see
Textbooks:
Family Health Care Nursing
·
.
Read Chapters 11, 16, 17. Same chapters in 5th edition
.
Overview
· For this discussion, discuss the benefits and barriers to incorporating the family into care of the mental health patient. You are caring for a patient who has just been diagnosed with a mental health issue. Describe benefits and barriers that may occur when incorporating the family into caring for this patient.
References:
· Initial Post: Minimum of two (2) total references: one (1) from required course materials and one (1) from peer-reviewed references.
Words Limits
· Initial Post: Minimum 200 words excluding references
Family
Health Care
Nursing
Theory, Practice, and Research
fifth edition
3921_FM_i-xxiv 06/06/14 2:55 PM Page i
3921_FM_i-xxiv 06/06/14 2:55 PM Page ii
Great nursing care begins with great resources…
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Joanna Rowe Kaakinen, PhD, RN
Professor, School of Nursing
Linfield College
Portland, Oregon
Deborah Padgett Coehlo, PhD, C-PNP,
PMHS, CFLE
Developmental and Behavioral Specialist
Juniper Ridge Clinic
Bend, Oregon
Rose Steele, PhD, RN
Professor, School of Nursing, Faculty of Health
York University
Toronto, Ontario, Canada
Aaron Tabacco, RN, BSN
Doctoral Candidate, School of Nursing
Oregon Health and Science University
Portland, Oregon
Shirley May Harmon Hanson, RN, PhD,
PMHNP/ARNP, FAAN, CFLE, LMFT
Professor Emeritus, School of Nursing
Oregon Health and Science University
Portland, Oregon
Adjunct Faculty, College of Nursing
Washington State University
Spokane, Washington
Family
Health Care
Nursing
Theory, Practice, and Research
fifth edition
3921_FM_i-xxiv 06/06/14 2:56 PM Page iii
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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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v
d e d i c a t i o n
VIVIAN ROSE GEDALY-DUFF, RN, DNS
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
JOANNA, DEBORAH, ROSE, AARON, AND SHIRLEY
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vii
f o r e w o r d
Iam proud to have been the founder of FamilyHealth Care Nursing: Theory, Practice, and Re-search with the first edition published in 1996.
I am honored to be asked to write this particular
foreword, as this fifth edition of this textbook at-
tests and gives credence to the ongoing evolution
and development in the field of family nursing.
This edition also marks the end of my long nursing,
academic, and writing career. It is time to retire and
step aside for the younger generation of family
nurses to take over. It is exciting to think about
what family nursing will look like in the future.
Family Health Care Nursing: Theory, Practice, and
Research (I–V) is an ever changing and comprehen-
sive textbook originally developed to reflect and
promote the art and science of family nursing. This
all-inclusive far-reaching compendium of integrat-
ing theory, practice, and research continues in this
fifth edition of this textbook.
All editions of this distinctive textbook were
published by F. A. Davis. I am grateful for their
faith, trust, and support in carrying the legacy of
family nursing forward. This book originated when
I was teaching family nursing at Oregon Health
and Science University (OHSU) School of Nursing
in Portland, Oregon. At that time there was no
comprehensive or authoritative textbook on the
nursing care of families that matched our program
of study. This was the impetus I needed to write
and edit the first edition of Family Health Care
Nursing: Theory, Practice, and Research (Hanson and
Boyd, 1996). The first edition met a need of nurs-
ing educators in many other nursing schools
around the world, so F. A. Davis invited me to re-
vise, update, and publish the second edition, which
came out in 2001. For the third edition, I asked two
additional scholars to join me in writing and editing
this edition: the late Dr. Vivian Rose Gedaly-Duff
from OHSU (see Dedication) and Dr. Joanna
Rowe Kaakinen, then from the University of
Portland and now from Linfield College Portland
campus. A separate Instructors’ Manual, a new feature
of the third edition, was developed by Dr. Deborah
Padgett Coehlo when she was on faculty at Oregon
State University (Bend, OR). This wonderful infu-
sion of nursing colleagues and scholars elevated this
textbook to a whole other level.
After my retirement from active full-time
teaching and professional practice, the capable
Dr. Joanna Rowe Kaakinen assumed the leadership
for the fourth edition (2010). Along with Drs. Vivian
Gedaly-Duff, Deborah Padgett Coehlo, and myself,
we produced the fourth edition of this cutting-
edge family nursing textbook that included some
Canadian-specific family content. For the fourth edi-
tion Dr. Deborah Padgett Coehlo wrote the first on-
line teachers’ manual that accompanied this edition;
two other online chapters were added to this fourth
edition: research in families/family nursing and
international family nursing. Dr. Joanna Rowe
Kaakinen is the lead editor of this fifth edition. In
thinking about the sixth edition and the future
of the text, a younger family nursing scholar
Aaron Tabacco (PhC) was added to the editorial
team. Dr. Rose Steele, our Canadian colleague from
Toronto, joined our writing team. Dr. Deborah
Coehlo continues as editor and now brings the
perspective of family nursing from her pediatric
practice as a PNP in Bend, Oregon. My last contri-
bution to this book is as editor on this fifth edition.
This edition has taken on a much more international
flair, especially for North America, as Canadian au-
thors were added to many of the writing teams.
The first three editions of this textbook received
the following awards: the American Journal of
Nursing Book of the Year Award and the Nursing
Outlook Brandon Selected Nursing Books Award.
Every new edition has been well received around
the world and every edition has brought forth new
converts to family nursing. Previous editions of the
text were translated or published in Japan, Portugal,
India, Pakistan, Bangladesh, Burma, Bhutan, and
3921_FM_i-xxiv 06/06/14 2:56 PM Page vii
Nepal. I anticipate even more international interest
for this fifth edition as the message of family nurs-
ing continues to spread across the globe. It is also
interesting to note that online sales of the book
come from many countries.
Contributors to this edition were selected from
distinguished practitioners, researchers, theorists,
scholars, and teachers from nursing and family so-
cial scientists across the United States and Canada.
Like any good up-to-date textbook, some subject
matter stayed foundational and other subject mat-
ter changed based on current evidence. As family
nursing evolved, different authors and editors were
added to the writing team. This textbook is a mas-
sive undertaking involving 30 committed nurses
and family scholars, not to mention the staff of
F. A. Davis. The five editors of this fifth edition are
grateful for this national and international dedica-
tion to family nursing. Together we all continue to
increase nursing knowledge pertaining to the nurs-
ing care of families across the globe.
This fifth edition builds on the previous edi-
tions. The primary shift in the direction of this edi-
tion is to make family nursing practice meaningful
and realistic for nursing students. The first unit of
the book addresses critical foundational knowledge
pertaining to families and nursing. The second unit
concentrates on theory-guided, evidence-based
practice of the nursing care of families across the
life span and in a variety of specialties. In addition
to the large increase of Canadian contributors, sub-
stantial updates took place in all chapters. A new
chapter, Trauma and Family Nursing, was added.
Other new or updated features of this edition in-
clude the following:
■ A strong emphasis on evidence-based prac-
tice in each chapter.
■ Five selected family nursing theories inter-
woven throughout the book.
■ Family case studies that demonstrate the
practice of family nursing.
■ Content that addresses family nursing in both
Canada and the United States (North America).
Family nursing, as an art and science, has trans-
formed in response to paradigm shifts in the pro-
fession and in society over time. As a nursing
student in the United States during the 1950s, the
focus of care was on individuals and centered in
hospitals. As time passed and the profession ma-
tured, nursing education and practice expanded and
shifted to more family-centered care and community-
based nursing. The codified version of family
nursing really emerged and peaked during the
1980s and 1990s in the United States and Canada,
where the movement was headquartered. Even
though this initial impetus for family nursing
came from North America, the concept spread
quickly around the world. Asian countries, in par-
ticular, have embraced family nursing, and though
they initially translated books coming from the
United States or Canada, they have matured to
creating their own books and theories for family
nursing. The Scandinavian countries have expanded
their own scholarship and tailored family nursing
to their own unique countries and populations.
Today, it could be said that family nursing is with-
out borders and that no one country owns family
nursing.
The International Family Nursing Association
(IFNA) was established in 2009 for the purpose of
advancing family nursing and creating a global
community of nurses who practice with families.
The 11th International Family Nursing Conference
(and the first official conference of IFNA) took
place June 19–22, 2013, in Minneapolis, Minnesota,
USA. This new professional body (IFNA) is assum-
ing the leadership for keeping family nursing at the
forefront of theory development, practice, research,
education, and social policy across the globe.
Family nursing has become more than just a
“buzzword” but rather an actual reality. Family
nursing is being taught in many educational insti-
tutions, practiced in multiple health care settings,
and globally actualized by many nurses. Nursing
care to individuals, regardless of place, occurs
within the context of families and communities—
all of which can be called “family nursing.” Most
everyone in the nursing profession agrees that a
profound, reciprocal relationship exists between
families, health, and nursing.
This book and current edition recognizes that
nursing as a profession has a close alignment with
families. Nurses share many of the responsibilities
with families for the care and protection of their
family members. Nurses have an obligation to help
families promote and advance the care and growth
of both individual family members and families as a
unit. This textbook provides nursing students the
knowledge base and the processes to become effec-
tive in their nursing care with families. Additionally,
families benefit when already practicing registered
viii Foreword
3921_FM_i-xxiv 06/06/14 2:56 PM Page viii
nurses use this knowledge to reorganize their nurs-
ing care to be more family centered and develop
working partnerships with families to strengthen
family systems. Family Health Care Nursing: Theory,
Practice, and Research was written by nurses for
nurses who practice nursing care of families.
Students will learn how to tailor their assessment
and interventions with families in health and ill-
ness, in physical as well as mental health, across
the life span, and in all the settings in which
nurses and families interface. I firmly believe that
this fifth edition of this textbook is at the cutting
edge of this practice challenge for the next decade,
and will help to marshal the nursing profession
toward improving nursing care of families.
—SHIRLEY MAY HARMON HANSON, RN, PhD,
PMHNP/ARNP, FAAN, CFLE, LMFT
Professor Emeritus, School of Nursing
Oregon Health and Science University
Portland, Oregon
Adjunct Faculty, College of Nursing
Washington State University
Spokane, WA
Foreword ix
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xi
p r e f a c e
Ask anyone about a time they were affected by
something that happened to one of their family
members, and you will be overwhelmed with the
intensity of the emotions and the exhaustive details.
Every individual is influenced significantly by their
families and the structure, function, and processes
within their families. Even individuals who do not
interact with their families have been shaped by
their families. The importance and connection be-
tween individuals and their families have been stud-
ied expansively in a variety of disciplines, including
nursing.
As such, the importance of working in partner-
ships with families in the health care system is evi-
dent. Yet many health care providers view dealing
with patients’ families as an extra burden that is too
demanding. Some nurses are baffled when a family
acts or reacts in certain ways that are foreign to their
own professional and personal family experiences.
Some nurses avoid the tensions and anxiety that
exist in families during a crisis situation. But it is in
just such situations that families most need nurses’
understanding, knowledge, and guidance. The pur-
pose of this book is to provide nursing students, as
well as practicing nurses, with the understanding,
knowledge, and guidance to practice family nursing.
This fifth edition of the textbook focuses on theory-
guided, evidence-based practice of the nursing care
of families throughout the family life cycle and
across a variety of clinical specialties.
Use of the Book
Family Health Care Nursing: Theory, Practice, and
Research, fifth edition, is organized so that it can be
used on its own and in its entirety to structure a
course in family nursing. An alternative approach
for the use of this text is for students to purchase
the book at the beginning of their program of study
so that specific chapters can be assigned for specialty
courses throughout the curriculum. The fifth edition
complements a concept-based curriculum design.
For example, Chapter 16, Family Mental Health
Nursing, could be assigned when students take their
mental health nursing course, and Chapter 13,
Family Child Health Nursing, could be studied
during a pediatric course or in conjunction with
life-span–concept curriculum for chronic illness
and acute care courses. Thus, this textbook could
be integrated throughout the undergraduate or
graduate nursing curriculum.
Canadian Content
Moreover, this fifth edition builds on successes
of the past editions and responds to recommenda-
tions from readers/users of past editions. Because
of the ever-evolving nature of families and the
changing dynamics of the health care system, the
editors added new chapters, consolidated chapters,
and deleted some old chapters. Importantly, this
fifth edition incorporates additional Canadian-
specific content. Though it is true that the United
States and Canada have different health care
systems, so many of the stressors and challenges
for families overlap. One of the editors for this
fifth edition, Rose Steele, is from Toronto and
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
Canada and the United States: Chapter 5, Family
Social Policy and Health Disparities; Chapter 12,
Family Nursing With Childbearing Families; and
Chapter 17, Families and Community/Public Health
Nursing. Two chapters in this edition were writ-
ten by an all-Canadian team: Chapter 6, Relational
Overview of the Fifth Edition
3921_FM_i-xxiv 06/06/14 2:56 PM Page xi
Nursing and Family Nursing in Canada and
Chapter 10, Families in Palliative and End-of-Life
Care. All of the chapters in this edition include in-
formation, statistics, programs, and interventions
that address the individual needs of families and fam-
ily nurses from both Canada and the United States.
Additions and Deletions
This edition contains one new chapter: Chapter 11,
Trauma and Family Nursing. Between the advanced
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
family violence, the need to understand, prevent,
treat, and monitor the effects of trauma on individ-
uals and families has never been more vital. There-
fore, we felt it was essential to include ways family
nurses could work with these families. All chapters
have been changed and updated significantly to reflect
the present state of “family,” current evidence-based
practice, research, and interventions. Many of the
chapters now include a second family case study to
illustrate further the evidence discussed throughout
that specific chapter. We deleted the chapter on the
future of families and family nursing because
changes in health care reform, social policy, and
families are occurring at such a rate that it is
impossible to predict what the future will hold.
Structure of the Book
Each chapter begins with the critical concepts to be
addressed within that chapter. The purpose of plac-
ing the critical concepts at the beginning of the
chapter is to focus the reader’s thinking and learning
and offer a preview and outline of what is to come.
Another organizing framework for the book is pre-
sented in Chapter 3, Theoretical Foundations for
the Nursing of Families. This chapter covers the im-
portance of using theory to guide the nursing of
families and presents five theoretical perspectives,
with a case study demonstrating how to apply these
five theoretical approaches in practice. These five
theories are threaded throughout the book and are
applied in many of the chapter case studies. As stated
earlier, most of the chapters include two case studies;
all of the case studies contain family genograms and
ecomaps.
The main body of the book is divided into three
units: Unit 1: Foundations in Family Health Care
Nursing, which includes Chapters 1 to 5; Unit 2:
Families Across the Health Continuum, which in-
cludes Chapters 6 to 11; and Unit 3: Nursing
Care of Families in Clinical Areas, which includes
Chapters 12 to 17. The Family Health Care Nursing
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
of settings. Each chapter also includes a Power-
Point presentation, Case Study Learning Activities,
and other online assets, which can be found at
www.DavisPlus.com.
UNIT 1
Foundations in Family Health
Care Nursing
Chapter 1: Family Health Care Nursing: An
Introduction provides foundational materials es-
sential to understanding families and nursing. Two
nursing scholars have worked on this chapter now
for three editions: Joanna Rowe Kaakinen, PhD,
RN, Professor at the Linfield College School of
Nursing and Shirley May Harmon Hanson, RN,
PhD, PMHNP/ARNP, FAAN, CFLE, LMFT,
Professor Emeritus at Oregon Health and Science
University School of Nursing. The chapter lays
down crucial foundational knowledge about fami-
lies and family nursing.
The first half of the chapter discusses dimen-
sions of family nursing and defines family, family
health, and healthy families. The chapter follows
with an explanation of family health care nursing
and the nature of interventions in the nursing
care of families, along with the four approaches
to family nursing (context, client, system, and
component of society). The chapter then presents
the concepts or variables that influence family
nursing, family nursing roles, obstacles to family
nursing practice, and the history of family nurs-
ing. The second half of the chapter elaborates on
theoretical ideas involved with understanding
family structure, family functions, and family
processes.
Chapter 2: Family Demography: Continuity
and Change in North American Families pro-
vides nurses with a basic contextual orientation to
the demographics of families and health. All three
authors are experts in statistics and family demog-
raphy. Three sociologists joined to update and
xii Preface
3921_FM_i-xxiv 06/06/14 2:56 PM Page xii
write this chapter: Lynne M. Casper, PhD, Profes-
sor of Sociology and Director of the South
California Population Research Center, University
of Southern California (USC); Sandra M. Florian,
MA, PhD Candidate, who is a graduate student/
research assistant, Population Research Center at
USC Department of Sociology; and Peter D. Brandon,
PhD, Professor, Department of Sociology, The
University at Albany (SUNY), New York. This
chapter examines changes and variations in North
American families in order to understand what
these changes portend for family health care nurs-
ing during the first half of this century. The subject
matter of the chapter is structured to provide fam-
ily nurses with background on changes in the
North American family so that they can understand
their patient populations. The chapter briefly
touches on the implications of these demographic
patterns on practicing family nursing.
Chapter 3: Theoretical Foundations for the
Nursing of Families is co-authored by two of the
editors of this textbook: Joanna Rowe Kaakinen and
Shirley May Harmon Hanson. This chapter lays the
theoretical groundwork needed to practice family
nursing. The introduction builds a case for why
nurses need to understand the interactive relation-
ship among theory, practice, and research. It also
makes the point that no single theory adequately de-
scribes the complex relationships of family structure,
function, and processes. The chapter then continues
by delineating and explaining relevant theories,
concepts, propositions, hypotheses, and conceptual
models. Selected for this textbook, and explained in
this chapter, are five theoretical/conceptual models:
Family Systems Theory, Developmental and Family
Life Cycle Theory, Bioecological Theory, Rowland’s
Chronic Illness Framework, and the Family Assess-
ment and Intervention Model. Using basic family
case studies, the chapter explores how each of the five
theories could be used to assess and plan interven-
tions for a family. This approach enables learners to
see how different interventions are derived from dif-
ferent theoretical perspectives.
Chapter 4: Family Nursing Assessment and
Intervention is co-authored by Joanna Rowe
Kaakinen and Aaron Tabacco, BSN, RN, Doctoral
Candidate, who is a Student Instructor, Under-
graduate Nursing Programs at Oregon Health
Sciences University, Portland, Oregon. The pur-
pose of this chapter is to present a systematic
approach to develop a plan of action for the fam-
ily, with the family, to address its most pressing
needs. These authors built on the traditional nurs-
ing process model to create a dynamic systematic
family nursing assessment approach. Assessment
strategies include selecting assessment instru-
ments, determining the need for interpreters, as-
sessing for health literacy, and learning how to
diagram family genograms and ecomaps. The
chapter also explores ways to involve families in
shared decision making, and explores analysis, a
critical step in the family nursing process that
helps focus the nurse and the family on identifi-
cation of the family’s primary concern(s). The
chapter uses a family case study as an exemplar to
demonstrate the family nursing assessment and
intervention.
Chapter 5: Family Social Policy and Health
Disparities exposes nurses to social issues that
affect the health of families and strongly challenge
nurses to become more involved in the political as-
pects of health policy. This chapter is co-authored
by two experienced nurses in the social policy arena
and a sociology professor: Isolde Daiski, RN,
BScN, EdD, Associate Professor, School of Nurs-
ing, from York University, Toronto, Ontario,
Canada; Casey R. Shillam, PhD, RN-BC, Director
of the BSN program at Western Washington State
University, Bellingham, Washington; Lynne M.
Casper, PhD, Professor Sociology at the Univer-
sity of Southern California; and Sandra Florian,
MA, a graduate student at the University of South-
ern California. These authors discuss the practice
of family nursing within the social and political
structure of society. They encourage the readers to
understand their own biases and how these
contribute to health disparities. In this chapter, stu-
dents learn about the complex components that
contribute to health disparities. Nurses are called
to become politically active, advocate for vulnera-
ble families, and assist in the development of
creative alternatives to social policies that limit ac-
cess to quality care and resources. These authors
present the difficulties families face in the current
political climate in both the United States and
Canada, as the legal definition of family is being
challenged and family life evolves. The chapter
touches on social policies, or lack of them, specifi-
cally policies that affect education, socioeconomic
status, and health insurance. The chapter also
explores determinants of health disparities, which
include infant mortality rates, obesity, asthma,
HIV/AIDS, aging, women’s issues, and health
literacy.
