandmother’s home Option 3: Nursing home
Child knows own home and is around Child has been to grandmother’s home New setting for child.
familiar surroundings. only a couple of times because it is in
a different city.
Home is adapted to the child’s needs Home is not adapted to the physical Setting can accommodate the child’s
and wheelchair. care needs of child, such as wheelchair special needs and wheelchair.
and bathing.
Caregiver would be the skills trainer Caregiver is grandmother, who the No personal relationship with care-
who knows the child. child knows well and has spent consid- givers in this setting. Grandmother
erable time with. could visit during day.
Parents are comfortable with the child Parents are comfortable with the child Parents do not have a relationship with
being with the skills worker during the being with grandmother. Grandmother the caregivers in this setting.
day, but do not have experience with has helped take care of child for short
this person at night. times before, such as a weekend.
Cost: $250 a day for 7 days for a total Cost: nothing. Cost: Covered by insurance.
of $1,750. This would come out of the
parents’ pocket because insurance does
not cover this care.

challenge to collaborate in the care and meet the health care decisions, Makoul and Clayman (2006)
needs of individuals and family members, nurses have outlined the following nine options for shared
may ask the following two sample questions from decision making (p. 307):
the PINT tool (Sobo, 2004, p. 258):
■ Doctor alone
1. When possible, what level of information ■ Doctor led and patient acknowledgment
would you prefer to receive? sought or offered
■ The simplest information possible ■ Doctor led and patient agreement sought or
■ More than the simplest, but want to keep offered
it on everyday terms ■ Doctor led and patient views/option sought
■ In-depth information that you can help me or offered
understand ■ Shared equally
■ As much in-depth and detailed informa- ■ Patient led and doctor views/opinions sought
tion as can be provided or offered
2. When possible, what decision-making role ■ Patient led and doctor agreement sought or

do you want to assume? offered

■ Leave all decisions to the health care team ■ Patient led and doctor acknowledgment

■ Have the care team make the decisions sought or offered

about care with serious consideration of ■ Patient alone

our views
One of the problems with the implementation
■ Share in the making of the decisions with
of shared decision making is that every health
the health care team
care provider has a different definition and un-
■ Make all the decisions about care with se-
derstanding of the components of this concept,
rious consideration of the health care team
as well as personal biases and beliefs about how
individuals and families may or may not wish
Supporting the hypothesis that not all families and to participate (Elwyn et al., 2012; Makoul &
family members want full involvement in making Clayman, 2006). Shared decision making is not
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Family Nursing Assessment and Intervention 125

just informing the family of the decisions and The following four points will help the family
keeping the lines of communication open, nor is break the plan into action steps:
it the health care providers determining what de-
cisions the family can make. Shared decision 1. We need the following type of help.
making requires that health care providers tailor 2. We need the following information.
their communication, accommodate their talk to 3. We need the following supplies or resources.
the level of the family, and present information 4. We need to involve or tell the following
in a way that allows the family to make informed people about our family action plan.
choices. Shared decision making includes the fol- For the purposes of clarity and evaluation, this
lowing steps as outlined by Makoul and Clayman plan should be a written document. The action
(2006, pp. 305–306): steps or interventions should be clear and concise.
■ The family and health care provider must de- The plan should outline specifically who need