Course Title: Community Health Nursing (Individual and Family)

Course No.: NCM 104

Learning Outcome: 1. Analyze changing definitions of family.

2. Discuss characteristics all families have in

common.

3. Identify five attributes that help explain how

families function as social systems.

4. Compare and contrast the variety of structures

that make up families.

5. Describe the functions of a family.

6. Identify the stages of the family life cycle and the

developmental tasks of a family as it grows.

7. Analyze the role of the community health nurse in

promoting the health of the family unit.

Content:

Module 4: THE FAMILY (2 HOURS)

This module aims to describe the overview of family and discuss how
a family’s culture influences its values, behaviors, prescribed roles, and
distribution of power.

Topic 1: Family as basic unit of society

Topic 2: Functions, Development stages, Health Task,
Characteristics of Family

Concept/Digest

• Community health nurses are intimately involved with families. Whether the
client is an individual within the context of the family or the family is the unit
of care, the family plays a critical role in the health of its members.
• Health habits, such as preventive care, diet, exercise, and physical activity,
are developed within the context of the family (Campbell, 2006). Health
beliefs, genetic influences, and care of the ill family member all take place
within the family environment.
Definition of Family
Family
• Basic unit in society, and is shaped by all forces surround it.
• Values, beliefs, and customs of society influence the role and function of
the family (invades every aspect of the life of the family)
• Is a unit of interacting persons bound by ties of blood, marriage or adoption.
o Constitute a single household, interacts with each other in their
respective familial roles and create and maintain a common culture.
• An open and developing system of interacting personalities with structure
and process enacted in relationships among the individual members
regulated by resources and stressors and existing within the larger
community (Smith & Maurer, 1995)
• Two or more people who live in the same household (usually), share a
common emotional bond, and perform certain interrelated social tasks
(Spradly & Allender, 1996)
• An organization or social institution with continuity (past, present, and
future). In which there are certain behaviors in common that affect each
other.
• Many family theorists suggest that a family consists of two or more
individuals who share a residence or live near one another; possess some
common emotional bond; engage in interrelated social positions, roles,
and tasks; and share cultural ties and sense of affection and belonging
(Anderson & Sabatelli, 2006; Friedman, Bowden, & Jones, 2003; Hanson,
Gedaly- Duff, & Kaakinen, 2005; McBride, 2006; Murray & Zent- ner, 2000).
• The common thread in the definitions is the recognition that the family itself
defines who its members are (Bomar, 2004).
Family functioning

• Is defined as those behaviors or activities by family members that maintain

the family and meet family needs, individual member needs, and society’s
views of family.
Family health

• Is concerned with how well the family functions together as a unit. It involves
not only the health of the members and how they relate to other members,
but also how well they relate to and cope with the community outside the
family.
The Filipino Family
Based on the Philippine Constitution, Family Code with focus on religious, legal,
and cultural aspects of the definition of family.
Section 1
• The state recognizes the Filipino family as the foundation of the nation.
Accordingly, it shall strengthen its solidarity and actively promote its total
development
Section 2
• Marriage, as an inviolable social institution, is the foundation of family and
shall be protected by the state.
Section 3
The state shall defend –
1. The right of spouses to found a family in accordance with their religious
convictions and the demands of responsible parenthood
2. The right of children to assistance including proper care and nutrition, and
special protection from all forms of neglect, abuse, cruelty, exploitation
and other conditions prejudicial to their development
3. The right of the family to a family living wage income
4. The right of families or family associations to participate in the planning and
implementation of policies and programs of that affect them

Section 4
• The family has the duty to care for its elderly members but the state may
also do so through just programs of social security