Preface xiii
3921_FM_i-xxiv 06/06/14 2:56 PM Page xiii
UNIT 2
Families Across the Health Continuum
Chapter 6: Relational Nursing and Family
Nursing in Canada is co-authored by Canadian
nursing scholars Colleen Varcoe, PhD, RN, Asso-
ciate Professor and Associate Research Director at
the University of British Columbia, School of
Nursing in Vancouver, British Columbia, Canada;
and Gweneth Hartrick Doane, PhD, RN, Profes-
sor, School of Nursing, University of Victoria,
British Columbia, Canada. Relational inquiry fam-
ily nursing practice is oriented toward enhancing
the capacity and power of people/families to live a
meaningful life (meaningful from their own per-
spective). Understanding and working directly with
context provides a key resource and strategy for
responsive, health-promoting family nursing prac-
tice. Grounded in a relational inquiry approach,
this chapter focuses specifically on the significance
of context in family nursing practice in Canada. The
chapter highlights the interface of sociopolitical,
historical, geographical, and economic elements in
shaping the health and illness experiences of fami-
lies in Canada and the implications for family nurs-
ing practice. The chapter covers some of the key
characteristics of Canadian society, and how those
characteristics shape health, families, health care,
and family nursing. Informed by a relational in-
quiry approach to family nursing, the chapter turns
to the ways nurses might practice more respon-
sively and effectively based on this understanding.
Chapter 7: Genomics and Family Nursing
Across the Life Span is authored by a nursing ex-
pert in nursing genomics, Dale Halsey Lea, MPH,
RN, CGC, FAAN, Consultant, Public Health
Genomics and Adjunct Lecturer for University of
Maine School of Nursing. The ability to apply an
understanding of genetics in the care of families is
a priority for nurses and for all health care
providers. As a result of genomic research and the
rapidly changing body of knowledge regarding ge-
netic influences on health and illness, more empha-
sis has been placed on involving all health care
providers in this field, including family nursing.
This chapter describes nursing responsibilities for
families of persons who have, or are at risk for
having, genetic conditions. These responsibilities
are described for families before conception,
with neonates, teens in families, and families with
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-
tion about genetic aspects of health or disease for
members of the family. The chapter begins with a
brief introduction to genomics and genetics. The
chapter then explains how families react to finding
out they are at risk for genetic conditions, and
decide how and with whom to disclose genetic in-
formation, and the critical aspect of confidentiality.
The chapter outlines the components of conduct-
ing a genetic assessment and history, and offers
interventions that include education and resources.
Several specific case examples and a detailed case
study illustrate nurses working with families who
have a genetic condition.
Chapter 8: Family Health Promotion is writ-
ten by Yeoun Soo Kim-Godwin, PhD, MPH, RN,
Professor of Nursing; and Perri J. Bomar, PhD,
RN, Professor Emeritus, who are both from
the School of Nursing at the University of North
Carolina, Wilmington. Fostering the health of the
family as a unit and encouraging families to value
and incorporate health promotion into their
lifestyles are essential components of family nurs-
ing practice. The purpose of this chapter is to in-
troduce the concepts of family health and family
health promotion. The chapter presents models to
illuminate these concepts, including the Model of
Family Health, Family Health Model, McMaster
Model of Family Functioning, Developmental
Model of Health and Nursing, Family Health Pro-
motion Model, and Model of the Health-Promoting
Family. The chapter also examines internal and
external factors through a lens of the bioecological
systems theory that influence family health promo-
tion. It covers family nursing intervention strate-
gies for health promotion, and presents two family
case studies demonstrating how different theoreti-
cal approaches can be used for assessing and inter-
vening in the family for health promotion. The
chapter also discusses the role of nurses and inter-
vention strategies in maintaining and regaining the
highest level of family health. Specific interventions
presented include family empowerment, anticipa-
tory guidance, offering information, and encour-
aging family rituals, routines, and time together.
Chapter 9: Families Living With Chronic
Illness is co-authored by Joanna Rowe Kaakinen
and Sharon A. Denham, DSN, RN, Professor,
Houston J. and Florence A. Doswell Endowed
xiv Preface
3921_FM_i-xxiv 06/06/14 2:56 PM Page xiv
Chair in Nursing for Teaching Excellence, Texas
Woman’s University, Dallas, Texas. The purpose
and focus of this chapter is to describe ways for
nurses to think about the impact of chronic illness on
families and to consider strategies for helping families
manage chronic illness. The first part of this chapter
briefly outlines the global statistics of chronic illness,
the economic burden of chronic diseases, and three
theoretical perspectives for working with families liv-
ing with chronic illness. The majority of the chapter
describes how families and individuals are challenged
to live a quality life in the presence of chronic illness
and how nurses assist these families. Specific atten-
tion is drawn to families with children who have a
chronic illness and families with an adult member
living with a chronic illness. The chapter addresses
adolescents who live with a chronic illness as they
transition from pediatric to adult medical care, sib-
lings of children with a chronic illness and their spe-
cific needs, and the needs of young caregivers who
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
helping its elderly parent and grandparent manage
living with Parkinson’s disease.
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,
Ontario, Canada; Carole A. Robinson, PhD, RN,
Associate Professor, University of British Columbia,
Okanagan School of Nursing, British Columbia,
Canada; and Kimberley A. Widger, PhD, RN, As-
sistant Professor, Lawrence S. Bloomberg Faculty of
Nursing, University of Toronto, Ontario, Canada.
This chapter details the key components to consider
in providing palliative and end-of-life care, as well
as families’ most important concerns and needs when
a family member experiences a life-threatening ill-
ness or is dying. It also presents some concrete
strategies to assist nurses in providing optimal pal-
liative and end-of-life care to all family members.
More specifically, the chapter begins with a brief
definition of palliative and end-of-life care, in-
cluding its focus on improving quality of life for
patients and their families. The chapter then out-
lines principles of palliative care and ways to
apply these principles across all settings and regard-
less of whether death results from chronic illness or
a sudden or traumatic event. Two evidence-based,
palliative care and end-of-life case studies con-
clude the chapter.
Chapter 11: Trauma and Family Nursing is
written by Deborah Padgett Coehlo, PhD, C-PNP,
PMHS, CFLE, Developmental and Behavioral Spe-
cialist, Juniper Ridge Clinic, Bend, Oregon, and ad-
junct faculty at Oregon State University. Dr. Coehlo
has been on the editorial team for two editions of
this text. Using theory-guided practice, this chapter
helps nurses develop knowledge about trauma and
family nurses’ key role in the field of trauma. It em-
phasizes the importance of prevention, early treat-
ment, encouraging family resilience, and helping the
family to make meaning out of negative events. This
chapter also stresses an understanding of secondary
trauma, or the negative effects of witnessing trauma
of others. This discussion is particularly salient for
family nurses, because they are some of the most
likely professionals to encounter traumatized victims
in their everyday practice. Two case studies explicate
family nursing when working with families who are
experiencing the effects of traumatic life events.
UNIT 3
Nursing Care of Families in Clinical
Areas
Chapter 12: Family Nursing With Childbearing
Families is written by Linda Veltri, PhD, RN, Clin-
ical Assistant Professor, Oregon Health Science
University, School of Nursing, Ashland, Oregon,
Campus; Karline Wilson-Mitchell, RM, CNM, RN,
MSN, Assistant Professor, Midwifery Education
Program, Ryerson University, Ontario, Canada; and
Kathleen Bell, MSN, CNM, AHN-BC, Clinical
Associate, School of Nursing, Linfield College,
Portland, Oregon. The focus of childbearing family
nurses is family relationships and the health of all
family members. Therefore, nurses involved with
childbearing families use family concepts and theo-
ries as part of developing the plan of nursing care. A
review of literature provides current evidence about
the processes families experience when deciding on
and adapting to childbearing, including theory and
clinical application of nursing care for families plan-
ning pregnancy, experiencing pregnancy, adopting
and fostering children, struggling with infertility,
and coping with illness during the early postpartum
period. This chapter starts by presenting theoretical
perspectives that guide nursing practice with child-
bearing families. It continues with an exploration of
Preface xv
3921_FM_i-xxiv 06/06/14 2:56 PM Page xv
family nursing with childbearing families before
conception through the postpartum period. The
chapter covers specific issues childbearing families
may experience, including postpartum depression,
attachment concerns, and postpartum illness. Nurs-
ing interventions are integrated throughout this
chapter to demonstrate how family nurses can help
childbearing families prevent complications, in-
crease coping strategies, and adapt to their expanded
family structure, development, and function. The
chapter concludes with two case studies that explore
family adaptations to stressors and changing roles
related to childbearing.
Chapter 13: Family Child Health Nursing
is written by Deborah Padgett Coehlo. A major
task of families is to nurture children to become
healthy, responsible, and creative adults who can
develop meaningful relationships across the life
span. Families experience the stress of normative
transitions with the addition of each child and
situational transitions when children are ill. Knowl-
edge of the family life cycle, child development,
and illness trajectory provides a foundation for
offering anticipatory guidance and coaching at
stressful times. Family life influences the promo-
tion of health and the experience of illness in chil-
dren, and is influenced by children’s health and
illness. This chapter provides a brief history of
family-centered care of children and then presents
foundational concepts that will guide nursing prac-
tice with families with children. The chapter goes
on to describe nursing care of well children and
families with an emphasis on health promotion,
nursing care of children and families in acute care
settings, nursing care of children with chronic ill-
ness and their families, and nursing care of children
and their families during end of life. Case studies
illustrate the application of family-centered care
across settings.
Chapter 14: Family Nursing in Acute Care
Adult Settings is written by Vivian Tong, PhD, RN,
and Joanna Rowe Kaakinen, PhD, RN, both profes-
sors of nursing at Linfield College-Good Samaritan
School of Nursing, Portland, Oregon. Hospitaliza-
tion for an acute illness, injury, or exacerbation of a
chronic illness is stressful for patients and their fam-
ilies. The ill adult enters the hospital usually in a
physiological crisis, and the family most often accom-
panies the ill or injured family members into the hos-
pital; both the patient and the family are usually in
an emotional crisis. Families with members who are
acutely or critically ill are seen in adult medical-
surgical units, intensive care or cardiac care units, or
emergency departments. This chapter covers the
major stressors that families experience during hos-
pitalization of adult family members, the transfer of
patients from one unit to another, visiting policies,
family waiting rooms, home discharge, family pres-
ence during cardiopulmonary resuscitation, with-
drawal or withholding of life-sustaining therapies,
end-of-life family care in the hospital, and organ do-
nation. The content emphasizes family needs during
these critical events. This chapter also presents a fam-
ily case study in a medical-surgical setting that
demonstrates how the Family Assessment and Inter-
vention Model and the FS3I can be used as the frame-
work to assess and intervene with a particular family.
Chapter 15: Family Health in Mid and Later
Life is co-authored by Diana L. White, PhD,
Senior Research Associate in Human Development
and Family Studies, Institute of Aging at Portland
State University, Portland, Oregon, and Jeannette
O’Brien, PhD, RN, Assistant Professor at Linfield
College–Good Samaritan School of Nursing, Port-
land, Oregon. The chapter employs the life course
perspective, family systems models, and develop-
mental theories as the guiding organizational struc-
ture. The chapter presents evidence-based practice
on working with adults in mid and later life, includ-
ing a review of living choices for older adults with
chronic illness, and the importance of peer rela-
tionships and intergenerational relationships to
quality of life. This chapter includes extensive
information about family caregiving for and by
older adults, including spouses, adult children, and
grandparents. Two case studies conclude the chap-
ter. One family case study illustrates the integrated
generational challenges facing older adults today.
The second case study addresses care of an elderly
family member who never married and has no chil-
dren. This case presents options for caregiving and
the complexity of living healthy.
Chapter 16: Family Mental Health Nursing
has been completely revised for this edition. It is
written by Laura Rodgers, PhD, RN, PMHNP,
Professor of Nursing at Linfield College–Good
Samaritan School of Nursing, Portland, Oregon.
Dr. Rodgers brings to her writing both her schol-
arly perspective and clinical practice as a psychiatric
nurse practitioner in private practice. The chapter
begins with a brief demographic overview of the
pervasiveness of mental health conditions (MHCs)
xvi Preface
3921_FM_i-xxiv 06/06/14 2:56 PM Page xvi
in both Canada and the United States. The remain-
der of the chapter focuses on the impact a specific
MHC can have on the individual with the MHC,
individual family members, and the family as a unit.
Although the chapter does not go into specific di-
agnostic criteria for various conditions, it does offer
nursing interventions to assist families. One case
study explores the impact and treatment of sub-
stance abuse. The second presents how a family
nurse can work with a family to improve the health
of all family members when one family member
lives with paranoid schizophrenia.
Chapter 17: Families and Community/Public
Health Nursing is co-authored by a North Amer-
ican writing team: Linda L. Eddy, PhD, RN,
CPNP, Associate Professor, Washington State
University Intercollegiate College of Nursing,
Vancouver, Washington; Annette Bailey, PhD,
RN, Assistant Professor, Daphne Cockwell School
of Nursing, Ryerson University, Toronto, Ontario,
Canada; and Dawn Doutrich, PhD, RN, CNS,
Associate Professor, Washington State University
Intercollegiate College of Nursing, Vancouver,
Washington. Healthy communities are comprised
of healthy families. Community/public health
nurses understand the effects that communities can
have on individuals and families, and recognize that
a community’s health is reflected in the health ex-
periences of its members and their families. This
chapter offers a description of community health
nursing promoting the health of families in com-
munities. It begins with a definition of community
health nursing, and follows with a discussion of
concepts and principles that guide the work of
these nurses, the roles they enact in working with
families and communities, and the various settings
where they work. This discussion is organized
around a visual representation of community health
nursing. The chapter ends with discussion of cur-
rent trends in community/public health nursing
and a family case study that demonstrates working
with families in the community.
Preface xvii
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3921_FM_i-xxiv 06/06/14 2:56 PM Page xviii
xix
c o n t r i b u t o r s
ANNETTE BAILEY, PhD, RN
Assistant Professor, Daphne Cockwell School of
Nursing
Ryerson University
Toronto, Ontario, Canada
KATHLEEN BELL, RN, MSN, CNM,
AHN-BC
Clinical Associate, School of Nursing
Linfield College
Portland, Oregon
PERRI J. BOMAR, PhD, RN
Professor Emeritus, School of Nursing
University of North Carolina at Wilmington
Wilmington, North Carolina
PETER D. BRANDON, PhD
Professor, Department of Sciology
The University at Albany – SUNY
Albany, New York
LYNNE, M. CASPER, PhD
Professor of Sociology and Director, Southern
California Population Research Center
University of Southern California
Los Angeles, California
DEBORAH PADGETT COEHLO, PhD,
C-PNP, PMHS, CFLE
Developmental and Behavioral Specialist
Juniper Ridge Clinic
Bend, Oregon
Adjunct Professor
Oregon State University
Bend, Oregon
ISOLDE DAISKI, RN, BScN, EdD
Associate Professor, School of Nursing
York University
Toronto, Ontario, Canada
SHARON A. DENHAM, DSN, RN
Professor and Houston J. and Florence A. Doswell
Endowed Chair in Nursing for Teaching Excellence,
College of Nursing
Texas Woman’s University, Dallas
Dallas, Texas
GWENETH HARTRICK DOANE, PhD, RN
Professor, School of Nursing
University of Victoria
Victoria, British Columbia, Canada
DAWN DOUTRICH, PhD, RN, CNS
Associate Professor, Intercollegiate College of
Nursing
Washington State University
Vancouver, Washington
LINDA L. EDDY, PhD, RN, CPNP
Associate Professor, Intercollegiate College of Nursing
Washington State University
Vancouver, Washington
SANDRA M. FLORIAN, MA
PhD Candidate, Department of Sociology
University of Southern California
Los Angeles, California
DALE HALSEY LEA, MPH, RN, CGC, FAAN
Adjunct Lecturer, School of Nursing
University of Maine
Cumberland Foreside, Maine
SHIRLEY MAY HARMON HANSON, RN, PhD,
PMHNP/ARNP, FAAN, CFLE, LMFT
Professor Emeritus, School of Nursing
Oregon Health and Science University
Portland, Oregon
Adjunct Faculty, College of Nursing
Washington State University
Spokane, Washington
3921_FM_i-xxiv 06/06/14 2:56 PM Page xix
JOANNA ROWE KAAKINEN, PhD, RN
Professor, School of Nursing
Linfield College
Portland, Oregon
YEOUN SOO KIM-GODWIN,
PhD, MPH, RN
Professor, School of Nursing
University of North Carolina, Wilmington
Wilmington, North Carolina
JEANNETTE O’BRIEN, PhD, RN
Assistant Professor, School of Nursing
Linfield College
Portland, Oregon
CAROLE A. ROBINSON, PhD, RN
Associate Professor, School of Nursing
University of British Columbia, Okanagan
Kelowna, British Columbia, Canada
LAURA RODGERS, PhD, PMHNP
Professor, School of Nursing
Linfield College
Portland, Oregon
CASEY R. SHILLAM, PhD, RN-BC
Director, School of Nursing
Western Washington University
Bellingham, Washington
ROSE STEELE, PhD, RN
Professor, School of Nursing, Faculty of Health
York University
Toronto, Ontario, Canada
AARON TABACCO, BSN, RN
Doctoral Candidate, School of Nursing
Oregon Health and Science University
Portland, Oregon
VIVIAN TONG, PhD, RN
Professor, School of Nursing
Linfield College
Portland, Oregon
COLLEEN VARCOE, PhD, RN
Associate Professor, School of Nursing
University of British Columbia
Vancouver, British Columbia, Canada
LINDA VELTRI, PhD, RN
Clinical Assistant Professor, School of Nursing
Oregon Health Science University, Ashland
Ashland, Oregon
DIANA L. WHITE, PhD
Senior Research Associate, Institute on Aging
Portland State University
Portland, Oregon
KIMBERLEY A. WIDGER, PhD, RN
Assistant Professor, Lawrence S. Bloomberg School of
Nursing
University of Toronto
Toronto, Ontario, Canada
KARLINE WILSON-MITCHELL, RM, CNM,
RN, MSN
Assistant Professor, Midwifery Education Program
Ryerson University
Toronto, Ontario, Canada
xx Contributors
3921_FM_i-xxiv 06/06/14 2:56 PM Page xx
xxi
r e v i e w e r s
ELLEN J. ARGUST, MS, RN
Lecturer
State University of New York
New Paltz, New York
AMANDA J. BARTON, DNP, FNP, RN
Assistant Professor
Hope College
Holland, Michigan
LAURA J. BLANK, RN, MSN, CNE
Assistant Clinical Professor
Northern Arizona University
Flagstaff, Arizona
BARBARA S. BROOME, PhD, RN
Associate Dean and Chair
University of South Alabama
Mobile, Alabama
SHARON L. CARLSON, PhD, RN
Professor
Otterbein College
Westerville, Ohio
BARBARA CHEYNEY, BSN, MS, RN-BC
Adjunct Faculty
Seattle Pacific University
Seattle, Washington
MICHELE D’ARCY-EVANS, PhD, CNM
Professor
Lewis-Clark State College
Lewiston, Idaho
MARGARET C. DELANEY, MS, CPNP, RN
Faculty Instructor
Benedictine University
Lisle, Illinois
SANDRA K. EGGENBERGER, PhD, RN
Professor
Minnesota State University Mankato
Mankato, Minnesota
ANNELIA EPIE, RN, MN(c)
Public Health Nurse
City of Toronto Public Health
Toronto, Ontario, Canada
BRIAN FONNESBECK, RN
Associate Professor
Lewis Clark State College
Lewiston, Idaho
MARY ANN GLENDON, PhD, MSN, RN
Associate Professor
Southern Connecticut State University
New Haven, Connecticut
RACHEL E. GRANT, RN, MN
Research Associate
University of Toronto
Toronto, Ontario, Canada
SHEILA GROSSMAN, PhD, FNP-BC
Professor and FNP Specialty Track Director
Fairfield University
Fairfield, Connecticut
AAFREEN HASSAN, RN
Registered Nurse
Scarborough Hospital
Toronto, Ontario, Canada
ANNA JAJIC, MN-NP, MSc, RPN, BSsN
Faculty and Nurse Practitioner
Douglas College
New West Minster, British Columbia, Canada
MOLLY JOHNSON, MSN, CPNP, RN
Nursing Instructor
Ohio University
Ironton, Ohio
KATHY KOLLOWA, MSN, RN
Nurse Educator
Platt College
Aurora, Colorado
3921_FM_i-xxiv 06/06/14 2:56 PM Page xxi
KEN KUSTIAK, RN, RPN, BScN, MHS(c)
Nursing Instructor
Grant MacEwan College
Ponoka, Alberta, Canada
MAUREEN LEEN, PhD, RN, CNE
Professor
Madonna University
Livonia, Michigan
KAREN ELIZABETH LEIF, BA, RN, MA
Nurse Educator
Globe University, Minnesota School of Business
Richfield, Minnesota
BARBARA MCCLASKEY, PhD, MN, RNC,
ARNP
Professor
Pittsburg State University
Pittsburg, Kansas
VICKI A. MOSS, DNSc, RN
Associate Professor
University of Wisconsin, Oshkosh
Oshkosh, Wisconsin
VERNA C. PANGMAN, MEd, MN, RN
Senior Instructor
University of Manitoba
Winnipeg, Manitoba, Canada
CINDY PARSONS, DNP, PMHNP-BC,
FAANP
Assistant Professor
University of Tampa
Tampa, Florida
SUSAN PERKINS, MSN, RN
Lead Faculty and Instructor
Washington State University
Spokane, Washington
CINDY PETERNELJ-TAYLOR, RN, BScN,
MSc, PhD(c)
Professor
University of Saskatchewan
Saskatoon, Saskatchewan, Canada
THELMA PHILLIPS, MSN, RN, NRP
Instructor
University of Detroit, Mercy
Detroit, Michigan
TREVA V. REED, BScN, MSN, PhD
Professor
Canadore College/Nipissing University
North Bay, Ontario, Canada
NANCY ROSS, PhD, ARNP
Professor
University of Tampa
Tampa, Florida
CARMEN A. STOKES, PhD(c), RN, MSN,
FNP-BC, CNE
Assistant Professor
University of Detroit, Mercy
Detroit, Michigan
JILL STRAWN, EdD, APRN
Associate Professor
Southern Connecticut State University
New Haven, Connecticut
SARA STURGIS, MSN, CRNP
Manager, Pediatric Clinical Research
Hershey Medical Center
Hershey, Pennsylvania
BARBARA THOMPSON, RN, BScN, MScN
Professor
Sault College
Sault Ste. Marie, Ontario, Canada
SHARON E. THOMPSON, MSN, RN
Assistant Clinical Professor
Northern Arizona University
Flagstaff, Arizona
MARYANN TROIANO, MSN, RN, APN
Assistant Professor and Family Nurse Practitioner
Monmouth University
West Long Branch, New Jersey
LOIS TSCHETTER, EdD, RN, IBCLC
Associate Professor
South Dakota State University
Brookings, South Dakota
WENDY M. WHEELER, RN, MN
Instructor
Red Deer College
Red Deer, Alberta, Canada
MARIA WHEELOCK, MSN, NP
Clinical Assistant Professor and Nurse Practitioner
State University of New York, Upstate Medical
University
Syracuse, New York
xxii Reviewers
3921_FM_i-xxiv 06/06/14 2:56 PM Page xxii
xxiii
t a b l e o f c o n t e n t s
U N I T 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 I T 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
3921_FM_i-xxiv 06/06/14 2:56 PM Page xxiii
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 I T 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
APPENDICES
appendix A Family Systems Stressor-Strength Inventory (FS3I) 583
appendix B The Friedman Family Assessment Model (Short Form) 599
INDEX 603
xxiv Table of Contents
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U N I T
1
Foundations in
Family Health
Care Nursing
3921_Ch01_001-032 05/06/14 10:54 AM Page 1
3921_Ch01_001-032 05/06/14 10:54 AM Page 2
3
Family Health Care Nursing
An Introduction
c h a p t e r 1
Joanna Rowe Kaakinen, PhD, RN
Shirley May Harmon Hanson, PhD, PMHNP/ARNP, FAAN, CFLE, LMFT
C r i t i c a l C o n c e p t s
■ 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
settings.
■ 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,
a philosophy and a way of interacting with families
about health care. It has evolved since the early
1980s as a way of thinking about, and working with,
families when a member experiences a health prob-
lem. This philosophy and practice incorporates the
following assumptions:
■ Health and illness affect all members of
families.
■ Health and illness are family events.
■ Families influence the process and outcome
of health care.
All health care practices, attitudes, beliefs, be-
haviors, and decisions are made within the context
of larger family and societal systems.
Families vary in structure, function, and processes.
The structure, functions, and processes of the family
influence and are influenced by individual family
3921_Ch01_001-032 05/06/14 10:54 AM Page 3
member’s health status and the overall health status
of the whole family. Families even vary within given
cultures because every family has its own unique
culture. People who come from the same family of
origin create different families over time. Nurses
need to be knowledgeable in the theories of families,
as well as the structure, function, and processes of
families to assist them in achieving or maintaining a
state of health.
2010a). In addition, ANA’s Nursing: Scope and Stan-
dards of Practice mandates that nurses provide family
care (ANA, 2010b). “Nurses have an ethical and
moral obligation to involve families in their health-
care practices” (Wright & Leahey, 2013, p. 1).
The overall goal of this book is to enhance
nurses’ knowledge and skills in the theory, practice,
research, and social policy surrounding nursing care
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.
THE FAMILY AND FAMILY HEALTH
Three foundational components of family nursing
are: (1) determining how family is defined, (2) un-
derstanding the concepts of family health, and (3)
knowing the current evidence about the elements
of a healthy family.
What Is the Family?
There is no universally agreed-upon definition of
family. Now more than ever, the traditional defini-
tion of family is being challenged, with Canadian
recognition of same-sex marriages and with several
states in the United States giving same-sex families
the freedom to marry. Family is a word that con-
jures up different images for each individual and
group, and the word has evolved in its meaning over
time. Definitions differ by discipline, for example:
■ Legal: relationships through blood ties,
adoption, guardianship, or marriage
■ Biological: genetic biological networks among
and between people
■ Sociological: groups of people living together
with or without legal or biological ties
■ Psychological: groups with strong emotional ties
4 Foundations in Family Health Care Nursing
When families are considered the unit of care—as
opposed to individuals—nurses have much broader
perspectives for approaching health care needs of
both individual family members and the family unit
as a whole (Kaakinen, Hanson, & Denham, 2010).
Understanding families enables nurses to assess the
family health status, ascertain the effects of the 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
and implement action plans customized for improved
health for each individual family member and the
family as a whole.
Recent advances in health care, such as changing
health care policies and health care economics,
ever-changing technology, shorter hospital stays,
and health care moving from the hospital to the
community/family home, are prompting changes
from an individual person paradigm to the nursing
care of families as a whole. This paradigm shift is
affecting the development of family theory, prac-
tice, research, social policy, and education, and it is
critical for nurses to be knowledgeable about and at
the forefront of this shift. The centrality of family-
centered care in health care delivery is emphasized
by the American Nurses Association (ANA) in its
publication, Nursing’s Social Policy Statement (ANA,
3921_Ch01_001-032 05/06/14 10:54 AM Page 4
Historically, early family social science theorists
(Burgess & Locke, 1953, pp. 7–8) adopted the
following traditional definition in their writing:
The family is a group of persons united by ties of mar-
riage, blood, or adoption, constituting a single house-
hold; interacting and communicating with each other
in their respective social roles of husband and wife,
mother and father, son and daughter, brother and sis-
ter; and creating and maintaining a common culture.
Currently, the U.S. Census Bureau defines family
as two or more people living together who are re-
lated by birth, marriage, or adoption (U.S. Census
Bureau, 2011). This traditional definition continues
to be the basis for the implementation of many social
programs and policies. Yet, this definition excludes
many diverse groups who consider themselves to be
families and who perform family functions, such as
economic, reproductive, and affective functions, as
well as child socialization. Depending on the social
norms, all of the following examples could be viewed
as “family”: married or remarried couples with bio-
logical or adoptive children, cohabitating same-sex
couples (gay and lesbian families), single-parent fam-
ilies with children, kinship care families such as two
sisters living together, or grandparents raising
grandchildren without the parents.
persons in health care planning with the patient’s
permission.
What Is Family Health?
The World Health Organization (2008) defined
health to include a person’s characteristics, behav-
iors, and physical, social, and economic environ-
ment. This definition applies to individuals and to
families. Anderson and Tomlinson (1992) sug-
gested that the analysis of family health must
include, simultaneously, health and illness, the in-
dividual and the collective. They underscored evi-
dence that the stress of a family member’s serious
illness exerts a powerful influence on family func-
tion and health, and that familial behavioral pat-
terns or reactions to illness influence the individual
family members. The term family health is often
used interchangeably with the terms family func-
tioning, healthy families, or familial health. To some,
family health is the composite of individual family
members’ physical health, because it is impossible
to make a single statement about the family’s phys-
ical health as a single entity.
The definition of family health adopted in this
textbook and that applies from the previous edition
(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?
While it is possible to define family health, it is
more difficult to describe a healthy family. Char-
acteristics used to describe healthy families or fam-
ily strengths have varied throughout time in the
literature. Krysan, Moore, and Zill (1990)
described “healthy families” as “successful families”
in a report prepared by the U.S. Department of
Health and Human Services. They identified some
Family Health Care Nursing: An Introduction 5
The definition of family adopted by this text-
book and that applies from the previous edition
(Kaakinen et al., 2010) is as follows: Family refers to
two or more individuals who depend on one another for
emotional, physical, and economic support. The members
of the family are self-defined. Nurses who work with
families should ask clients who they consider to be
members of their family and should include those
3921_Ch01_001-032 05/06/14 10:54 AM Page 5
of the ideas put forward by many family scholars
over time. For example, Otto (1963) was the first
scholar to develop psychosocial criteria for assess-
ing family strengths, and he emphasized the need
to focus on positive family attributes instead of the
pathological approach that accentuated family
problems and weaknesses. Pratt (1976) introduced
the idea of the “energized family” as one whose
structure encourages and supports individuals to
develop their capacities for full functioning and
independent action, thus contributing to family
health. Curran (1985) investigated not only family
stressors but also traits of healthy families, incor-
porating moral and task focus into traditional family
functioning. These traits are listed in Box 1-1.
For more than three decades, Driver, Tabares,
Shapiro, Nahm, and Gottman (2011) have studied
the interactional patterns of marital success or fail-
ure. The success of a marriage does not depend on
the presence or the amount of conflict. Success of
a marriage depends primarily on how the couple
handles conflict. The presence of four characteris-
tics of couple interaction was found to predict
divorce with 94% accuracy (Carrere, Buehlman,
Coan, Gottman, & Ruckstuhl, 2000):
1. Criticism: These are personal attacks that
consist of negative comments, to and about
each other, that occur over time and that
erode the relationship.
2. Contempt: This is the most corrosive of the
four characteristics between the couple.
Contempt includes comments that convey
disgust and disrespect.
3. Defensiveness: Each partner blames the other
in an attempt to deflect a verbal attack.
4. Stonewalling: One or both of the partners
refuse to interact or engage in interaction,
both verbally and nonverbally.
In contrast, conflict is addressed in three ways in
positive, healthy marriages. Validators talk their
problems out, expressing emotions and opinions,
and are skilled at reaching a compromise. Volatiles
are two partners who view each other as equals, as
they engage in loud, passionate, explosive interac-
tions that are balanced by a caring, loving relation-
ship. Their conflicts do not include the four
negative characteristics identified earlier. The last
type of couple is the Avoiders. Avoiders simply agree
not to engage in conflicts, thus minimizing the cor-
rosive effects of negative conflict resolution. The
crucial point in all three styles of healthy conflict is
that both partners engage in a similar style. Thus
how conflict is used and resolved in the parental or
couple dyad relationship suggests the health and
longevity of the family unit.
The described positive interactions occur far
more often than the negative interactions in hap-
pily married couples. These healthy family couples
find ways to work out their differences and prob-
lems, are willing to yield to each other during their
arguments, and make purposeful attempts to repair
their relationship.
Olson and Gorall (2005) conducted a longitudi-
nal study on families, in which they merged the
concepts of marital and family dynamics in the
Circumplex Model of Marital and Family Systems.
They found that the ability of the family to demon-
strate flexibility is related to its ability to alter fam-
ily leadership roles, relationships, and rules,
including control, discipline, and role sharing.
Functional, healthy families have the ability to
change these factors in response to situations. Dys-
functional families, or unhealthy families, have less
ability to adapt and flex in response to changes. See
Figures 1-1 and 1-2, which depict the differences
in functional and dysfunctional families in the Cir-
cumplex Model. Balanced families will function
more adequately across the family life cycle and
6 Foundations in Family Health Care Nursing
BOX 1-1
Traits of a Healthy Family
■ Communicates and listens
■ Fosters table time and conversation
■ Affirms and supports each member
■ Teaches respect for others
■ Develops a sense of trust
■ Has a sense of play and humor
■ Has a balance of interaction among members
■ Shares leisure time
■ Exhibits a sense of shared responsibility
■ Teaches a sense of right and wrong
■ Abounds in rituals and traditions
■ Shares a religious core
■ Respects the privacy of each member
■ Values service to others
■ Admits to problems and seeks help
Source: From Kaakinen, J. R., Hanson, S. M. H., & Denham, S.
(2010). Family health care nursing: An introduction. In
J. W. Kaakinen, V. Gedaly-Duff, D. P. Coehlo, & S. M. H. Hanson
(Eds.), Family health care nursing: Theory, practice and re-
search (4th ed.). Philadelphia, PA: F. A. Davis, with permission.
3921_Ch01_001-032 05/06/14 10:54 AM Page 6
Family Health Care Nursing: An Introduction 7
BALANCED FAMILY
Rigid,
Inflexible
One person is
in charge and is
highly controlling.
Negotiation is
limited.
Rules do not
change.
Roles are strictly
enforced.
Leadership is
democratic.
Roles are stable;
there is some role
sharing.
Rules are enforced
with few changes.
Leadership is
equalitarian with
a democratic
approach to
decision making.
Negotiation is open
and actively
includes children.
Roles are shared
and are age
appropriate.
There are frequent
changes in
leadership and roles.
Rules are flexible
and readily adjusted.
Leadership is
erratic and limited.
Decisions are
impulsive.
Roles are unclear
and shift from
person to person.
Flexible
Family
Very
Flexible
Chaotic,
Overly
Flexible
Somewhat
Inflexible
FIGURE 1-1 Family flexibility continuum.
BALANCED FAMILY
Cohesion
Disconnected
There is extreme
emotional
separateness.
There is little family
involvement.
Family does not
turn to each other
for support.
Members have
some time apart
from family but also
spend some time
together.
Joint support and
decision making
take place.
Strike equilibrium
with moderate
separateness and
togetherness.
Family members
can be both
independent and
connected to the
family.
Decision making
is shared.
There is emotional
closeness and
loyalty.
More time is spent
together than alone.
Family members
have separate and
shared couple
friends.
There is extreme
emotional
connection, and
loyalty is demanded.
There is little private
space. Family
members are highly
dependent on each
other and reactive
to each other.
Connected
Very
Connected
Overly
Connected
Somewhat
Connected
FIGURE 1-2 Family cohesion continuum.
3921_Ch01_001-032 05/06/14 10:54 AM Page 7
tend to be healthier families. The family commu-
nication skills enable balance and help families to
adjust and adapt to situations. Couples and families
modify their levels of flexibility and cohesion to
adapt to stressors, thus promoting family health.
FAMILY HEALTH CARE NURSING
The specialty area of family health care nursing has
been evolving since the early 1980s. Some question
how family health care nursing is distinct from
other specialties that involve families, such as
maternal-child health nursing, community health
nursing, and mental health nursing. The definition
and framework for family health care nursing adopted
by this textbook and that applies from the previous
edition (Kaakinen et al., 2010) is as follows:
The process of providing for the health care needs
of families that are within the scope of nursing
practice. This nursing care can be aimed toward the
family as context, the family as a whole, the family
as a system, or the family as a component of society.
Family nursing takes into consideration all four
approaches to viewing families. At the same time,
it cuts across the individual, family, and community
for the purpose of promoting, maintaining, and
restoring the health of families. This framework
illustrates the intersecting concepts of the individual,
the family, nursing, and society (Fig. 1-3).
Another way to view family nursing practice is
conceptually, as a confluence of theories and strate-
gies from nursing, family therapy, and family social
science as depicted in Figure 1-4. Over time, family
nursing continues to incorporate ideas from family
therapy and family social science into the practice
of family nursing. See Chapter 3 for discussion
about how theories from family social science, fam-
ily therapy, and nursing converge to inform the
nursing of families.
Several family scholars have written about lev-
els of family health care nursing practice. For ex-
ample, Wright and Leahey (2013) differentiated
among several levels of knowledge and skills that
family nurses need for a generalist versus special-
ist practice, and they defined the role of higher
education for the two different levels of practice.
They propose that nurses receive a generalist
or basic level of knowledge and skills in family
nursing during their undergraduate work, and ad-
vanced specialization in family nursing or family
therapy at the graduate level. They recognize that
advanced specialists in family nursing have a
narrower focus than generalists. They purport,
however, that family assessment is an important
skill for all nurses practicing with families. Bomar
(2004) further delineated five levels of family
health care nursing practice using Benner’s levels
of practice: expert, proficient, competent, ad-
vanced beginner, and novice. See Table 1-1,
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).
8 Foundations in Family Health Care Nursing
FIGURE 1-3 Family nursing conceptual framework.
Nursing
models
Family therapy
theory
Family social
science theory
Family
nursing
FIGURE 1-4 Family nursing practice.
3921_Ch01_001-032 05/06/14 10:54 AM Page 8
NATURE OF INTERVENTIONS
IN FAMILY NURSING
The following 10 interventions family nurses use
provide structure to working with families regard-
less of the theoretical underpinning of the nursing
approach. These are enduring ideas that support the
practice of family nursing (Gilliss, Roberts, Highley,
& Martinson, 1989; Kaakinen et al., 2010):
1. Family care is concerned with the experience
of the family over time. It considers both the
history and the future of the family group.
2. Family nursing considers the community
and cultural context of the group. The fam-
ily is encouraged to receive from, and give
to, community resources.
3. Family nursing considers the relationships
between and among family members, and
recognizes that, in some instances, all indi-
vidual members and the family group will
not achieve maximum health simultaneously.
4. Family nursing is directed at families whose
members are both healthy and ill regardless
of the severity of the illness in the family
member.
5. Family nursing is often offered in settings
where individuals have physiological or
psychological problems. Together with
competency in treatment of individual
health problems, family nurses must recog-
nize the reciprocity between individual
family members’ health and collective
health within the family.
6. The family system is influenced by any
change in its members. Therefore, when
caring for individuals in health and illness,
the nurse must elect whether to attend to
the family. Individual health and collective
health are intertwined and will be influenced
by any nursing care given.
7. Family nursing requires the nurse to ma-
nipulate the environment to increase the
likelihood of family interaction. The physi-
cal absence of family members, however,
does not preclude the nurse from offering
family care.
8. The family nurse recognizes that the person
in a family who is most symptomatic may
change over time; this means that the focus
of the nurse’s attention will also change
over time.
Family Health Care Nursing: An Introduction 9
Table 1-1 Levels of Family Nursing Practice
Level of Practice Generalist/Specialist Education Client
Expert
Proficient
Competent
Advanced beginner
Novice
All levels
Family nursing theory development
Family nursing research
All levels
Beginning family nursing research
Individual in the family context
Interpersonal family nursing
Family unit
Family aggregates
Individual in the family context
Interpersonal family nursing
(family systems nursing)
Family unit
Individual in the family context
Advanced specialist
Advanced specialist
Beginning specialist
Generalist
Generalist
Doctoral degree
Master’s degree with
added experience
Master’s degree
Bachelor’s degree with
added experience
Bachelor’s degree
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.
3921_Ch01_001-032 05/06/14 10:54 AM Page 9
9. Family nursing focuses on the strengths of
individual family members and the family
group to promote their mutual support and
growth.
10. Family nurses must define with the family
which persons constitute the family and
where they will place their therapeutic
energies.
These are the distinctive intervention statements
specific to family nursing that appear continuously
in the care and study of families in nursing, regard-
less of the theoretical model in use.
APPROACHES TO FAMILY NURSING
Four different approaches to care are inherent in
family nursing: (1) family as the context for indi-
vidual development, (2) family as a client, (3) family
as a system, and (4) family as a component of soci-
ety (Kaakinen et al., 2010). Figure 1-5 illustrates
these approaches to the nursing of families. Each
approach derived its foundations from different
nursing specialties: maternal-child nursing, pri-
mary care nursing, psychiatric/mental health nurs-
ing, and community health nursing, respectively.