THE FILIPINO FAMILY AND ITS CHARACTERISTICS

The basic social units of Philippine society are the nuclear family
1. Although the basic unit is the nuclear family, the influence of kinship is felt
in all segments of social organizations
2. Extensions of relationships and descent patterns are bilateral
3. Kinship circles is considerably greater because effective range often
includes the third cousin
4. Kin group is further enlarged by a finial, spiritual or ceremonial ties. Filipino
marriage is not an individual but a family affair
5. Obligation goes with this kingship system
6. Extended family has a profound effect on daily decisions
7. There is a great degree of equality between husband and wife
8. Children not only have to respect their parents and obey them, but also
have to learn to repress their repressive tendencies
 9. The older siblings have something of authority of their parents.
Types of Family
• There are many types of family.
• They change overtime as a consequence of BIRTH, DEATH, MIGRATION,
SEPARATION and GROWTH OF FAMILY MEMBERS
A. Structure
NUCLEAR- a father, a mother with child/children living together but apart
from both sets of parents and other relatives.
EXTENDED- composed of two or more nuclear families economically and
socially related to each other. Multigenerational, including married
brothers and sisters, and the families.
SINGLE PARENT-divorced or separated, unmarried or widowed male or
female with at least one child.
BLENDED/RECONSTITUTED-a combination of two families with children from
both families and sometimes children of the newly married couple. It is also
a remarriage with children from previous marriage.
COMPOUND-one man/woman with several spouses
COMMUNAL-more than one monogamous couple sharing resources
COHABITING/LIVE-IN-unmarried couple living together
DYAD—husband and wife or other couple living alone without children
GAY/LESBIAN-homosexual couple living together with or without children
NO-KIN- a group of at least two people sharing a relationship and
exchange support who have no legal or blood tie to each other
FOSTER- substitute family for children whose parents are unable to care for
them
FUNCTIONAL TYPE:
FAMILY OF PROCREATION- refers to the family you yourself created.
FAMILY OF ORIENTATION -refers to the family where you came from.
B. Decisions in the family (Authority)
PATRIARCHAL – full authority on the father or any male member of the family
e.g. eldest son, grandfather
MATRIARCHAL – full authority of the mother or any female member of the
family, e.g. eldest sister, grandmother
EGALITARIAN- husband and wife exercise a more or less amount of
authority, father and mother decides
DEMOCRATIC – everybody is involve in decision making
AUTHOCRATIC-
LAISSEZ-FAIRE- “full autonomy”
 MATRICENTRIC- the mother decides/takes charge in absence of the father
(e.g. father is working overseas)
PATRICENTIC- the father decides/ takes charge in absence of the mother

C. Decent (cultural norms, which affiliate a person with a particular group of

kinsman for certain social purposes)
PATRILINEAL – Affiliates a person with a group of relatives who are related
to him though his father
BILATERAL- both parents
MATRILINEAL – related through mother
D. Residence
PATRILOCAL – family resides / stays with / near domicile of the parents of
the husband
MATRILOCAL – live near the domicile of the parents of the wife
Ackerman States that the Function of Family are:
1. Insuring the physical survival of the species
2. Transmitting the culture, thereby insuring man’s humanness
• Physical functions of the family are met through parents providing food,
clothing and shelter, protection against danger provision for bodily repairs
after fatigue or illness, and through reproduction
• Affectional function – the family is the primary unit in which he child test his
emotional reactions
• Social functions – include providing social togetherness, fostering self
esteem and a personal identity tied to family identity, providing opportunity
for observing and learning social and sexual roles, accepting responsibility
for behavior and supporting individual creativity and initiative.

Universal Function of the Family by Doode

1. REPRODUCTION – for replacement of members of society: to perpetuate
the human species
2. STATUS PLACEMENT of individual in society
3. BIOLOGICAL and MAINTENANCE OF THE YOUNG and dependent members
4. Socialization and care of the children;
5. Social control

THE FAMILY AS A UNIT OF CARE

Rationale for Considering the Family as a Unit of Care:
• The family is considered the natural and fundamental unit of society
 • The family as a group generates, prevents, tolerates and corrects health
problems within its membership
THE FAMILY AS THE CLIENT
Characteristics of a Family as a Client
1. The family is a product of time and place-
• A family is different from other family who lives in another location in
many ways.
• A family who lived in the past is different from another family who lives
at present in many ways.
2. The family develops its own lifestyle
• Develop its own patterns of behavior and its own style in life.
3. The family operate as a group
• A family is a unit in which the action of any member may set of a whole
series of reaction within a group, and entity whose inner strength may
be its greatest single supportive factor when one of its members is
stricken with illness or death.
4. The family accommodates the needs of the individual members.
• An individual is unique human being who needs to assert his or herself in
a way that allows him to grow and develop.
5. The family relates to the community
• Family develops a stance with respect to the community:
1. The relationship between the families is wholesome and reciprocal; the
family utilizes the community resources and in turn, contributes to the
improvement of the community.
2. There are families who feel a sense of isolation from the community.
6. The family has a growth cycle
• Families pass through predictable development stages (Duvall & Miller,
1990)
STAGES:
Stage 1: MARRIAGE & THE FAMILY
▪ Involves merging of values brought into the relationship from the
families of orientation.
▪ Includes adjustments to each other’s routines (sleeping, eating,
chores, etc.), sexual and economic aspects.
Stage 2: EARLY CHILDBEARING FAMILY
▪ Birth or adoption of a first child which requires economic and social
role changes
▪ Oldest child: 2-1/2 years
 Stage 3: FAMILY WITH PRE-SCHOOL CHILDREN
▪ This is a busy family because children at this stage demand a great
deal of time related to growth and development needs and safety
considerations.
▪ Oldest child: 2-1/2 to 6 years old
Stage 4: FAMILY WITH SCHOOL AGE CHILDREN
▪ Parents at this stage have important responsibility of preparing their
children to be able to function in a complex world while at the same
time maintaining their own satisfying marriage relationship.
▪ Oldest child: 6-12 years old
Stage 5: FAMILY WITH ADOLESCENT CHILDREN
▪ A family allows the adolescents more freedom and prepare them for
their own life as technology advances-gap between generations
increases
▪ Oldest child: 12-20 years old
Stage 6: THE LAUNCHING CENTER FAMILY
▪ Stage when children leave to set their own household-appears to
represent the breaking of the family
▪ Empty nests
Stage 7: FAMILY OF MIDDLE YEARS
▪ Family returns to two partners nuclear unit
▪ Period from empty nest to retirement
Stage 8: FAMILY IN RETIREMENT/OLDER AGE
Stage 9: PERIOD FROM RETIREMENT TO DEATH OF BOTH SPOUSES