All four approaches have legitimate implications
for nursing assessment and intervention. The ap-
proach that nurses use is determined by many fac-
tors, including the health care setting, family
circumstances, and nurse resources. Figure 1-6
shows how a nurse can view all four approaches to
families through just one set of eyes. It is important
to keep all four perspectives in mind when working
with any given family.
Family as Context
The first approach to family nursing care focuses
on the assessment and care of an individual client
in which the family is the context. Alternate labels
for this approach are family centered or family
focused. This is the traditional nursing focus, in
which the individual is foreground and the family
is background. The family serves as context for the
individual as either a resource or a stressor to the
individual’s health and illness. Most existing nurs-
ing theories or models were originally conceptual-
ized using the individual as a focus. This approach
is rooted in the specialty of maternal-child nursing
and underlies the philosophy of many maternity
and pediatric health care settings. A nurse using
this focus might say to an individual client: “Who
in your family will help you with your nightly med-
ication?” “How will you provide for child care
when you have your back surgery?” or “It is won-
derful for you that your wife takes such an interest
in your diabetes and has changed all the food
preparation to fit your dietary needs.”
Family as Client
The second approach to family nursing care cen-
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
event of one family member. In this approach, all
members of the family are in the foreground. The
family is seen as the sum of individual family mem-
bers, and the focus concentrates on each individual.
The nurse assesses and provides health care for
each person in the family. This approach is seen
typically in primary care clinics in the communities
where primary care physicians (PCPs) or nurse
practitioners (NPs) provide care over time to all
individuals in a given family. From this perspective,
a nurse might ask a family member who has just be-
come ill: “How has your diagnosis of juvenile dia-
betes affected the other individuals in your family?”
“Will your nightly need for medication be a prob-
lem for other members of your family?” “Who in
your family is having the most difficult time with
your diagnosis?” or “How are the members of your
family adjusting to your new medication regimen?”
Family as System
The third approach to care views the family as a
system. The focus in this approach is on the family
as a whole as the client; here, the family is viewed
as an interactional system in which the whole is
more than the sum of its parts. In other words, the
interactions between family members become the
target for the nursing interventions. The interven-
tions flow from the assessment of the family as a
whole. The family nursing system approach focuses
on the individual and family simultaneously. The
emphasis is on the interactions between family
members, for example, the direct interactions be-
tween the parental dyad or the indirect interaction
between the parental dyad and the child. The more
children there are in a family, the more complex
these interactions become.
10 Foundations in Family Health Care Nursing
3921_Ch01_001-032 05/06/14 10:54 AM Page 10
This interactional model had its start with the
specialty of psychiatric and mental health nursing.
The systems approach always implies that when
something happens to one part of the system, the
other parts of the system are affected. Therefore, if
one family member becomes ill, it affects all other
members of the family. Examples of questions that
nurses may ask in a systems approach include the fol-
lowing: “What has changed between you and your
spouse since your child was diagnosed with juvenile
Family Health Care Nursing: An Introduction 11
Family as System
Interactional family
Family as Component
of Society
Legal
Financial
EducationFamily
Health
Religion Social
Church
School
Family Home
Bank
Medical Center
Family as Context
Individual as foreground
Family as background
Family as Client
Family as foreground
Individual as background
+ + + +
FIGURE 1-5 Approaches to family nursing.
3921_Ch01_001-032 05/06/14 10:54 AM Page 11
diabetes?” or “How has the diagnosis of juvenile
diabetes affected the ways in which your family is
functioning and getting along with each other?”
Family as Component of Society
The fourth approach to care looks at the family as
a component of society, in which the family is
viewed as one of many institutions in society, sim-
ilar to health, educational, religious, or economic
institutions. The family is a basic or primary unit
of society, and it is a part of the larger system of
society (Fig. 1-7). The family as a whole interacts
with other institutions to receive, exchange, or give
communication and services. Family social scien-
tists first used this approach in their study of fami-
lies in society. Community health nursing has
drawn many of its tenets from this perspective as it
focuses on the interface between families and com-
munity agencies. Questions nurses may ask in this
approach include the following: “What issues has
the family been experiencing since you made the
school aware of your son’s diagnosis of HIV?” or
“Have you considered joining a support group for
families with mothers who have breast cancer?
Other families have found this to be an excellent
resource and a way to reduce stress.”
VARIABLES THAT INFLUENCE
FAMILY NURSING
Family health care nursing has been influenced by
many variables that are derived from both historical
and current events within society and the profession
of nursing. Examples include changing nursing
theory, practice, education, and research; new
knowledge derived from family social sciences and
the health sciences; national and state health care
policies; changing health care behavior and atti-
tudes; and national and international political
events. Chapters 3 and 5 provide detailed discus-
sions of these areas.
Figure 1-8 illustrates how many variables influ-
ence contemporary family health nursing, making
the point that the status of family nursing is
dependent on what is occurring in the wider
society—family as community. A recent example
of this point is that health practices and policy
changes are under way because of the recognition
that current costs of health care are escalating and,
at the same time, greater numbers of people are un-
derinsured or uninsured and have lost access to
health care. The goal of this health care reform is
to make access and treatment available for everyone
at an affordable cost. That will require a major shift
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 nursing.
FAMILY NURSING ROLES
Families are the basic unit of every society, but it is
also true that families are complex, varied, dynamic,
12 Foundations in Family Health Care Nursing
System
Component
Context
Client
FIGURE 1-6 Four views of family through a lens.
Society
Family
Individual
FIGURE 1-7 Family as primary group in society.
3921_Ch01_001-032 05/06/14 10:54 AM Page 12
and adaptive, which is why it is crucial for all nurses
to be knowledgeable about the scientific discipline
of family nursing, and the variety of ways nurses
may interact with families (Kaakinen et al., 2010).
The roles of family health care nurses are evolving
along with the specialty. Figure 1-9 lists the many
roles that nurses can assume with families as the
focus. This figure was constructed from some of
the first family nursing literature that appeared, and
it is a composite of what various scholars believe to
be some of the current roles of nurses. Keep in
mind that the health care setting affects roles that
nurses assume with families.
Health teacher: The family nurse teaches about
family wellness, illness, relations, and parenting, to
name a few topics. The teacher-educator function
is ongoing in all settings in both formal and informal
Family Health Care Nursing: An Introduction 13
Technology-Internet
Megatrends
Economy
Policies
Housing
Education
Media
Health care delivery system
Environmental
Culture
Policy Making/Agendas
United Nations
Families
Health
United States/Canada
Health
Families
Economic
Child Care
Environmental
State and Local Governments
Divorce laws
Health care
Economics
Organizations
National Council of
Family Relations
Children’s Defense Fund
Groves Family Conference
Marriage and Family
Therapists Associations
Religious Organizations
..
…..
…
SOCIETY
Policy Related Theories/
Agendas
Strengths Perspective
Family Stress and Coping
Family Systems
Family Process
Family Structure &
Function
Family Development
Self-Care
Health Promotion
Family Interaction
Related Disciplines
Anthropology
Family Sociology
Family Psychology
Family Therapy
Family Science
Behavioral Sciences
Theology
Social Work
THEORIES
Primary care
(health promotion)
Secondary care
(health protection)
Tertiary care
(recovery/rehabilitation)
Families
Health
Vulnerable to illness
or dysfunction
Acute illness &
recovery
Chronic illness/
rehabilitation
FAMILY HEALTH
NURSING
..
.
.
Nursing Organizations
American Nurses Association
Standards of Nursing
Practice
Social Policy Statement
Agenda for Health Care
Reform
National League of Nursing
Accreditation Standards
American Association of
Colleges of Nurses
Family nursing interest groups
(i.e., ANA Council of
Nurse Researchers and
Western Nursing
Research Society)
National Association of Nurse
Practitioners
International Family Nursing
Biennial Conference
Family Nursing
Theory/Research
Nursing Paradigm
Family Nursing Research
Family transitions
Chronic illness and the
family
Acute illness and the
family
Health Promotion
Single Parents and
Health
Specialties in Nursing
Family nurse practitioner
Maternal child nursing
Family and community
health nursing
Psychiatric mental health
nursing
Home health nursing
Pediatric nursing
.
..
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.)
3921_Ch01_001-032 05/06/14 10:54 AM Page 13
ways. Examples include teaching new parents how
to care for their infant and giving instructions
about diabetes to a newly diagnosed adolescent boy
and his family members.
Coordinator, collaborator, and liaison: The
family nurse coordinates the care that families re-
ceive, collaborating with the family to plan care.
For example, if a family member has been in a trau-
matic accident, the nurse would be a key person in
helping families to access resources—from inpa-
tient care, outpatient care, home health care, and
social services to rehabilitation. The nurse may
serve as the liaison among these services.
“Deliverer” and supervisor of care and tech-
nical expert: The family nurse either delivers or
supervises the care that families receive in various
settings. To do this, the nurse must be a technical
expert both in terms of knowledge and skill. For
example, the nurse may be the person going into
the family home on a daily basis to consult with the
family and help take care of a child on a respirator.
Family advocate: The family nurse advocates for
families with whom he works; the nurse empowers
family members to speak with their own voice, or the
nurse speaks out for the family. An example is a school
nurse advocating for special education services for a
child with attention-deficit hyperactivity disorder.
Consultant: The family nurse serves as a consultant
to families whenever asked or whenever necessary.
In some instances, she consults with agencies to
facilitate family-centered care. For example, a clini-
cal nurse specialist in a hospital may be asked to as-
sist the family in finding the appropriate long-term
care setting for their sick grandmother. The nurse
comes into the family system by request for a short
period and for a specific purpose.
Counselor: The family nurse plays a therapeutic
role in helping individuals and families solve prob-
lems or change behavior. An example from the
mental health arena is a family that requires help
with coping with a long-term chronic condition,
such as when a family member has been diagnosed
with schizophrenia.
“Case-finder” and epidemiologist: The family
nurse gets involved in case-finding and becomes a
tracker of disease. For example, consider the situation
in which a family member has been recently diag-
nosed with a sexually transmitted disease. The nurse
would engage in sleuthing out the sources of the
transmission and in helping other sexual contacts to
seek treatment. Screening families and subsequent re-
ferral of the family members may be a part of this role.
Environmental specialist: The family nurse con-
sults with families and other health care professionals
to modify the environment. For example, if a man
with paraplegia is about to be discharged from the
hospital to home, the nurse assists the family in mod-
ifying the home environment so that the patient can
move around in a wheelchair and engage in self-care.
Clarify and interpret: The nurse clarifies and in-
terprets data to families in all settings. For example,
if a child in the family has a complex disease, such
as leukemia, the nurse clarifies and interprets in-
formation pertaining to diagnosis, treatment, and
prognosis of the condition to parents and extended
family members.
Surrogate: The family nurse serves as a surrogate
by substituting for another person. For example,
the nurse may stand in temporarily as a loving par-
ent to an adolescent who is giving birth to a child
by herself in the labor and delivery room.
Researcher: The family nurse should identify
practice problems and find the best solution for
dealing with these problems through the process of
scientific investigation. An example might be
14 Foundations in Family Health Care Nursing
Theory
developer
Advocate
Role model
Researcher
Surrogate
Environmental
modifier
Technical expert
(Deliver/supervise care)
Coordinator
collaborator
Liaison
Counselor
Clarifier-interpreter
Case finder
(Epidemiologist)
Case manager
Health education
Consultant
Family
FIGURE 1-9 Family nursing roles.
3921_Ch01_001-032 05/06/14 10:54 AM Page 14
collaborating with a colleague to find a better
intervention for helping families cope with incon-
tinent elders living in the home.
Role model: The family nurse is continually serv-
ing as a role model to other people. A school nurse
who demonstrates the right kind of health in per-
sonal self-care serves as a role model to parents and
children alike.
Case manager: Although case manager is a con-
temporary name for this role, it involves coordina-
tion and collaboration between a family and the
health care system. The case manager has been em-
powered formally to be in charge of a case. For
example, a family nurse working with seniors in the
community may become assigned to be the case
manager for a patient with Alzheimer’s disease.
OBSTACLES TO FAMILY NURSING
PRACTICE
There are several obstacles to practicing family
nursing. A vast amount of literature is available
about families, but there has been little taught
about families in the nursing curricula until
the past three decades. Most practicing nurses have
not had exposure to family theory or concepts dur-
ing their undergraduate education and continue to
practice using the individualist paradigm. Even
though there are several family assessment models
and approaches, families are complex, so no one as-
sessment approach fits all family situations. There
is a paucity of valid and reliable psychometrically
tested family evaluation instruments.
Furthermore, some students and nurses may be-
lieve that the study of family and family nursing is
“common sense,” and therefore does not belong
formally in nursing curricula, either in theory or
practice. Nursing also has strong historical ties with
the medical model, which has traditionally focused
on the individual as client, rather than the family.
At best, families have been viewed in context, and
many times families were considered a nuisance in
health care settings—an obstacle to overcome to
provide care to the individual.
Another obstacle is the fact that the traditional
charting system in health care has been oriented to
the individual. For example, charting by exception
focuses on the physical care of the individual and
does not address the whole family or members of
families. Likewise, the medical and nursing diagnos-
tic systems used in health care are disease centered,
and diseases are focused on individuals and have lim-
ited diagnostic codes that pertain to the family as a
whole. To complicate matters further, most insur-
ance companies require that there be one identified
patient, with a diagnostic code drawn from an indi-
vidual disease perspective. Thus, even if health care
providers are intervening with entire families, com-
panies require providers to choose one person in the
family group as the identified patient and to give that
person a physical or mental diagnosis, even though
the client is the whole family. Although there are
family diagnostic codes that address care with fami-
lies, insurance companies may not pay for care for
those codes, especially if the care is more psycholog-
ical or educational in nature. See Chapter 4 for a
detailed discussion on diagnostic codes.
The established hours during which health care
systems provide services pose another obstacle
to focusing on families. Traditionally, office hours
take place during the day, when family members
cannot accompany other family members. Recently,
some urgent care centers and other outpatient set-
tings have incorporated evening and weekend hours
into their schedules, making it possible for family
members to come in together. But many clinics and
physician offices still operate on traditional Monday
through Friday, 9:00 a.m. to 5:00 p.m. schedules,
thus making it difficult for all family members to at-
tend together. These obstacles to family-focused
nursing practice are slowly changing; nurses should
continue to lobby for changes that are more con-
ducive to caring for the family as a whole.
HISTORICAL PERSPECTIVES
A brief historical outline of the development of the
specialty of family nursing will help nurses under-
stand how nurses have actually always provided
care for the family from several different view-
points. An outline of the history of families in
North America is presented to provide an overview
of the family development up until present time.
History of Family Nursing
Family health nursing has roots in society from pre-
historic times. The historical role of women has been
inextricably interwoven with the family, for it was the
Family Health Care Nursing: An Introduction 15
3921_Ch01_001-032 05/06/14 10:54 AM Page 15
responsibility of women to care for family members
who fell ill and to seek herbs or remedies to treat the
illness. Women have been the primary child care
providers throughout history. In addition, through
“proper” housekeeping, women made efforts to pro-
vide clean and safe environments for the maintenance
of health and wellness for their families (Bomar, 2004;
Ham & Chamings, 1983; Whall, 1993).
During the Nightingale era in the late 1800s, the
development of nursing families became more
explicit. Florence Nightingale influenced both the
establishment of district nursing of the sick and
poor, and the work of “health missionaries”
through “health-at-home” teaching. She believed
that cleanliness in the home could eradicate high
infant mortality and morbidity rates. She encour-
aged family members of the fighting troops to
come into the hospitals during the Crimean War
to take care of their loved ones. Nightingale sup-
ported helping women and children achieve good
health by promoting both nurse midwifery and
home-based health services. In 1876, in a docu-
ment titled “Training Nurses for the Sick Poor,”
Nightingale encouraged nurses to serve in nursing
both sick and healthy families in the home environ-
ment. She gave both home-health nurses and
maternal-child nurses the mandate to carry out
nursing practice with the whole family as the unit
of service (Nightingale, 1979).
In colonial America, women continued the
centuries-old traditions of nurturing and sustaining
the wellness of their families and caring for the ill.
During the industrial revolution of the late 18th
century, family members began to work outside the
home. Immigrants, in particular, were in need of
income, so they went to work for the early hospi-
tals. This was the real beginning of public health
and school nursing. The nurses involved in the
beginning of the labor movement were concerned
with the health of workers, immigrants, and
their families. Concepts of maternal-child and
family care were incorporated into basic curricu-
lums of nursing schools. In fact, maternity nursing,
nurse midwifery, and community nursing histori-
cally focused on the quality of family health.
Margaret Sanger fought for family planning. Mary
Breckenridge formed the famous Frontier Nursing
Service (midwifery) to provide training for nurses
to meet the health needs of mountain families.
A concerted expansion of public health nursing
occurred during the Great Depression to work
with families as a whole. Nevertheless, before and
during World War II, nursing became more
focused on the individual, and care became central-
ized in institutional and hospital settings, where it
remained until recently.
Since the 1950s, at least 19 disciplines have stud-
ied the family and, through research, produced fam-
ily assessment techniques, conceptual frameworks,
theories, and other family material. Recently, this
interdisciplinary work has become known as family
social science. Family social science has greatly in-
fluenced family nursing in the United States, largely
because of the professional interdisciplinary group
called National Council of Family Relations and its
large number of family publications. Many family
nurses have become active in this organization. In
addition, some nurses are now receiving advanced
degrees in family social science departments around
the country.
Nursing theorists started in the 1960s to system-
atize nursing practice. Scholars began to articulate the
philosophy and goals of nursing care. Initially, theo-
rists were concerned only with individuals, but grad-
ually, individuals became viewed as part of a larger
social system. Also in the 1960s, the NP movement
began espousing the family as a primary unit of care
in practice, although the grand theories of nursing
focused primarily on the individual and not families.
The 1980s saw a shift in focus to families as a
unit of care in America and Canada. Small numbers
of people across these countries gathered together
to discuss and share family nursing concepts. Fam-
ily nurses started defining the scope of practice,
family concepts, and how to teach this information
to the next generation of nurses. Family nursing
has both old and new traditions and definitions.
The discipline and science of family nursing is now
beyond youth, more like a young adult, but still
in a state of growing up and maturing. The first na-
tional family nursing conferences were held in the
United States (Portland, Oregon) in 1986–1989.
The International Family Nursing Conferences
(IFNC) began in the late 1980s and has been held
around the world every 2 or 3 years since that time.
The 11th International Family Nursing Confer-
ence was held in June 2013 in Minneapolis, Min-
nesota. The International Family Nursing
Association (IFNA) grew out of IFNC and became
active in 2009–2010. See Table 1-2 for a composite
of historical factors that contributed to the devel-
opment of family health as a focus in nursing.
16 Foundations in Family Health Care Nursing
3921_Ch01_001-032 05/06/14 10:54 AM Page 16
Family Health Care Nursing: An Introduction 17
Table 1-2 Historical Factors Contributing to the Development of Family Health as a Focus in
Nursing
Time Period Events
Pre-Nightingale era
Mid-1800s
Late 1800s
Early 1900s
1960s
1970s
1980s
Revolutionary War “camp followers” were an example of family health focus before Florence Nightingale’s
influence.
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.
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.
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).
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.
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).
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.
(continued)
3921_Ch01_001-032 05/06/14 10:54 AM Page 17
18 Foundations in Family Health Care Nursing
Table 1-2 Historical Factors Contributing to the Development of Family Health as a Focus in
Nursing—cont’d
Time Period Events
1990s
2000s
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).
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).
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
sector.
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
A brief macro-analytical history of families is im-
portant to an understanding of family nursing. The
past helps to make the present realities of family
life more understandable, because the influence of
the past is evident in the present. This historical
approach provides a means of conceptualizing fam-
ily over time and within all of society. History helps
to dispel preferences for family forms that are only
personally familiar and broaden nurses’ views of the
world of families.
Prehistoric Family Life
Archaeologists and anthropologists have found
evidence of prehistoric family life, existing before
the time of written historical sources. These fam-
ily forms varied from present-day forms, but the
functions of the family have been assumed to have
remained somewhat constant over time. Families
were then and are now a part of the larger commu-
nity and constitute the basic unit of society.
It is postulated that the family structure, process,
and function were a response to everyday needs in
prehistoric times, just as they are in modern times.
As communities grew, families and communities
became more institutionalized and homogeneous
as civilization progressed. Family culture was that
aspect of life derived from membership in a partic-
ular group and shared by others. Family culture
was composed of values and attitudes that allowed
early families to behave in a predictable fashion.
Man and woman dyads are the oldest and most
tenacious unit in history. Biologically, human chil-
dren need care and protection longer than other
animals’ offspring. These needs led humans to
form long-term relationships. Economic pairing
was not always the same as reproductive pairing,
3921_Ch01_001-032 05/06/14 10:54 AM Page 18
but it was a by-product of reproductive pairing.
Moreover, a variety of skills were required for liv-
ing, and no single person possessed all skills; there-
fore, male and female roles began to differ and
become defined. Early in history, children were
part of the economic unit. As small groups of con-
jugal families formed communities, the complexity
of the social order increased.
European History
Many Americans are of European ancestry and stem
from the family structure that was present there.
Social organizations called families emphasized
consanguineous (genetic) bonds. The tendency to-
ward authority was concentrated in a few individuals
at the top of the hierarchical structure (kings, lords,
fathers). Men were the heads of families.
Property of family transferred through the male
line. Women left home to join their husbands’
families. Mothers did not establish strong bonds
with their daughters because the daughters even-
tually left their homes of origin to join their hus-
bands’ families of origin. Women and children
were property to be transferred. Marriage was a
contract between families, not individuals. Ex-
tended patriarchal family characteristics prevailed
until the advent of industrialism.
Industrialization
Great stability existed within family systems until
the Industrial Revolution. The revolution first ap-
peared in England around 1750 and spread to
Western Europe and North America. Some believe
that the nuclear family idea started with the Indus-
trial Revolution. Extended families had always been
the norm until families left farms and moved into
the cities, or until men left their families in order
to work in the factories. Some women stayed at
home, maintaining the house and caring for the
children, while other women and children took up
labor in the city factories.
When factories of the Industrial Revolution
started to be built, people began moving about. The
state had begun to provide services that families pre-
viously had performed for their members. Informal
contractual arrangements between public and state
power and nuclear families took place, in which the
state gave fathers the power and authority over their
families in exchange for male individuals giving the
state their loyalty and service. Women were not
expected to love husbands but to obey them.
Society today is still living with bequests of pa-
triarchal family life. Women are still struggling to
get out from under the rules and expectations of
the state and of men. The women’s movement and
the National Organization for Women (NOW) are
two of the forces that have improved the level of
equality of women in modern society. A lot more
work needs to be done on the issues of equality for
all Americans, including gender differences.
In recent years, men have also begun identifying
the bondage they experience. They cannot meet all
of the needs of families and feel inadequate for fail-
ing to do so. This is especially true of men who can-
not access the resources of money, occupation, and
occupational status through education. A men’s
movement is afoot that is promoting male causes,
although this movement is not as dynamic as it may
be in the future. One of the organizations support-
ing this work is the National Congress for Men.
North American Families
North American society and families were molded
from the beginning by economic logic rather than
consanguineous logic. America does not have the
history of Europe’s preindustrial age. English pa-
triarchy was not transplanted in its pure form to
America. Both women and men had to labor in the
New World. This gave women new power. Also,
the United States had an ethic of achieved status
rather than status inherited through familial lines.
Children were also experiencing a changing sta-
tus in American families. Originally, they were part
of the economic unit and worked on farms. Then
with the great immigration of the early 1900s, the
expectation shifted to parents creating a better
world for their children than they themselves had.
To do this, children had to become more educated
to deal with the developing society. Each generation
of children has generally obtained more education
and income than their parents; they left the family
farms and moved to distant cities. As a result of this
change, parents lost assurance that their children
would take care of them during their old age.
In addition, the functions of families were
changing greatly. The traditional roles that families
played were being displaced by the growing num-
bers and kinds of social institutions. Families began
increasingly surrendering to public agencies many
of the socialization functions they previously per-
formed, such as child education, health care, and
child care.
Family Health Care Nursing: An Introduction 19
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Families Today
Today, families cannot be separated from the larger
system of which they are a part, nor can they be sep-
arated from their historical past. Some people argue
that families are in terrible condition, like a rudder-
less ship in the dark. Other people hail the changes
that continue to occur in families, and approve the
diversity and options that address modern needs.
Idealizing past family arrangements and decrying
change has become commonplace in the media. Just
as some families of both the past and present engage
in behaviors that are destructive to individuals and
other social institutions, there are families of the
past and present that provide healthy environments.
The structure, function, and processes of families
have changed, but the family will continue to sur-
vive and thrive. It is, in fact, the most tenacious unit
in society (Kaakinen et al., 2010).
FAMILY STRUCTURE, FUNCTION,
AND PROCESS
Knowledge about family structure, functions, and
processes is essential for understanding the com-
plex family interactions that affect health, illness,
and well-being (Kaakinen et al., 2010). Knowl-
edge emerging from the study of family structure,
function, and process suggests concepts and a
framework that nurses can use to provide effective
assessment and intervention with families. Many
internal and external family variables affect indi-
vidual family members and the family as a whole.
Internal family variables include unique individual
characteristics, communication, and interactions,
whereas external family variables include location
of family household, social policy, and economic
trends. Family members generally have compli-
cated responses to all of these factors. Although
some external factors may not be easily modifi-
able, nurses can assist family members to manage
change, conflict, and care needs. For instance, a
sudden downturn in the economy could result in
the family breadwinner becoming unemployed.
Although nurses are unable to alter this situation
directly, understanding the implications on the
family situation provides a basis for planning more
effective interventions that may include financial
support programs for families. Nurses can assist
members with coping skills, communication pat-
terns, location of needed resources, effective use
of information, or creation of family rituals or
routines (Kaakinen et al., 2010).
Nurses who understand the concepts of family
structure, function, and process can use this knowl-
edge to educate, counsel, and implement changes
that enable families to cope with illness, family cri-
sis, chronic health conditions, and mental illness.
Nurses prepared to work with families can assist
them with needed life transitions (Kaakinen et al.,
2010). For example, when a family member expe-
riences a chronic condition such as diabetes, family
roles, routines, and power hierarchies may be chal-
lenged. Nurses must be prepared to address the
complex and holistic family problems resulting
from illness, as well as to care for the individual’s
medical needs.
Family Structure
Family structure is the ordered set of relationships
within the family, and between the family and other
social systems (Denham, 2005). There are many
tools available for nurses to use in conducting
assessments of family structure. The most funda-
mental tools are family genograms and ecomaps,
which will be introduced later in this chapter.
These tools are not new in nursing, but their pop-
ularity among nurses and other providers is grow-
ing due to the clearly perceived value of the
knowledge they generate. Genograms and ecomaps
are beginning to make their way out of more ob-
scure settings such as specialty genetics clinics and
into mainstream home health, public health, and
even acute care settings (Svarvardoittir, 2008).
In terms of family nursing assessment and inter-
vention, it is logical to begin with the “who” of
families before moving to the “how” or “why.” In
determining the family structure, the nurse needs
to identify the following:
■ The individuals who comprise the family
■ The relationships between them
■ The interactions between the family members
■ The interactions with other social systems
Family patterns of organization tend to be rela-
tively stable over time, but they are modified gradu-
ally throughout the family life cycle and often change
radically when divorce, separation, or death occurs.
In today’s information age and global society, sev-
eral ideas about the “best family” coexist simultane-
ously. Different family types have their strengths and
20 Foundations in Family Health Care Nursing
3921_Ch01_001-032 05/06/14 10:54 AM Page 20
limitations, which directly or indirectly affect indi-
viduals and family health. Many families still adhere
to more customary forms and patterns, but many
of today’s families fall into categories more clearly
labeled nontraditional (Table 1-3). Nurses will con-
front families structured differently from their own
families of origin and will encounter family types
that conflict with personal value systems. For nurses
to work effectively with families, they must maintain
open and inquiring minds.
Families in the past were more homogeneous
than they are today. Whereas the past norm in
predominately Caucasian families was a two-
parent family (traditional nuclear family) living to-
gether with their biological children, many other
family forms are acknowledged and recognized
today. It is important to note that the average per-
son born today will experience many family forms
during his or her lifetime. Figure 1-10 depicts the
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-
sonal lives but also with the patients with whom
they work in health care settings (Kaakinen &
Birenbaum, 2012).
Understanding family structure enables nurses
assisting families to identify effective coping
strategies for daily life disturbances, health care
crises, wellness promotion, and disease preven-
tion (Denham, 2005). In addition, nurses are cen-
tral in advocating and developing social policies
relevant to family health care needs. For example,
taking political action to increase the availability
of appropriate care for children could reduce the
financial and emotional burden of many working
and single-parent families when faced with pro-
viding care for sick children. Similarly, caregiving
responsibilities and health care costs for acutely
and chronically ill family members place increas-
ing demands on family members. Nurses well
informed about different family structures can
Family Health Care Nursing: An Introduction 21
Family of
origin
Single-
parent
family
Stepfamily Cohabi-
tation
Commuter
marriage
AdulthoodChildhood
Developmental process
Single-
parent
family
Cohabi-
tation
Stepfamily
Widow/
widower
Married/agingfamily
Spouse
biological/stepparent
Partner/parentC
us
to
di
al
pa
re
nt
S
po
us
e/
pa
re
nt
Pa
rtn
er
Li
ve
s
in
Li
ve
s
in
Lives in
Single
Married
FIGURE 1-10 An individual’s potential family life experiences.
Married couple, no children
Husband, wife, children (may or
may not be legally married)
Two postdivorce families with
children as members of both
Nuclear family plus blood relatives
Husband, wife, and children of
previous relationships
One parent and child(ren)
Group of men, women, and children
Unmarried man and woman sharing
a household
Same-gender couple
One person in a household
Table 1-3 Variations of Family and Household
Structures
Family Type Composition
Nuclear dyad
Nuclear
Binuclear
Extended
Blended
Single parent
Commune
Cohabitation
(domestic partners)
Homosexual
Single person (adult)
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identify specific needs of unique families, provide
appropriate clinical care to enhance family re-
silience, and act as change agents to enact social
policies that reduce family burdens.
Family Functions
A functional perspective has to do with the ways
families serve their members. One way to describe
the functional aspect of family is to see the unit
as made up of intimate, interactive, and interde-
pendent persons who share some values, goals,
resources, responsibilities, decisions, and commit-
ment over time (Steinmetz, Clavan, & Stein, 1990).
Family function relates to the larger purposes or
roles of families in society at large. It is important
to be clear that there is a distinction between the
concepts of family function (the prescribed social
and cultural obligations and roles of family in soci-
ety) and family functioning (the processes of family
life). Family functioning has been described as “the
individual and cooperative processes used by devel-
oping persons as to dynamically engage one an-
other and their diverse environments over the life
course” (Denham, 2003a, p. 277). Family function
includes the ways a family reproduces offspring, in-
teracts to socialize its young, cooperates to meet
economic needs, and relates to the larger society.
Nurses should ask about specific characteristics that
factor into achieving family or societal goals, or
both. Families’ functional processes such as social-
ization, reproduction, economics, and health care
provision are areas nurses can readily assess and
address during health care encounters. Nursing
interventions can enhance the family’s protective
health function when teaching and counseling is
tailored to explicit learning needs. Family cultural
context and individual health literacy needs are
closely related to functional needs of families.
Nurses become therapeutic agents as they assist
families to identify social supports and locate com-
munity resources during times of family transitions
and health crisis. Five specific family functions are
worth deeper investigation here: reproductive,
socialization, affective, economic, and health care.
Reproductive Functions of the Family
The survival of a society is linked to patterns of re-
production. Sexuality serves the purposes of pleas-
ure and reproduction, but associated values differ
from one society to another. Traditionally, the
family has been organized around the biological
function of reproduction. Reproduction was
viewed as a major concern for thousands of years
when populating the earth was continually threat-
ened by famine, disease, war, and other life uncer-
tainties. Norms about sexual intercourse affect the
fertility rate. Fertility rate is “the average number
of children that would be born per woman if all
women lived to the end of their childbearing years
and bore children according to a given fertility rate
at each age” (World Factbook, 2013). In general,
global fertility rates are in decline, with the most
pronounced decline being in industrialized coun-
tries, especially Western Europe (World Factbook,
2013). Global concerns about overpopulation and
environmental threats, as well as personal views of
morality and financial well-being, have been rea-
sons for limiting numbers of family births.
Since the 1980s, the reproductive function has
become increasingly separated from the family
(Kaakinen et al., 2010). As mores and norms
change over time, it is not deemed “unacceptable”
in many industrialized countries for birth to occur
outside of marriage. Abstinence, various forms of
contraception, tubal ligation, vasectomy, family
planning, artificial insemination, and abortion have
various degrees of social acceptance as means to
control reproduction. Many aspects of reproduc-
tion continue to be the subject of social and ethical
controversy. Nurses working with families find
themselves at the forefront of practical issues
related to providing care in this complex context.
The ethical dilemmas surrounding abortion,
for example, seem compounded by technological
advances that affect reproduction and problems
of infertility. Reproductive technologies are guided
by few legal, ethical, or moral guidelines. Artificial
insemination by husband or donor, in vitro fertil-
ization, surrogate mothers, and artificial embry-
onization, in which a woman other than the woman
who will give birth to and raise the child donates
an egg for fertilization, create financial and moral
dilemmas. Although assistive reproductive tech-
nologies can provide a biological link to the child,
some families are choosing to adopt children. Many
are wrangling over the issues implicit in cross-racial
and cross-cultural adoptions. Reproductive tech-
nologies and adoption are being considered by
all family types to add children to the family unit.
Religious, legal, moral, economic, and technologi-
cal challenges will continue to cause debates in the
22 Foundations in Family Health Care Nursing
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years ahead about family control over reproduc-
tion, such as gender selection of child.
Socialization Functions of the Family
A major function for families is to raise and social-
ize their children to fit into society. Families have
great variability in the ways they address the phys-
ical and emotional needs, moral values, and eco-
nomic needs of children, and these patterns are
influenced specifically by the role of parenting and
somewhat by the larger society (Grusec, 2011).
Children are born into families without knowledge
of the values, language, norms, morals, communi-
cation, or roles of the society in which they live. A
major function of the family continues to be to so-
cialize them about family life and ground them in
the societal identity of which they are a part. The
function of the family relative to socialization in-
cludes protection, mutual reciprocity or interde-
pendence between family members, control,
guided learning, and group participation, and all
these functions are assumed to be operative in all
cultures (Grusec, 2011).
Although the family is not the only institution
of society that participates in socialization of chil-
dren, it is generally viewed as having primary re-
sponsibility for this function. When children fail to
meet societal standards, it is common to blame this
on family deficits and parental inadequacies; how-
ever, it is important to keep in mind that the issues
are more complex than simple finger pointing.
Today, patterns of socialization require appro-
priate developmental care that fosters dependence
and leads to independence (Denham, 2005). Social-
ization is the primary way children acquire the so-
cial and psychological skills needed to take their
place in the adult world. Parents combine social
support and social control as they equip children
to meet future life tasks. Parental figures interact
in multiple roles such as friends, lovers, child care
providers, housekeepers, financial providers, recre-
ation specialists, and counselors. Children growing
up within families learn the values and norms of
their parents and extended families.
Another role of families in the socialization
process is to guide children through various rites
of passage. Rites of passage are ceremonies that an-
nounce a change in status in the ways members are
viewed. Examples include events such as a baptism,
communion, circumcision, puberty ritual, gradua-
tion, wedding, and death. These occasions signal
to others changes in role relationships and new ex-
pectations. Understandings about families’ unique
rites of passage can assist nurses working with
diverse health care needs.
Affective Functions of the Family
Affective function has to do with the ways family
members relate to one another and those outside
the immediate family boundaries. Healthy families
are able to maintain a consistent level of involve-
ment with one another, yet at the same time, not
become too involved in each other’s lives (Peterson
& Green, 2009). The healthiest families have em-
pathetic interaction where family members care
deeply about each other’s feeling and activities, and
are emotionally invested in each other. Families
with a strong affective function are the most effec-
tive type of families (Peterson & Green, 2009). All
families have boundaries that help to buffer stresses
and pressure of systems outside the family on its
members. Healthy families protect their bound-
aries, but at the same time, give members room to
negotiate their independence. Achieving this bal-
ance is often difficult in our fast-paced culture. And
it is particularly difficult in families with adoles-
cents (Peterson & Green, 2009). Emotional in-
volvement is a key to successful family functioning.
Researchers have identified several characteristics
of strong families. Among these are expressions of
appreciation, spending time together, strong com-
mitment to the family, good communication, and
positive conflict resolution (Peterson & Green,
2009). When family members feel that they are
supported and encouraged and that their personal
interests are valued, family interaction becomes
more effective.
Families provide a sense of belonging and iden-
tity to their members. This identity often proves to
be vitally important throughout the entire life cycle.
Within the confines of families, members learn de-
pendent roles that later serve to launch them into
independent ones. Families serve as a place to learn
about intimate relationships and establish the foun-
dation for future personal interactions. Families
provide the initial experience of self-awareness,
which includes a sense of knowing one’s own gen-
der, ethnicity, race, religion, and personal charac-
teristics. Families help members become acquainted
with who they are and experience themselves in
relationships with others. Families provide the sub-
stance for self-identity, as well as a foundation for
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other-identity. Within the confines of families, in-
dividual members learn about love, care, nurtu-
rance, dependence, and support of the dying.
Resilience implies an ability to rebound from
stress and crisis, the capacity to be optimistic, solve
problems, be resourceful, and develop caring sup-
port systems. Although unique traits alter potential
for emotional and psychological health, individuals
exposed to resilient family environments tend to
have greater potential to achieve normative devel-
opmental patterns and positive sibling and parental
relationships (Denham, 2005).
Research on parent-child interactions needs
to consider the quantity and quality of time spent
together, the kinds of activities engaged in, and pat-
terns of interaction to understand member feelings
toward each other. More needs to be known about
relationships with nonresidential parents as well as
families characterized by polyamory, families in
which there is more than one loving sexual relation-
ship at the same time with the consent and knowl-
edge of all partners (Pallotta-Chiarolli, 2006).
Variables such as the quality of couples’ relation-
ships, the ways families’ conflicts are handled,
whether abuse or violence has previously occurred
in the households or members’ lives, frequency of
children’s contact with nonresidential parents,
shared custody arrangements, and emotional rela-
tionships between parents and children appear to be
important predictors of family affective functions.
Affective functions can best be understood by
gathering information from all of the various mem-
bers involved within a household; lack of access to
all points of view within families should not prevent
nurses from gaining knowledge from those to
whom they have access. It is quite reasonable to in-
quire about the perceptions and experiences of
some individuals through key family informants,
but nurses must always remember that more certain
knowledge should come from the specific individu-
als themselves, particularly as family members are
known to have diverse viewpoints on issues that af-
fect health and family life. Shared or discrepant
views among family members have an important
influence on the overall functioning of families’
management of illness (Knafl, Breitmayer, Gallo, &
Zoeller, 1996 Knafl, Deatrick, & Gallo, 2008).
Economic Functions of the Family
Families have an important function in keeping
both local and national economies viable. Economic
conditions significantly affect families. When
economies become turbulent so become families’
structures, functions, and processes. People make
decisions about when to enter the labor force, when
to marry, when to have children, and when to retire
or come out of retirement based on economic fac-
tors (Bianchi, Casper, & King, 2005). For a detailed
discussion on family and economics, see Chapter 2.
Family income provides a substantial part of fam-
ily economics, but an equally important aspect has to
do with economic interactions and consumerism re-
lated to household consumption and finance. Money
management, housing decisions, consumer spending,
insurance choices, retirement planning, and savings
are some of the issues that affect family capacity
to care for the economic needs of its members
(Lamanna & Reidmann, 2011. These values and
skills are passed down to children within the family
structure. Financial vulnerability and bankruptcy
have increased for middle-class families (Denham,
2005). The ability of the family to earn a sufficient
income and to manage its finances wisely is a critical
factor related to economic well-being.
In order to meet their own economic needs and
maintain family life and health, family members
take upon themselves a number of contributory
roles for obtaining and utilizing the wages. Family
nurses should explore the types of resources avail-
able or lacking as families engage in providing
health care functions to their members.