12 BEHAVIORS INDICATING A WELL FAMILY

1. Able to provide for physical emotional and spiritual needs of family
members
2. Able to be sensitive to the needs of the family members
3. Able to communicate thought and feelings effectively
4. Able to provide support, security and encouragement
5. Able to initiate and maintain growth producing relationship
6. Maintain and create constructive and responsible community relationships
7. Able to grow with and through children
8. Ability to perform family roles flexibly
9. Able to help oneself and to accept help when appropriate
10. Demonstrate mutual respect for the individuality of family members
11. Ability to use a crisis experience as a means of growth
 12. Demonstrate concern of family unity, loyalty and interfamily cooperation

FAMILY HEALTH TASK

• Health task differ in degrees from family to family
• TASK- is a function, but with work or labor overtures assigned or demanded
of the person
• Duvall & Niller identified 8 task essential for a family to function as a unit:

Eight Family Tasks (Duvall & Niller)

1. Physical maintenance- provides food shelter, clothing, and health care to
its members being certain that a family has ample resources to provide
2. Socialization of Family– involves preparation of children to live in the
community and interact with people outside the family.
3. Allocation of Resources- determines which family needs will be met and
their order of priority.
4. Maintenance of Order– task includes opening an effective means of
communication between family members, integrating family values and
enforcing common regulations for all family members.
5. Division of Labor – who will fulfill certain roles e.g., family provider, home
manager, children’s caregiver
6. Reproduction, Recruitment, and Release of family member
7. Placement of members into larger society –consists of selecting community
activities such as church, school, politics that correlate with the family
beliefs and values
8. Maintenance of motivation and morale– created when members serve as
support people to each other

5 Family Health Tasks (Maglaya, A., 2004)

1. Recognizing interruptions of health development
2. Making decisions about seeking health care/ to take action
3. Dealing effectively health and non-health situations
4. Providing care to all members of the family
5. Maintaining a home environment conducive to health maintenance

Family Roles
• Nurturing figure– primary caregiver to children or any dependent member.
• Provider – provides the family’s basic needs.
 • Decision maker– makes decisions particularly in areas such as finance,
resolution, of conflicts, use of leisure time etc.
• Problem-solver– resolves family problems to maintain unity and solidarity.
• Health manager– monitors the health and ensures that members return to
health appointments.
• Gate keeper-Determines what information will be released from the family
or what new information cam be introduced.

Theoretical Approaches to Family Health Care (family apgar)

Family Models
• the use of family model provides a perspective of focus for understanding
the family
• have categorized according to their basic focus as developmental,
interactional structural-functional, and systems model
Developmental Models
Duvall’s and Stevenson’s Family development model
• Evelyn Duvall’ (1977) family developmental framework provides guide to
examine and analyze the basic changes and developmental tasks
common to most families during their life cycle. Although each family has
unique characteristics normative patterns of sequential development are
common to all families

STAGES OF DEVELOPMENT BASIC FAMILY TASK

Beginning Families / Early Physical maintenance
childbearing
Families with preschoolers
Families with school children
Families with teen-agers
Launching center families
Middle-aged families
Aging Families
Allocation of resources
Division of labor
Socialization of members.
Reproduction, recruitment and
release of Members
Maintenance of order Placement of
members in larger community
Maintenance of motivation and
morale