Health Care Functions of the Family
Family members often serve as the primary health
care providers to their families. Individuals regu-
larly seek services from a variety of health care pro-
fessionals, but it is within the family that health
instructions are followed or ignored. Family mem-
bers tend to be the primary caregivers and sources
of support for individuals during health and illness.
Families influence well-being, prevention, illness
care, maintenance care associated with chronic ill-
ness, and rehabilitative care. Family members often
care for one another’s health conditions from the
cradle to the grave. Families can become particu-
larly vulnerable when they encounter health
threats, and family-focused nurses are in a position
where they can provide education, counseling, and
assistance with locating resources. Family-focused
care implies that when a single individual is the tar-
get of care, the entire family is still viewed as the
unit of care (Denham, 2003a).
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Health care functions of the family include many
aspects of family life. Family members have differ-
ent ideas about health and illness, and often these
ideas are not discussed within families until prob-
lems arise. Availability and cost of health care in-
surance is a concern for many families, but many
families lack clarity about what is and is not covered
until they encounter a problem. Lifestyle behav-
iors, such as healthy diet, regular exercise, and al-
cohol and tobacco use, are areas that family
members may not associate with health and illness
outcomes. Risk reduction, health maintenance, re-
habilitation, and caregiving are areas where families
often need information and assistance. Family
members spend far more time taking care of health
issues of family members than professionals do.
Family Processes
Family process is the ongoing interaction between
family members through which they accomplish
their instrumental and expressive tasks (Denham,
2005). Family process indicators describe the inter-
actions between members of a family, including
their relationships, communication patterns, time
spent together, and satisfaction with family life
(World Family Map, 2013). In part, family process
makes every family unique within its own particular
culture. Families with similar structures and func-
tions may interact differently. Family process, at
least in the short term, appears to have a greater ef-
fect on the family’s health status than family struc-
ture and function, and in turn, processes within
families are more affected by alterations in health
status. Family process certainly appears to have the
greatest implications for nursing actions. For ex-
ample, for the chronically ill, an important deter-
minant for successful rehabilitation is the ability to
assume one’s familial roles. For rehabilitation
to occur, family members have to communicate
effectively, make decisions about atypical situa-
tions, and use a variety of coping strategies. The
usual familial power structure may be threatened
or need to change to address unique individual
needs. Ultimately, the success or failure of the
adaptation processes will affect individual and
family well-being.
Alterations in family processes most likely occur
when the family faces a transition brought about by
developmental changes, adding or subtracting family
members, an illness or accident, or other potential
crisis situations, such as natural disasters, wars, or
personal crises. The family’s current modes of op-
eration may become ineffective, and members are
confronted with learning new ways of coping with
change. For example, when coping with the stress
of a chronic illness, families experience alterations
in role performance and in power. When individ-
uals are unable to perform usual roles, other mem-
bers are expected to assume them. A shift in family
roles may result in the loss of individual power.
During times of change, family nurses can assist
family members to communicate, make decisions,
identify ways to cope with multiple stressors, re-
duce role strain, and locate needed resources.
Family communication patterns, member inter-
actions, and interaction with social networks are sev-
eral areas related to family processes that nurses
need to assess systematically. Nursing interventions
that promote resiliency in family processes vary with
the degree of strain faced by the family. Families
have complex needs related to adaptation, goal at-
tainment, integration, pattern, and tension manage-
ment. When family processes are ineffective or
disrupted, the families and their members may be at
risk for problems pertinent to health outcomes, and
the family itself could be in danger of disintegrating.
Following is a discussion of a few family processes
that nurses can influence through their relationships
with families in caregiving situations. The family
processes covered here include family coping, family
roles, family communication, family decision mak-
ing, and family rituals and routines.
Family Coping
Every family has its own repertoire of coping
strategies, which may or may not be adequate in
times of stress, such as when a family member ex-
periences an altered health event such as the diag-
nosis of diabetes, a stroke, or a fractured leg in a
biking accident. Coping consists of “constantly
changing cognitive and behavioral efforts to man-
age specific external and/or internal demands that
are appraised as taxing or exceeding the resources
of the person” (Lazarus & Folkman, 1984, p. 141).
Families with support can withstand and rebound
from difficult stressors or crises (Walsh, 2011b),
which is referred to as family resilience. “Family re-
silience is the successful coping of family members
under adversity that enables them to flourish with
warmth, support, and cohesion” (Black & Lobo,
2008, p. 33).
Family Health Care Nursing: An Introduction 25
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Not all families have the same ability to cope be-
cause of multiple reasons. There is no universal list
of key effective factors that contribute to family re-
siliency, but a review of research and literature by
Black and Lobo (2008) found the following simi-
larities across studies for those families that cope
well: a positive outlook, spirituality, family member
accord, flexibility, communication, financial man-
agement, time together, mutual recreational inter-
ests, routines and rituals, and social support (Black
& Lobo, 2008). According to Walsh (2011b) some
key processes in family resiliency include belief sys-
tem, organizational patterns, and family communi-
cation. The family’s belief system involves making
meaning of adversity, maintaining a positive out-
look, and being able to transcend adversity through
a spiritual/faith system (Walsh, 2011b). The fami-
lies’ organization patterns, which speak to their
flexibility, connectedness, and social and economic
resources, help the family maintain resilience.
Finally, families who communicate with clarity,
allow open emotional expression, and have a col-
laborative problem-solving approach facilitate fam-
ily resiliency (Walsh, 2011b).
Nurses have the ability to support families in
times of stress and crisis through empowering
processes that work well and are familiar to the
family. Using a strengths-based approach, family
nurses help families to adjust and adapt to stressors
(Black & Lobo, 2008; Walsh, 2011c). Nurses can
help families in establishing priorities and respond-
ing to everyday needs when a health event occurs
that threatens family stability. For example, when
an unexpected death in the family occurs, family
members are called on to make multiple decisions.
At the same time, they may not be able to remem-
ber phone numbers, think of whom to call in what
order, decide who should pick up the kids, deter-
mine which funeral home to use, or decide how or
what to tell children or aging parents. Helping
families to work through steps and set priorities
during this situation is an important aspect of fam-
ily nursing.
Even families who function at optimal levels
may experience difficulties when stressful events
pile up. Even families that cope well may still feel
stressed (Black & Lobo, 2008). Today’s families
encounter many challenges that leave them vulner-
able to a myriad of stressors. Vulnerability can re-
sult from poverty, illness, abuse, and violence.
Coping capacities are enhanced whenever families
demonstrate resilience or the capacity to survive in
the midst of struggle, adversity, and long-term con-
flict. Families who recover from crisis tend to be
more cohesive, value unique member attributes,
support one another without criticism, and focus
on strengths (Black & Lobo, 2008).
Family Roles
Understanding family roles is crucial in family
nursing as it is one area in which nurses can help
families to adapt, negotiate, give up expectations,
or find additional resources to help decrease family
stress during times when a family member is ill.
Within the family, regardless of structure, each
family position has a number of attached roles, and
each role is accompanied by expectations. After a
review of the family literature, Nye (1976) identi-
fied eight roles associated with the position of
spouse/partner:
■ Provider
■ Housekeeper
■ Child care
■ Socialization
■ Sexual
■ Therapeutic
■ Recreational
■ Kinship
With the rates of divorce and cohabitation in
North America, traditional roles such as provider
and child care role are stressed and unfold differ-
ently. In addition, other roles are added relative to
relationship, such as father who lives apart from
children, stepparent, and/or half-sibling.
Traditionally, the provider role has been as-
signed to husbands, whereas wives assumed the
housekeeper, child care, and other caregiving roles.
With societal changes and variations in family
structure, however, the traditional enactment of
these roles is not viable for some families anymore
(Gaunt, 2013). In two-parent heterosexual families,
the roles are still primarily organized by gender,
with men as breadwinners and women as primary
caregivers (Scott & Braun, 2009). Other family
roles form based on generation or location in the
family (Haddock, Zimmerman, & Lyness, 2005),
such as, for example, middle child, mother, father,
stepsister, niece, and grandfather. Attitudes have
changed somewhat in regard to rigid gender role
enactment (who does what), but the research shows
that, in reality, little change has occurred, and most
26 Foundations in Family Health Care Nursing
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families remain gender based (Haddock et al.,
2005; Scott & Braun, 2009).
What has changed relative to family roles is the
number of mothers who work outside of the home
and the role of the father. The rate of mothers with
infants under 1 year old working outside of the
home is 55.8% (Bureau of Labor Statistics, 2011).
Even though more women work outside of the
home and men are participating and doing more in
the home and with child care in the family than
ever before, the responsibility for child care still re-
mains largely with women (Kaakinen et al., 2010).
The role of the father has changed, but the degree
of change is unsure. A 2011 Pew Research Center
report indicates that one in four children under
the age of 18 years lives apart from their father
(Livingston & Parker, 2011). Many fathers who
live with their children are active in their day-to-
day activities. Fathers who live apart from their
children are often involved in e-mail and phone
conversations and visitation in varying amounts of
time. But 27% of the fathers who do not live with
their children indicate that they have not been in
communication with their children in the last year.
In general, the Pew report found no consensus on
whether or not today’s fathers are more involved
in the family life of their children than previous
generations of fathers (Livingston & Parker, 2011).
In every household, members have to decide the
ways work and responsibilities will be divided and
shared. Roles are negotiated, assigned, delegated,
or assumed. Division of labor within the family
household occurs as various members assume roles,
and as families change over time and over the fam-
ily life cycle. For example, family members need to
reconfigure role allocation after the birth or death
of family members.
Provider role: The provider role has undergone
significant change in the past few decades. Whereas
American men were once viewed as the sole pri-
mary family breadwinner, this has changed signifi-
cantly. In today’s world, many families need more
than one income to meet basic needs. Work con-
ditions have become increasingly stressful for men
and women, and external work obligations impinge
on members’ abilities to meet familial role obliga-
tions. For example, working mothers in Canada
were found to rely on processed and fast conven-
ience foods in the majority of meal preparations,
thus increasing the risk of poor health outcomes for
the family members, such as obesity (Slater,
Sevenhuysen, Edginton, & O’Neil, 2012).
Housekeeper and child care roles: Today,
many women experience significant role strain in
balancing provider and other familial roles.
Women who work continue to be responsible for
most housekeeping and child care responsibilities
(Haddock et al., 2005). Women who work outside
the home still perform 80% of the child care and
household duties (Walsh, 2011a). In a survey by
Hewlett and Luce (2006), 77% of women and 66%
of men who worked over 60 hours a week said they
were unable to maintain their household, 66% of
the sample reported they did not get sufficient
sleep, and half reported not getting enough exer-
cise. Although husbands’ roles in child care are in-
creasing, their focus is often on playing with the
children rather than meeting basic needs. Women
still are primary in meeting health care needs of all
family members, including children and men.
Sick role: Individuals learn health and illness be-
haviors in their family of origin. Health behaviors
are related to the primary prevention of disease, and
include health promotion activities to reduce sus-
ceptibility to disease and actions to reduce the effects
of chronic disease. Kasl and Cobb (1966) identified
three types of health behaviors in families:
■ Health behavior is any activity undertaken by
a person believing himself to be healthy for
the purpose of preventing disease or detecting
it at an asymptomatic stage.
■ Illness behavior is any activity, undertaken by
a person who feels ill, to define the state of
his health and to discover a suitable remedy.
■ Sick-role behavior is any activity undertaken
for the purpose of getting well, by those who
consider themselves ill.
Once a family member becomes ill, she demon-
strates various illness behaviors or enacts the “sick
role.” Parsons (1951) defines four characteristics of
a person who is sick:
■ While sick, the person is temporarily exempt
from carrying out normal social and family
roles. The more severe the illness, the freer
one is from role obligations.
■ In general, the sick person is not held
responsible for being ill.
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■ The sick person is expected to take actions to
get well, and therefore has an obligation to
“get well.”
■ The sick person is expected to seek compe-
tent professional medical care and to comply
with medical advice on how to “get well.”
Voluminous research has been conducted on the
theoretical concepts of the sick role. Some criti-
cisms of the Parsons perspective the sick role are as
follows: (1) some individuals reject the sick role; (2)
some individuals are blamed for their illness, such
as alcoholics or individuals with AIDS; and (3)
sometimes independence is encouraged in persons
who have a chronic illness as a way to “get well.”
Regardless of the theoretical debates about the
sick role, individuals in families experience acute and
chronic illness. Each family, depending on its family
processes, defines the sick role differently. Most
“sick” people require some level of care; someone
needs to assume the family caregiver role. The care-
giving role may be as simple as a stop at the store on
the way home to buy chicken soup or pick up med-
icines, or as involved as providing around-the-clock
care for someone. The female individuals in our so-
ciety still provide the majority of the care required
when family members become sick or injured.
Role strain, conflict, and overload: Family roles
are affected, some more than others, when a family
member becomes ill. Usually the women in the
family add the role of family caregiver to their
other roles. Nurses have a crucial role in helping
families adjust to illness by discussing and exploring
role strain, role conflict, and role overload. Nurses
can facilitate family adaptation by helping to
problem-solve role negotiations and helping fam-
ilies access outside resources.
Lack of competence in role performance may
be a result of role strain. Some researchers have
found that sources of role strain are cultural and
interactional. Interactional sources of role strain
are related to difficulties in the delineation and en-
actment of familial roles. Heiss (1981) identifies
five sources of difficulties in the interaction process
that place strain on a family system:
■ Inability to define the situation
■ Lack of role knowledge
■ Lack of role consensus
■ Role conflict
■ Role overload
The inability to define the situation creates am-
biguity about what one should do in a given sce-
nario. Continual changes in family structures and
gender roles means that members increasingly en-
counter situations in which guidelines for action
are unclear. Single parents, stepparents, nonresi-
dent fathers, and cohabitating partners deal daily
with situations for which there are no norms. What
right does a stepparent have to discipline the new
spouse’s child? Is a nonresident father expected to
teach his child about AIDS? What name or names
go on the mailbox of cohabitating partners? Who
can sign for consent when divorced parents share
custody?
Regardless of whether the issues are substantive,
they present daily challenges to the people in-
volved. Some choose to withdraw from the situa-
tion, and others choose to redefine the situation
when they are uncertain how to act. For instance,
a blended family might want to operate in the same
way as a traditional family but may experience con-
flict when thinking about which members to in-
clude in family decision making. When a solution
cannot be found, family members suffer the conse-
quences of role strain.
Role strain sometimes results when family
members lack role knowledge, or they have no
basis for choosing between several roles that
might seem appropriate. In America, most people
are not taught how to be parents, and much
learning is observational and experiential. Social-
ization related to caregiving of a chronically ill
family member seldom occurs, and many individ-
uals are unfamiliar with and unprepared to as-
sume the roles necessary for providing care.
When an individual is learning how to be a parent
or a caregiver, role training may be required.
Knowledge may be acquired by peer observation,
trial and error, or explicit instruction. Parents
may have limited opportunities to observe peers,
and other family members may not have the
knowledge necessary to help. Thus, the family
may need to seek external resources or obtain
needed information using other means such as
child care classes, self-help groups, or instruction
from health professionals. When individuals are
unable to figure out their roles in a situation, it
limits their problem-solving abilities.
Family members may lack role consensus, or be
unable to agree about the expectations attached to
a role. One family role that is often the source
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of family disagreement is the housekeeping role,
especially for dual-career couples. Men who have
been socialized into more traditional male roles
are less inclined to accept responsibility for house-
hold tasks readily and may limit the amount of
time they are willing to spend on these activities.
When active participation does not meet the
wife’s expectations, she tends to assume responsi-
bility for the greater number of household tasks.
If she has been socialized into thinking that
women are accountable for traditional housekeep-
ing roles, she may feel guilty or neglectful if she
asks for help. Lack of agreement about the role
sometimes results in familial discord and impedes
satisfaction with the partner. Negotiation is likely
the most effective way to reach consensus about
things that can be done.
Role conflict occurs when expectations about
familial roles are incompatible. For example, the
therapeutic role might involve becoming a care-
giver to an elderly parent, but expectations of this
new role may be incompatible with that of
provider, housekeeper, sexual partner, and child
care provider. Does one go to the child’s baseball
game or to the doctor with the elderly parent?
Role conflict may occur when roles present con-
flicting demands. Individuals and families often
have to set priorities. Demands of caregiver and
provider roles may be conflicting and may conflict
with other therapeutic familial tasks. The care-
giver may withdraw from activities that, in the
short term, seem superfluous, but in the long term
are sources of much-needed energy. Family
nurses are likely to encounter members facing
many strains because of role conflict, and may
need to assist by providing information and sug-
gesting ways the family could negotiate roles to
discover meaningful solutions.
A source of role strain closely related to role
conflict is role overload. In role overload, the in-
dividual lacks resources, time, and energy to meet
role demands. As with role conflict, the first option
usually considered is to withdraw from one of
the roles. Maintaining a balance between energy-
enhancing and energy-depleting roles reduces role
strain. An alternative to withdrawing from a role
might be to seek time away from some role re-
sponsibilities. For example, a friend of the family
member could relieve the primary caregiver for
several hours. Nurses could arrange for a home-
health aide to assist with personal care hygiene.
The dependent family member can be temporarily
cared for in a residential facility while the other
family members go on a vacation, which is called
respite care.
It is the role of the nurse to help families who
experience role strain, conflict, and overload. Using
anticipatory guidance, nurses work closely with
families to discuss and define the family flow of en-
ergy and resources when confronted with a family
caregiving situation. See Chapter 4 for ways to
work with families who experience stress related to
caregiving and caregiving roles.
Family Communication
Communication is an ongoing, complex, chang-
ing activity and is the means through which
people create, share, and regulate meaning in a
transactional process to make sense of their world
(Dance, 1967). In all families, communication
is continuous in that it defines their present reality
and constructs family relationships (Dance, 1967).
It is through communication that families find
ways to adapt to changes as they seek family sta-
bility. Families that are highly adaptive change
more easily in response to demands. Families with
low adaptability have a fixed or more rigid style of
interacting (Olson & Gorall, 2005). “Family
adaptability is manifested in how assertive family
members are with each other, the amount of con-
trol in the family, family discipline practices,
negotiation, how rigid family roles are adhered to,
and the nature and enforcement of rules in the
family” (Segrin & Flora, 2011, p. 17).
Family communication affects family physical
and mental health. Most programs and interven-
tion strategies for improving family communica-
tion are beyond the role and experience of nurses
with undergraduate education. The role of the
nurse is to facilitate family communication at times
when families are stressed by changes that occur
with its members, such as birth of an infant, growth
and development issues of children, when family
members become ill, or the death of family mem-
bers. It is the role of the nurse to assist family com-
munication to achieve healthful outcomes.
Family Decision Making
Communication and power are family processes
that influence decision making. Family decision
making is not an individual effort but a joint one.
Most health care decisions should be made from a
Family Health Care Nursing: An Introduction 29
3921_Ch01_001-032 05/06/14 10:54 AM Page 29
family perspective. Each decision has at least five
features: the person raising the issue, what is being
said about the issue, supporting action to what is
being said, the importance of what is being said,
and the responses of the individuals (Friedman,
Bowden, & Jones, 2003).
Decision making provides opportunity for vari-
ous family members to make a contribution to the
process, support one another, and jointly set and
strive to achieve goals. Disagreements within a
family are natural, because members often have dif-
ferent points of view. It is important for members
to share their various viewpoints with one another.
Problem solving is part of the decision-making
process, and frequently means that differences in
opinion and emotions need consideration.
Family communication processes influence
decision-making outcomes. In the Pew Research
Center (2006) report on family communication,
46% of the 3,014 subjects indicated that they
turned to their families for help and advice when
they had problems. Keep in mind that in family
conflicts, the expression of anger is not necessarily
destructive, but contempt, belligerence, and defen-
siveness are counterproductive (Gottman, Coan,
Carrere, & Swanson, 1998). Nurses working with
families can facilitate family communication skills
to help families find an effective way for resolving
differences and making decisions.
Families want to be involved in varying degrees
with health care decisions. Families are often
asked to help make end-of-life decisions, not to
resuscitate a loved one or to withdraw/withhold
life-sustaining therapies. See Chapter 4 for infor-
mation on shared decision making.
Family Rituals and Routines
Family rituals and routines have been studied for
decades, beginning with Bossard and Boll (1950).
Rituals are associated with formal celebrations, tra-
ditions, and religious observances with symbolic
meaning, such as bar mitzvahs, weddings, funerals.
Routines are patterned behaviors or interactions
that closely link to daily or regular activities, such
as bedtime procedure, mealtimes, greetings, and
treatment of guests (Buchbinder, Longhofer, &
McCue, 2009). Families have unique rituals and
routines that provide organization and give mean-
ing to family life. When family rituals and routines
are disrupted by illness, the family system as a
whole is affected; therefore, it can affect the health
of each family member and the family as a whole
(Buchbinder et al., 2009). The importance and
value of rituals in everyday life has been clearly ex-
plored in anthropological and sociological litera-
ture, but the significance of rituals is largely
ignored by nurses (Denham, 2003b).
Assessing rituals and routines related to specific
health or illness needs provides a basis to envision
distinct family interventions and to devise specific
plans for health promotion and disease manage-
ment, especially when adherence to medical regi-
mens is critical or caregiving demands are
burdensome to the families (Fiese, 2007). For
example, when a family member develops type
2 diabetes, the whole family may adapt its cooking,
eating, and shopping habits to accommodate
the needs of this family member (Denham,
Manoogian, & Schuster, 2007). It enhances com-
pliance with chronic illness treatment when the
family incorporates illness regimens into the basic
family tasks and practices (Buchbinder et al., 2009).
SUMMARY
This chapter provides an introduction and broad
overview to family health care nursing. The follow-
ing major concepts were discussed in this chapter:
■ 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 settings.
■ 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 pro-
mote health and wellness, as well as prevent
30 Foundations in Family Health Care Nursing
3921_Ch01_001-032 05/06/14 10:54 AM Page 30
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.
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33
Family Demography
Continuity and Change in North
American Families
c h a p t e r 2
Lynne M. Casper, PhD
Sandra M. Florian, MA, PhD Candidate
Peter D. Brandon, PhD
C r i t i c a l C o n c e p t s
■ 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.
(continued)
3921_Ch02_033-066 05/06/14 10:55 AM Page 33
If there is one “mantra” about family life in the last
half century, it is that the family has undergone
tremendous change. No other institution elicits as
contentious debate as the North American family.
Many argue that the movement away from marriage
and traditional gender roles has seriously degraded
family life. Others view family life as amazingly
diverse, resilient, and adaptive to new circumstances
(Cherlin, 2009; Popenoe, 1993; Stacey, 1993).
Any assessment of the general “health” of family
life in North America, and the health and well-being
of family members, especially children, requires a
look at what is known about demographic and so-
cioeconomic trends that affect families. A pragmatic
approach to family nursing requires an understand-
ing of the broader changes in family within the pop-
ulation. The latter half of the 20th century was
characterized by tumultuous change in the econ-
omy, civil rights, and sexual freedom and by dra-
matic improvements in health and longevity.
Marriage and family life felt the reverberations of
these societal changes.
In the first decades of the 21st century, as North
Americans reassess where they have come from and
where they are going, one thing stands out—rhetoric
about the dramatically changing family may be a step
behind the reality. Recent trends suggest a quieting
of changes in the family in Canada, as well as the
United States, or at least of the pace of change. Little
change occurred in the proportions of two-parent or
single-parent families since the mid-1990s (U.S.
Census Bureau, 2011d). After a significant increase
in the proportion of children living with unmarried
parents, the living arrangements of children
stabilized, as did the living arrangements of young
adults and elderly persons. The divorce rate in-
creased substantially in the mid-1960s and 1970s,
reached its peak in 1980, slightly declined during the
1990s, and has remained relatively constant since
then. In the United States, between 43% and 46% of
marriages contracted today are expected to end in di-
vorce (Schoen & Canudas-Romo, 2006). The rapid
growth in cohabitation among unmarried adults has
also slowed. In Canada, divorce rates also increased
during the 1970s and 1980s, peaked slightly later in
1987, but have slightly declined since then. In 2008,
41% of marriages were expected to end in divorce
within the first 30 years (Statistics Canada, 2012b).
Yet, family life is still evolving. Young adults
have often postponed marriage and children to
complete higher education before attempting to
enter labor markets that have become inhospitable
to poorly educated workers. Accompanying this
delay in marriage was the continued increase in
births to unmarried women. By 2010, 41% of all
births in the United States were to unmarried
women (Martin et al., 2012).
Within marriage or marriage-like relationships,
the appropriate roles for each partner are shifting as
North American societies accept and value more
equal roles for men and women. The widening role
of fathers has become a major agent of change in the
family. More father-only families exist than in the
past, and after divorce, fathers are more likely to
share custody of children with the mother. Within
two-parent families, fathers are also more likely to be
involved in the children’s care than in the past
(Hernandez & Brandon, 2002). In addition, the
34 Foundations in Family Health Care Nursing
C r i t i c a l C o n c e p t s ( c o n t . )
■ 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.
3921_Ch02_033-066 05/06/14 10:55 AM Page 34
number of same-sex couples has been increasing,
and a larger proportion of them are now raising chil-
dren. Family roles in same-sex couples are more
likely to be negotiated than in opposite-sex families.
Whether the slowing, and in some cases, cessa-
tion, of change in family living arrangements is a
temporary lull or part of a new, more sustained
equilibrium will only be revealed in the next
decades of the 21st century. New norms may be
emerging about the desirability of marriage, the
optimal timing of children, and the involvement
of fathers in child rearing and mothers in bread-
winning. Understanding the evolution of North
American families and the implications these
changes have for family nursing requires taking the
pulse of contemporary family life.
This chapter examines changes and variations
in North American families in order to understand
what these changes portend for family health care
nursing during the first half of this century. This
chapter draws on information pertaining to fam-
ily demography from a variety of data sources
(Box 2-1). The reader should note that family
nursing is not the major focus of this chapter.
The subject matter of the chapter is structured to
provide family nurses with background on
changes in the North American family so that
they can understand their patient populations.
The chapter does briefly touch upon the impli-
cations of these demographic patterns for prac-
ticing family nursing.
Where possible, statistics have been reported for
both the United States and Canada, but compara-
ble data for Canada were not always readily acces-
sible for the topics covered in this chapter. Readers
should note that data are not always collected in the
Family Demography: Continuity and Change in North American Families 35
BOX 2-1
Sources of Information on Demography and Public Health
Many of the statistics discussed in this chapter draw
on information from the Current Population Surveys
(CPS) collected by the U.S. Census Bureau. This is a
continuous survey of about 60,000 households, se-
lected at random to be representative of the national
population. Each household is interviewed monthly for
two 4-month periods. During February through April of
each year, the CPS collects additional demographic and
economic data, including data on health insurance
coverage, from each household. This Annual Demo-
graphic Supplement is the most frequently used source
of data on demographic and economic trends in the
United States and is the data source for the majority
of statistics presented in this chapter regarding changes
in the family.
For estimates for small areas or subgroups of the pop-
ulation, demographers often used data from the “long
form” of the decennial census, which collected data from
one-sixth of all households. The census collects a range of
economic and demographic information, including in-
comes and occupations, housing, disability status, and
grandparent responsibility for children. The census cannot
match the detail found in more specialized surveys. For
example, only four short questions measure disability for
children; surveys designed for precise and complete
estimates of disabilities will usually have dozens of such
questions. Since 2004, the American Community Survey
replaced the sample data from the census and now
provides a more continuous flow of estimates for states,
cities, counties, and even towns and rural areas, for which
estimates were made only once a decade.
Moreover, several large health-related surveys are
conducted by the National Center for Health Statistics.
The National Health Interview Survey (NHIS) is a large,
continuous survey of about 43,000 households per year,
covering the civilian, noninstitutionalized population of
the United States. The NHIS is the major source of infor-
mation on health status and disability, health-related
behaviors, and health care utilization for all age groups.
The National Health and Nutrition Examination Survey
(NHANES) includes physical examinations, mental health
questionnaires, dietary data, analyses of urine and blood,
and immunization status from a random sample of
Americans (about 10,000 in each 2-year cycle). NHANES
also collects some basic demographic and income data. It
is the major source of information on trends in obesity,
cholesterol status, and a host of other conditions in the
national population, and in particular age groups and
racial/ethnic groups. The National Survey of Family
Growth (NSFG) is the primary source of information on
marriage and divorce trends, pregnancy, contraceptive
use, and fertility behaviors, and the ways in which they
vary among different groups and over time. Birth and
death certificates, sent by hospitals and funeral homes to
state offices of vital events registration, provide the raw
material for calculating fertility and mortality rates and life
expectancy. The data are collected from the states and
analyzed by the National Center for Health Statistics.
In Canada, the National Population Health Survey has
interviewed a panel of respondents every 2 years since
1994 to track changes in health-related behaviors, risk
factors, and health outcomes.
3921_Ch02_033-066 05/06/14 10:55 AM Page 35
same year and that some family indicators are
defined and measured differently across the two
countries.
A CHANGING ECONOMY
AND SOCIETY
Consider the life of a North American young
woman reaching adulthood in the 1950s or early
1960s. Such a woman was likely to marry straight
out of high school or to take a clerical or retail sales
job until she married. She would have moved out
of her parents’ home only after she married to form
a new household with her husband. This young
woman was likely to marry by about age 20 in the
United States (U.S. Census Bureau, 2008), age 22
in Canada, and begin a family soon thereafter. If
she were working when she became pregnant, she
would probably have quit her job and stayed home
to care for her children and husband while her hus-
band had a steady job that paid enough to support
the entire family. Thus, usually someone was at
home who had the time to care for the health needs
of family members, to schedule routine checkups
with doctors and dentists, and to take family mem-
bers to these appointments.
Fast-forward to the first decades of the 21st cen-
tury. A young woman reaching adulthood in the
first decades of the 21st century is not likely to
marry before her 26th birthday. She will probably
attend higher education and is likely to live by her-
self, with a boyfriend, or with roommates before
marrying. She may move in and out of her parents’
house several times before she gets married. Like
her counterpart reaching adulthood in the 1950s,
she is likely to marry and have at least one child,
but the sequence of those events may well be re-
versed. She probably will not drop out of the labor
force after she has children, although she may cur-
tail the number of hours she is employed. She is
much more likely to divorce, and possibly even to
remarry, compared with a young woman in the
1950s or 1960s. Because she is more likely to be a
single mother and to be working outside of the
home, she is also not as likely to have the time nec-
essary to devote to caring for the health of family
members.
A dramatic change in women’s participation in
the labor market occurred after 1970, as mothers
with young children began entering the labor force
in greater numbers. Historically, unmarried mothers
(either never married or formerly married) of
young children had higher labor force participation
rates than married mothers. These women often
were the only earners in their families. One notable
change has been the increase in the combination of
paid work and mothering among married mothers.
In 1960, for example, in the United States, only
19% of married mothers with children younger
than age 6 were in the labor force. By 2011, the
proportion increased to 62% (U.S. Census Bureau,
2011e). In Canada, 28% of women with children
under the age of 3 were employed in 1976 com-
pared with 64% in 2009. Among mothers with
children under the age of 16 living at home, the
proportion is even higher at 73% (Statistics
Canada, 2010). Another truly remarkable change
has been the increase in the labor force participa-
tion of single mothers from 44% to 77% between
1980 and 2011 (U.S. Census Bureau, 2011j).
In Canada, the proportion of single mothers who
were employed in 1976 was 28% and increased
to 69% in 2009 (Statistics Canada, 2010). What
does this trend imply for family nursing? The
majority of North American families with young
children in the mid-20th century had mothers who
were home full-time to care for the health needs of
family members, whereas at the beginning of the
21st century such families were in the minority.
Changes in the Economy
Economic conditions have an influence on young
people’s decisions about when to enter the labor
force, when to marry, and when to have children
(and how many children to have). After World War
II, the United States and Canada enjoyed an eco-
nomic boom characterized by rapid economic
growth, full employment, rising productivity,
higher wages, low inflation, and increasing earn-
ings. A man with a high-school education in the
1950s and 1960s could secure a job that paid
enough to allow him to purchase a house, support
a family on one income, and join the swelling ranks
of the middle class.
The economic realities of the 1970s and 1980s
were quite different. The two decades after the
oil crisis, which began in 1973, were decades of
economic change and uncertainty marked by a
shift away from manufacturing and toward serv-
ices, stagnating or declining wages (especially for
36 Foundations in Family Health Care Nursing
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Family Demography: Continuity and Change in North American Families 37
less-educated workers), high inflation, and a
slowdown in productivity growth. The 1990s
were just as remarkable for the turnaround: sus-
tained prosperity, low unemployment, and eco-
nomic growth that seems to have reached many
in the poorest segments of society (Farley, 1996;
Levy, 1998). The Great Recession, which began
in 2008, reversed this trend, and many men and
women joined the ranks of the unemployed.
When the economy is on such a roller coaster,
family life often takes a similar ride. Marriage oc-
curred early and was nearly universal in the decades
after World War II; mothers remained in the home
to rear children as the baby-boom generation was
born and nurtured. When baby boomers hit work-
ing age in the 1970s, the economy was not as hos-
pitable as it had been for their parents. They
postponed marriage, delayed having children, and
found it difficult to establish themselves in the
labor market.
Many of the baby boomers’ own children began
reaching working age in the 1990s and 2000s, when
individuals’ economic fortunes were increasingly
dependent on their educational attainment. Those
who attended higher education were much more
likely to become self-sufficient and to live inde-
pendently from their parents (Rosenfeld, 2007).
High-school graduates who did not go to higher
education discovered that jobs with high pay and
benefits were in relatively short supply. In the
United States, a high-school graduate in full-time
work earned about 25% (allowing for inflation) less
than a comparable new worker would have earned
20 years earlier (Farley, 1996). The increasing rel-
ative benefits of further education encouraged
more young men and women to delay marriage and
attend higher education.
Partly because of these changes in the econ-
omy, both men and women are remaining single
longer and are more likely to leave home to pur-
sue higher education, to live with a partner, and
to launch a career before taking on the responsi-
bility of a family of their own. The traditional
gender-based organization of home life (in which
mothers have primary responsibility for care of
the home and children and fathers provide finan-
cial support) has not disappeared, but young
women today can expect to be employed while
raising children, and young men are more likely
to share in some child-rearing and household
tasks. Thus, in the first decades of this century,
men are more likely to play a role in looking after
the health of family members than they were in
previous decades.
Before World War II, most men worked nearly
to the end of their lives. Retirement was a privi-
lege for the wealthy or the fortunate workers
whose companies provided pensions. Currently,
with increases in life expectancy and healthier
lives, the passage of the Social Security Acts in
1936 and 1938 in the United States, and the in-
stitution of provincial (in the 1920s) and federal
(since 1952) pensions in Canada, most workers
can look forward to at least a modest guaranteed
income for themselves and their spouses and
minor children. Social Security benefits constitute
more than half of the household income for two-
thirds of Americans older than 65. The increased
availability of public pensions made possible a
growing period of retirement for most workers, a
steady decrease in poverty rates for older people,
and an increase in the proportion of older people
maintaining their own households separately from
their adult children.
Changing Family Norms
In 1950, in North America, there was one domi-
nant and socially acceptable way for adults to live
their lives. Those who deviated could expect to be
censured and stigmatized. The “ideal” family was
composed of a homemaker-wife, a breadwinner-
father, and two or more children. Americans shared
a common image of what a family should look like
and how mothers, fathers, and children should be-
have. These shared values reinforced the impor-
tance of the family and the institution of marriage
(McLanahan & Casper, 1995). This vision of fam-
ily life showed amazing staying power, even as its
economic underpinnings were eroding. For this
1950s-style family to exist, North Americans had
to support distinct gender roles, and the economy
had to be vibrant enough for an average man to
support a family financially on his own.
Government policies and business practices per-
petuated this family type by reserving the best jobs
for men and discriminating against working
women when they married or had a baby. Begin-
ning in the 1960s, though, women and people from
minority backgrounds gained legal protections in
the workplace and discriminatory practices began
to recede.
3921_Ch02_033-066 05/06/14 10:55 AM Page 37
A transformation in attitudes toward family be-
haviors also took place. People became more ac-
cepting of divorce, cohabitation, and sex outside
marriage; less sure about the universality and per-
manence of marriage; and more tolerant of blurred
gender roles and of mothers working outside the
home (Bianchi, Raley, & Casper, 2012; Cherlin,
2009). Society became more open-minded about a
variety of living arrangements, family configura-
tions, and lifestyles.
Although the transformation of many of these
attitudes occurred throughout the 20th century, the
pace of change accelerated in the 1960s and 1970s.
These years brought many political, social, and
medical upheavals affecting gender issues and views
of the family. The women’s liberation movement
included a highly publicized, although unsuccessful,
attempt to pass the Equal Rights Amendment
(ERA) to the Constitution of the United States.
New and effective methods of contraception were
introduced in the 1950s and 1960s. In 1973, the
U.S. Supreme Court ruled that state laws banning
abortion were unconstitutional. In Canada, abor-
tion was illegal until 1969 when the law was
changed to allow abortions for health reasons. Pop-
ular literature and music heralded the sexual revo-
lution and an era of “free love.” In all industrialized
countries, a new ideology was emerging during
these years that stressed personal freedom, self-
fulfillment, and individual choice in living arrange-
ments and family commitments (Bianchi et al.,
2012; Cherlin, 2009). People began to expect more
out of marriage and to leave marriages that failed to
fulfill their expectations. Certainly not all Americans
approved of all these changes in beliefs and behav-
iors. The general North American culture changed,
though, as divorce and single parenting became
more widespread realities.
An Aging Society
For Americans born in 1900, the average life
expectancy was less than 50 years. But the early
decades of the 20th century brought such tremen-
dous advances in the control of communicable
diseases of childhood that life expectancy at birth
increased to 70 years by 1960. Rapid declines
in mortality from heart disease—the leading cause
of death—significantly lengthened life expectancy
for those aged 65 or older after 1960 (Treas &
Torrecilha, 1995). By 2009, life expectancy at birth
was nearly 79 years for Americans (National Cen-
ter for Health Statistics, 2008) and 81 years for
Canadians (World Health Organization, 2011). An
American woman who reached age 60 in 2009
could expect to live an additional 25 years, on av-
erage, and a 60-year-old American man would live
another 22 years. For Canadians, life expectancy
at age 60 is even higher—26 years for women and
23 years for men. Women continue to outlive men
in North America, though the gender gap in recent
years has shrunk somewhat, primarily because
of the delayed effects of smoking trends (men have
always been more likely to smoke than women, but
they have reduced smoking much more than
women in recent decades). The gap in life ex-
pectancy between men and women means that
women tend to outlive their husbands and women
predominate in the older age groups. About 60%
of the population 75 years and older in the United
States and Canada are women (Statistics Canada,
2012d).
Partly because more North Americans are sur-
viving until older ages, and partly because of a
long-term decline in fertility rates, the propor-
tion of the population aged 65 or older has
grown. In 1900, only 1 of every 25 Americans was
aged 65 or older (nearly 3% of the total popula-
tion). By 2011, the proportion was more than
3 in 25 (13% of the total population). In 2011,
the first of some 78 million baby boomers
reached their 65th birthdays, and the rate of in-
crease of the population of elderly persons began
to accelerate. By 2030, it is expected that one in
five Americans will be aged 65 or older. The sce-
nario for Canada is similar, although Canada has
a slightly higher proportion of the population
aged 65 and older; in 2011, 14.8% of Canada’s
population was 65 years and older compared with
13.3% of U.S. residents (Statistics Canada,
2011a; U.S. Census Bureau, 2011d).
People do not suddenly become old on their
65th birthday, of course. Together with improve-
ments in life expectancy have come improvements
in the disability rates at older ages, so that North
Americans are not only living longer than in the
past but also enjoying more years of life without
chronic illness or disabilities. In the United States,
65 is still a convenient marker for “old age” in
health policy terms, because it is the age at which
most Americans become eligible for medical and
hospital insurance funded mainly by the federal
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government through Medicare. By 65, as well,
most workers (both men and women) have left full-
time work, though many continue to work part-
time, or for part of the year, often at different jobs
than those they pursued during most of their ca-
reers. Given the growing number of elderly per-
sons, the Canadian government will raise the
eligible age for Old Age Security (OAS) from 65 to
67 between 2023 and 2029 to ease pressures on the
OAS budget and to ensure the program’s sustain-
ability (Service Canada, 2012).
The aging of the population is often considered
a major cause of increasing demand for medical
services and of the growth in medical expenditures.