• Duvall’s developmental model is an excellent guide for assessing, analyzing

and planning around basic family tasks developmental stage, however, this
model does not include the family structure or physiological aspects, which
should be considered for a comprehensive view of the family.
STEVENSON’S FAMILY DEVELOPMENTAL MODEL
• Joanne Stevenson (1977) describes the basic tasks and responsibilities of
families in four stages.
STRUCTURAL- FUNCTIONAL MODEL
• Friedman’s Structural- Functional Family Model
• Was developed from sociological frameworks and systems theory by
Marilyn Friedman (1986)
Friedman’s Family Model Components
STRUCTURAL COMPONENTS FUNCTIONAL COMPONENTS

Family composition Affective

Value systems Physical necessities and care

Communication patterns Economic

Role structure Reproductive

Socialization and social placement

Power structure Family coping

SYSTEMS MODEL
Calgary’s Family Model (system’s model)
• Is an integrated conceptual framework of several theorists.
• Model is based on three major categories: family structure, function and
development. Each is further subdivided into parts that interacts with others
and changes the whole family configuration.

Calgary Family Model

Family Structure Family Development Family Functions
Internal developmental stage daily living activities
Family composition developmental tasks allocation of tasks
Rank order of member’s attachments
Subsystems in family
Boundaries of family External Expressive
Culture Communication
Religion Problem-solving
Social class status Roles
And mobility Control
Environment Beliefs
Extended family Alliances/coalitions

• This model is comprehensive and incorporates three major areas, namely,

the structure, function and development of the family.
• It is complex, with too many sub concepts for the health worker to explore
and focus.
• It can be applied to any type of family with any health-related problems.

FAMILY APGAR QUESTIONNAIRE (SMILKESTEIN, 1978)

HARDLY
ALWAYS SOMETIMES
EVER
(2 PTS.) (1 pt.)
(0 PT.)
I am satisfied with the help I receive from
my family when something is troubling
me.
I am satisfied with the way my family
discovers items of common interest and
shares problem-solving with me.
I find that my family accepts my wishes
to take on new activities or make
changes in my lifestyle.
I am satisfied with the way my family
expresses affection and responds to my
feelings such as anger, sorrow and love
I am satisfied with the way my family and
I spend time together.

Scoring:
Check one of the three choices:
Total Score:
7-10 = suggests a highly functional family
4-6 = moderately dysfunctional family
0-3 = severely dysfunctional family
Health as a Goal of Family Health Care

Roles of Health Care Provider in Family Health Care

• Health monitor
• Provider of care
• Coordinator
 • Facilitator
• Teacher
• Counselor
UNIVERSAL CHARACTERISTICS OF FAMILIES

• Several observations can be made about families in general.

• First, each family is unique, with its own distinct problems and strengths.
When you approach the door of a house or push the buzzer of an
apartment, you cannot assume what the family inside will be like.
Consequently, you will have to gather information about each particular
family to achieve nursing objectives.
• Second, every family shares some universal characteristics with every other
family. These universal characteristics provide an important key to
understanding each family’s uniqueness.
• Five of the most important family universals for community health nursing
are:
1. Every family is a small social system.
2. Every family has its own cultural values and rules.
3. Every family has structure.
4. Every family has certain basic functions.
5. Every family moves through stages in its life cycle.
ATTRIBUTES OF FAMILIES AS SOCIAL SYSTEMS
• When a community health nurse sits in a living room talking with a young
mother about her new infant, it is difficult to keep in mind that all the other
family members are present by way of their influence.
• Systems theory offers some insights about
how families operate as social systems.
Knowing the attributes of living systems
or open systems can help strengthen
understanding of family structure and
function.
• There are five attributes of open systems
that help explain how families function:
1. families are interdependent,
2. families maintain boundaries
3. families exchange energy with their
environments
4. families are adaptive
5. families are goal-oriented.

1. Interdependence Among Members

• All the members of a family are
interdependent; each member’s actions affect the other members,
and what affects the family system affects each family member.
• It is possible to illustrate the pattern of interactions between members
using a family map (Fig. 18.1). This tool can reveal a great deal about
the interdependence of family members. The way parents relate to
each other, for instance, influences the quality of their parenting.
2. Family Boundaries
• Families as systems set and maintain boundaries that include some
people as members while excluding others (Denham, 2005; McBride,
2006).
3. Energy Exchange
• To function adequately as open systems, families exchange materials or
information with their environment (Friedman et al., 2003). This process
is called energy exchange.
4. Adaptive Behavior
• Families are adaptive, equilibrium-seeking systems. In accordance with
their nature, families never stay the same. They shift and change in
response to internal and external forces.
• Internally, the family composition changes as new members are added
or members leave through death or divorce. Roles and relationships
change as members advance in age and experience; normative
 expectations change as members resolve their tensions and differing
points of view.
• Externally, families are bombarded by influences from sources, such as
school, work, peers, neighbors, religion, and government; consequently,
they are forced to accommodate to new demands.
5. Goal-Directed Behavior
• Families as social systems are goal directed.
• Families exist for a purpose—to establish and maintain a milieu that pro-
motes the development of their members.
FAMILY CULTURE
• Family culture is the acquired knowledge that family members use to
interpret their experiences and to generate behaviors that influence family
structure and function.
• Three aspects of family culture deserve special consideration:
1. family members share certain values that affect family behavior
2. certain roles are prescribed and defined for family members,
3. a family’s culture deter- mines its distribution and use of power.
1. Shared Values and Their Effect on Behavior
• Although families share many broad cultural values drawn from the
larger society in which they live, they also develop unique variants.
2. Prescribed Roles
• Roles, the assigned or assumed parts that members play during day-
to-day family living, are bestowed and defined by the family
(Denham, 2005; Hanson et al., 2005; McBride, 2006).
• Family members play several roles at the same time. This intrarole
functioning can be exceptionally taxing. A woman may play the role
of wife to her husband, daughter to her mother who lives with her,
and mother to each of her children.
3. Power Distribution
• Power—the possession of control, authority, or influence over others—
assumes different patterns in each family.
• Rudolf Dreikurs (1964) advocated that families form a “family council”
for shared decision making and distribution of tasks. Today, many
families practice joint decision making and equal participation by all
members, and the community health nurse may suggest this activity for
families not using such a method.
TRADITIONAL FAMILIES
• Traditional family structures are those that are most familiar to us.
 1. Nuclear family - husband, wife, and children living together in the same
household. In nuclear families, the workload distribution between the
two adults can vary.
2. Nuclear-dyad family- consists of a husband and wife living together
who have no children or who have grown children living outside the
home.
3. Single-adult families - in which one adult is living alone by choice or
because of separation from a spouse or children or both.
4. Multi- generational family- A household in which a widowed woman
lives with her divorced daughter and two young grandchildren
5. Kin-network - particularly in close-knit ethnic communities, in which
several nuclear families live in the same household or near one another
and share goods and services.
6. Augmented family - A variation of the kin-network. This is a family group
in which extended family members or nonrelatives or both live with and
provide significant care to the children (Barnes, 2001).
7. Blended family- In this structure, single parents marry and raise the
children from each of their previous relationships together.
8. Single-parent families- include one adult (either father or mother)
caring for a child or children as a result of a temporary relationship, a
legal separation or divorce, or the death of a spouse. In single-parent
families, the parent may or may not be employed.
9. Commuter family - Both partners in this family work, but their jobs are in
different cities. The pattern is usually for one partner to live, work, and
perhaps raise children in the “home” city, while the second partner lives
in the other city and commutes home.
Nontraditional or Contemporary Families
• Society has begun to accept nontraditional definitions of family.
• The concept of wider family was initially presented by Marciano (1991) and
is defined as a family that “emerges from lifestyle, is voluntary, and
independent of necessary biological or kin connections” (p. 160).
• “With today’s wide variety of family types and structures, the most
advanced definition of family may be ‘the family is who the client says it is’”
(Bell & Wright, 1993, p. 391).
• Some contemporary family structures are becoming more common and
are generally accepted by society.
THE TRADITIONAL AND NONTRADITIONAL AMERICAN FAMILY
Exercises/Questions:
1. Within a small group of your peers, individually define family and then compare
each of your definitions. How similar and how different is each definition? What in
each person’s background contributes to the differences in the definitions? Was
each of the peers in nursing? If not, how did that contribute to any differences in
the definitions?
2. Analyze two families (other than your own) that you know well, one traditional
and the other nontraditional (contemporary), and answer the following questions:
• If the major breadwinner in this family became permanently disabled and
unable to work or lost his or her income, how would the family most likely
respond immediately and in the long term?
• What are some of this family’s rules for operation and the values underlying
the rules?
• Structurally, what kind of family is this?
• What are the strongest and weakest functions performed by this family, and
why do you think this is so?
• In what developmental stage is this family, and how does it affect their
functioning?