Population aging is, indeed, one factor, because
older people in every country consume more med-
ical care than younger adults. The major causes of
increased health expenditures in industrialized
countries, however, have been changes in medical
technology, including increased use of pharmaceu-
ticals, rather than the simple growth of the popu-
lation of elderly persons (Reinhardt, 2003).
Increased life expectancy translates into ex-
tended years spent in family relationships. A couple
who marry in their twenties could spend the next
50 years together, assuming they remain married.
Couples in the past were much more likely to ex-
perience the death of one spouse earlier in their
adult years. Longer lives (together with lower birth
rates) also mean that people spend a smaller por-
tion of their lives parenting young children. More
parents live long enough to be part of their grand-
children’s and even great-grandchildren’s lives
(Bengtson, 2001). Many adults are faced with the de-
mands of caring for extremely elderly parents about
the time they reach retirement age and begin to ex-
perience health limitations of older age themselves.
Immigration and Ethnic Diversity
In 1965, the U.S. Congress amended the Immigra-
tion and Naturalization Act to create a fundamental
change in the nation’s policy on immigration. Visas
for legal immigrants were no longer to be based on
quotas for each country of origin; instead, prefer-
ence would be given to immigrants joining family
members in the United States. The legislation also
removed limitations on immigration from Latin
America and Asia. The numbers of legal immi-
grants to the United States increased, to an average
of 900,000 persons per year in the 1990s and to
1.1 million in 2011. Immigration has likewise in-
creased in Canada from about 140,000 in 1980 to
249,000 in 2011. In 2011, 66% of legal immigrants
were admitted to the United States because family
members already living there petitioned the gov-
ernment to grant them entry (U.S. Department of
Homeland Security, 2012). For Canada, the corre-
sponding figure is 61% (Citizenship and Immigra-
tion Canada, 2011). Immigrant visas were also
granted for economic reasons, usually after em-
ployers petitioned the government for admission
of persons with special skills or for humanitarian
reasons, including asylum granted to refugees be-
cause of well-founded fear of persecution in their
home countries. In the United States and Canada,
immigration laws provide refugees with resettle-
ment assistance including temporary health care
services. The goal of these programs is to promote
and improve the health of refugees, as well as
to control the potential spread of any contagious
diseases brought into the country by these immi-
grants. The benefits of these health programs
are restricted to the prevention and treatment
of disease that poses a risk to the public health
and safety (Citizenship and Immigration Canada,
2012; U.S. Centers for Disease Control and
Prevention, 2010).
In addition to legal immigrants, an estimated
10.8 million illegal immigrants lived in the United
States in 2010, either because they entered without
detection or because they stayed longer than
allowed by a temporary visa (Hoefer, Rytina, &
Baker, 2011). In 2010, the U.S. Census Bureau es-
timated that there were 40 million U.S. residents
born outside the country, nearly 13% of the total
population (Grieco et al., 2012). Because immi-
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
for a larger share of young families. In 2010, for ex-
ample, 20% of all births in the United States were
to mothers born outside the country (U.S. Census
Bureau, 2010e). Illegal immigrants are ineligible
for any type of federal public benefits including
welfare, Social Security, and health services such as
Medicaid and Medicare (U.S. Department of
Health and Human Services, 2009).
Estimates based on 2007 U.S. American Com-
munity Survey data reveal that 55 million people
older than age 5 speak a language other than Eng-
lish at home, the most common being Spanish
Family Demography: Continuity and Change in North American Families 39
3921_Ch02_033-066 05/06/14 10:55 AM Page 39
(34.5 million) and Chinese (2.5 million). In the
United States, half of adults 18 to 40 years old who
speak Spanish at home reported that they could
not speak English well (Shin & Kominski, 2010).
Keep in mind, however, that the overwhelming
majority of those who do not speak English well
are recent immigrants. More than 96% of the
native-born who speak Spanish at home report
that they can speak English well (Saenz, 2004). In
Canada, although English and French are still
dominant, more than 200 languages are now spo-
ken in the country. In 2011, 6.6 million people,
representing nearly 20% of the Canadian popula-
tion, reported speaking a language other than
English or French at home. Of them, a third, or
2.1 million, reported speaking only a language
other than English or French at home, primarily
Asian languages. The 10 most common foreign
languages spoken in 2011 in Canada were Punjabi,
Chinese (not specified), Cantonese, Spanish,
Tagalog, Arabic, Mandarin, Italian, Urdu, and
German (Statistics Canada, 2012h).
The majority of foreign-born U.S. residents live
in states that are the traditional “gateways” to
immigrant populations: California, New York,
Florida, Texas, and Illinois. In recent decades,
however, significant increases have occurred in the
immigrant populations of most parts of the coun-
try, including the rural South and the Upper Mid-
west, which had seen few immigrants for most of
the 20th century (Singer, 2004).
Implications for Health Care Providers
The aging and the growing diversity of the American
and Canadian populations, combined with shifts
in the economy and changing norms, values,
and laws, have altered the context for the nursing
care of families. As the population ages, the
demand will increase for nurses who specialize in
caring for elderly persons, and even those who do
not choose a geriatric specialty will find that older
people constitute an increasing portion of the
patient population. Improvements in health and
physical functioning among those aged 60 to 70
reduce the need for care among this group. Yet
rates of population growth are greatest for those
aged 80 and older, implying an increased demand
for care among the “oldest old” who are likely to
suffer from poorer health and require substantial
care. Because women continue to outlive men, on
average, nurses are more likely to be dealing with
the health care needs of older women than of men.
Extended lives and delayed childbearing have in-
creased the chances that adults will experience the
double whammy of having to provide care and
financial support for their children and their par-
ents. Families in these situations can face consider-
able time and money pressures.
At the same time that changing gender roles
point to more men in families taking on caregiving
duties, more women are in the labor force and un-
available to care for family members, and it is
doubtful that the increase in men’s time in caregiv-
ing will fully compensate for the decrease in
women’s time. Individuals and families are increas-
ingly turning to extended kin and informal care
providers to meet their health needs. Societal
changes also influence individuals’ life-course
trajectories. All these changes in individual lives
and family relationships are transforming North
American households and families and, in turn,
changing the context in which health needs are de-
fined and both formal and informal health care are
provided. Nurses are more likely to encounter
fathers seeking health care for their children, and
individuals whose health needs are met by informal
extended kin or untrained caretakers, especially
among the fragile and older populations.
The growth of the immigrant population, and
its spread throughout both the United States and
Canada, has meant that patient populations in
many regions are more racially and ethnically
diverse than in the past. Working with a diverse
pool of immigrant and refugee populations, health
care providers may encounter health conditions
and diseases unusual in North America. Nurses in
North America work with families whose cultural
backgrounds, perceptions of sickness, and expecta-
tions of healers may be different from those
with which they are familiar. Everyone providing
health care can expect to face both the challenges
and the professional rewards of adapting to a
diverse patient population.
LIVING ARRANGEMENTS
The demographic changes for individuals dis-
cussed earlier in this chapter are reflected
in changes in living arrangements, which have
become more diverse over time. For most statistical
40 Foundations in Family Health Care Nursing
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purposes, a family is defined as two or more peo-
ple living together who are related by blood, mar-
riage, or adoption (Casper & Bianchi, 2002).
Most households (defined by the U.S. Census
Bureau as one or more people who occupy a
house, apartment, or other residential unit, as op-
posed to “group quarters” such as nursing homes
or student dormitories) are maintained by fami-
lies. Demographic trends, including late mar-
riage, divorce, and single parenting, have resulted
in a decrease in the “family share” of U.S. and
Canadian households. In 1960, in the United
States, 85% of households were family house-
holds; by 2012, just 66% were family households
(U.S. Census Bureau, 2012). Married-couple
family households with children under 18 consti-
tuted 44% of all households in 1960, but only
20% of all households in 2012 (authors’ calcula-
tions from U.S. Census Bureau, 2012). Nonfam-
ily households, which consist primarily of people
who live alone or who share a residence with
roommates or with a partner, have been on the
rise. The fastest growth was among persons living
alone, although much of this growth occurred
during the 1960s and 1970s. The proportion of
households with just one person more than dou-
bled from 13% to 27% between 1960 and 2012
(authors’ calculations from U.S. Census Bureau,
2012). Thus, fewer Americans live with family
members who can help care for them when they
are ill or injured.
In Canada, in 1981, two-thirds of households
were single-family households maintained by
married or cohabitating couples, but by 2011 the
percentage declined to 56% (Statistics Canada,
2011c). As in the United States, the percentage
of households that contained two parents with
children declined from 36% in 1981 to 26% in
2011. The proportion of Canadian households
that contained one person grew from 20% in
1981 to 28% in 2011. Single-person households
were the fastest growing type of household
(Casper & Bianchi, 2002). With the diversity of
family forms that have emerged, nurses are in-
creasingly likely to encounter patients who are
living alone and have no one to help them in the
home should they become seriously ill. Nurses
will come into contact with more single-mother
families who are more likely than other types of
families to be time poor and cash strapped. In
fact, most families with children today do not
conform to the traditional notion of a breadwinner/
homemaker family.
Living Arrangements of Elderly Persons
Improvements in the health and financial status of
older Americans helped generate a revolution in
lifestyles and living arrangements among elderly
persons. Older North Americans now are more
likely to spend their later years with their spouse or
live alone, rather than with adult children as in the
past. The options and choices differ between eld-
erly women and elderly men, however, in large part
because women live longer than men, yet have
fewer financial resources.
At the beginning of the 20th century, more than
70% of Americans aged 65 or older resided with kin
(Ruggles, 1994). In part because of increased
incomes of elderly persons but also because of
declining numbers of children and increased di-
vorce rates, the proportion of elderly adults living
alone has increased dramatically. Just 15% of wid-
ows aged 65 or older lived alone in 1900, whereas
66% lived alone in 2011 (Ruggles, 1996; U.S. Census
Bureau, 2011b). In 2011, 44% of the population
aged 65 and older lived alone (U.S. Census Bureau,
2011l).
A woman is likely to spend more years living
alone after a spouse dies than will a man because
life expectancy is about 3 years longer for an elderly
woman than for an elderly man, and because
women usually marry men older than themselves.
As a result, older American women are nearly twice
as likely as men to be living alone (37% vs. 19%)
(U.S. Census Bureau, 2011b). This pattern is sim-
ilar in Canada; for example, in 2011 among Cana-
dians aged 65 and older, 32% of women lived alone
compared with only 16% of men (Statistics
Canada, 2011b). Just under half of all American
women aged 75 and older live by themselves (U.S.
Census Bureau, 2011b). Living alone can mean de-
lays in getting attention for illness or injury and can
complicate arrangements for informal care or
transportation to formal care when needed.
Elderly American women are also more than
twice as likely as men to be living with someone
other than their spouse (19% vs. 9%), in part be-
cause they tend to live longer and reach advanced
ages when they are most likely to need the physical
care and the financial help others can provide
(authors’ calculations from U.S. Census Bureau,
Family Demography: Continuity and Change in North American Families 41
3921_Ch02_033-066 05/06/14 10:55 AM Page 41
2012). In the United States, 43% of adults over 65
will reside in assisted living facilities at some point
in their lives. In Canada, a larger proportion of
women (33%) than men (22%) aged 85 and older
lived in institutional settings in 2011 (Statistics
Canada, 2011b). Elderly men who need help with
activities of daily living (ADLs) such as eating,
bathing, or getting around generally receive infor-
mal care from their wives, whereas elderly women
with disabilities are more likely to rely on assistance
from grown children, to live with other family
members, or to enter a nursing home (Silverstein,
Gans, & Yang, 2006).
To explain trends in living arrangements among
elderly persons, researchers have focused on a
variety of constraints and preferences that shape
people’s living arrangement decisions (Bianchi,
Hotz, McGarry, & Seltzer, 2008). The number and
sex of children generally affect the likelihood that
an elderly person will live with relatives. The
greater the number of children, the greater the
chances that there will be a son or daughter who
can take care of an elderly parent. Daughters are
more likely than sons to provide housing and care
for an elderly parent, presumably as an extension
of the traditional female caretaker role and stronger
norms of filial responsibility. Geographical distance
from children is also a key factor; having children
who live nearby promotes co-residence when living
independently is no longer feasible for the elderly
person (Haxton & Harknett, 2009; Silverstein
et al., 2006).
Older Americans with higher income and bet-
ter health are more likely to live independently
(Klinenberg, 2012). In the United States, since
1940, growth in Social Security benefits ac-
counted for half of the increase in independent
living among elderly persons (McGarry &
Schoeni, 2000). By contrast, elderly Americans in
financial need are more likely to live with rela-
tives (Klinenberg, 2012).
Social norms and personal preferences also
determine the choice of living arrangements for
elderly persons (Seltzer, Lau, & Bianchi, 2012;
Silverstein et al., 2006). Many elderly individuals
are willing to pay a substantial part of their in-
comes to maintain their own residence, which sug-
gests strong personal preferences for privacy and
independence (Klinenberg, 2012). Social norms
involving family obligations and ties may be espe-
cially important when examining racial and ethnic
differences in the living arrangements of elderly
persons. Immigrants and ethnic minorities are more
likely than whites to live with an elderly relative
not only because of their often limited economic
circumstances, but also because their cultural norms
and values stipulate moral obligations to care for
the elderly (Cohen & Casper, 2002; Glick & Van
Hook, 2002).
Despite the trend toward independent living
among older Americans, many of them are not able
to live alone without assistance. Many families who
have older kin in frail health provide extraordinary
care. One study in New York City, for example,
found that 40% of those who reported caring for
an elderly relative devoted 20 or more hours per
week to such informal care, and 80% of caregivers
had been providing care for more than a year
(Navaie-Walsier et al., 2001).
Despite the growth of home-health services and
adult day-care centers, most long-term care con-
sists of care provided informally, usually by spouses
or younger relatives (Stone, 2000). Adult women,
in particular, are likely to have primary responsi-
bility for home care of frail elderly persons, often
including parents-in-law. Some evidence suggests
that female caregivers experience greater levels of
stress than do male caregivers (Yee & Schulz,
2000). Research has shown that even relatively low-
cost interventions, such as support groups and tele-
phone counseling, to assist informal caregivers can
greatly reduce the harmful effects of such stress on
caregivers’ health (Belle & REACH II Investiga-
tors, 2006).
Living Arrangements of Young Adults
The young-adult years (ages 18–30) have been
described as “demographically dense” because
these years involve many interrelated life-altering
transitions (Rindfuss, 1991). Between these ages,
young people usually finish their formal schooling,
leave home, develop careers, marry, and begin
families, but these events do not always occur in
this order. Delayed marriage extends the period
during which young adults can experiment with
alternative living arrangements before they adopt
family roles. Young adults may experience any
number of independent living arrangements
before they marry, as they change jobs, pursue
education, and move into and out of intimate re-
lationships. They may also return to their parents’
42 Foundations in Family Health Care Nursing
3921_Ch02_033-066 05/06/14 10:55 AM Page 42
homes for periods of time, if money becomes tight
or at the end of a relationship.
In 1890, half of American women had married
by age 22, and half of American men had married
by age 26. The ages of entry into marriage dipped
to an all-time low during the post–World War II
baby-boom years, when the median age at first
marriage reached 20 years for women and 23 years
for men in 1956. Age at first marriage then began
to increase and reached 26 years for women and
28 years for men by 2009 (Kreider & Ellis, 2011b).
In Canada, the average age at marriage increased
from 25 years in 1972 to 31 years in 2008 for men
and from 23 years to 29 years for women (Statistics
Canada, 2008). In 1960, it was unusual for a woman
to reach age 25 without marrying; only 10% of
women aged 25 to 29 had never married (Casper
& Bianchi, 2002). In 2011, 50% of women aged
25 to 29 in the United States and 64% of men in
the same age group had never been married (U.S.
Census Bureau, 2011h).
This delay in marriage has shifted the family and
living arrangement behaviors in young adulthood
in three important ways. First, later marriage coin-
cides with a greater diversity and fluidity in living
arrangements in young adulthood. Second, delay-
ing marriage has accompanied an increased likeli-
hood of entering a cohabitating union before
marriage. Third, the trend to later marriage affects
childbearing; it tends to delay entry into parent-
hood and, at the same time, increases the chances
that a birth (sometimes planned but more often un-
intended) occurs before marriage (Bianchi &
Casper, 2000).
Many demographic, social, and economic fac-
tors influence young adults’ decisions about where
and with whom to live (Casper & Bianchi, 2002).
Family and work transitions are influenced greatly
by fluctuations in the economy, as well as by chang-
ing ideas about appropriate family life and roles for
men and women. Since the 1980s, the transition to
adulthood has been hampered by recurring reces-
sions, tight job markets, slow wage growth, and
soaring housing costs, in addition to the confusion
over roles and behavior sparked by the gender rev-
olution. Even though young adults today may pre-
fer to live independently, they may not be able to
afford to do so (Rosenfeld, 2007). Many entry-level
jobs today offer low wages, yet housing costs have
soared, putting independent living out of reach for
many young adults. Higher education, increasingly
necessary in today’s labor market, is expensive, and
living at home may be a way for families to curb
higher education expenses. Even when young
adults attend school away from home, they still fre-
quently depend on their parents for financial help
and may return home after graduation if they can-
not find a suitable job.
The percentage of young men living in their
parents’ homes was 59% in 2011, about the same
as in 1970, whereas the percentage increased for
young women from 39% to 50% (U.S. Census
Bureau, 2011i). In Canada, the proportion of
young adults who resided with their parents in-
creased dramatically from 28% in 1981 to 44% in
2006 (Statistics Canada, 2007).
Young adults who leave home to attend school,
join the military, or take a job have always had, and
continue to have, high rates of “returning to the
nest” and have become known as “boomerang chil-
dren.” Those who leave home to get married have
had the lowest likelihood of returning home,
although returns to the nest have increased over
time even in this group.
American parents often take in their children
after they return from the military or school, or
when they are between jobs. In the past, however,
many American parents apparently were reluctant
to take children in if they had left home simply to
gain “independence.” This is not true today. Before
the 1970s, leaving home for simple independence
was probably the result of friction within the fam-
ily, whereas today, leaving and returning home
seems to be a common part of a successful transi-
tion to adulthood (Klinenberg, 2012; Rosenfeld,
2007). In the past, a young adult may have been
reluctant to move back in with parents because a
return home implied failure; fewer stigmas are
attached to returning home these days (Casper &
Bianchi, 2002).
Changing demographic behaviors among young
adults and their living arrangements have implica-
tions for family health care nursing. In contrast to
the situation in Canada, in the United States,
young adults often lack health insurance and, in
many cases, are not financially independent, reduc-
ing the likelihood that they will receive routine
checkups or seek medical care when the need arises
(Casper & Haaga, 2005). The increasing numbers
of people showing up in emergency rooms and
urgent care settings put additional pressure on the
health care providers, especially nurses. Also, the
Family Demography: Continuity and Change in North American Families 43
3921_Ch02_033-066 05/06/14 10:55 AM Page 43
acuity level of the medical problems in these young
adults is greater because they did not seek earlier
treatment.
Unmarried Opposite-Sex Couples
One of the most significant household changes
in the second half of the 20th century in North
America was the increase in men and women living
together without marrying. The increase of cohab-
itation outside marriage appeared to counterbalance
some of the delay of marriage among young adults
and the overall increase in divorce. Unmarried-
couple households made up less than 1% of U.S.
households in 1960 and 1970 (Casper & Cohen,
2000). This share increased just over 2% by 1980,
and to nearly 9% by 2011, representing 7.6 million
family groups (U.S. Census Bureau, 2011m).
Unmarried-couple households also are increas-
ingly likely to include children. In 1978, 24% of
unmarried-couple households included children
younger than 15; by 2011, 40% of unmarried-
partner family groups included children. Although
the percentage of U.S. households consisting of an
unmarried couple is small, many Americans have
lived with a partner outside marriage at some point.
Nearly 62% of the couples who married between
1997 and 2002 had lived together before marriage,
up from 49% in 1985 to 1986, and a big jump from
just 8% of first marriages in the late 1960s (Bumpass
& Lu, 2000; Kennedy & Bumpass, 2008).
In Canada, cohabitating couples are known as
common-law couples. The 2001 Canadian Census
showed that increasing proportions of families were
headed by common-law couples, from 5.6% in 1981
to 13.8% in 2001. By 2011 this figure increased to
17% (Statistics Canada, 2012e). As in the United
States, more Canadian children are living with
common-law (cohabitating) parents. Nearly 44% of
common-law couples in 2011 have children under
age 24 residing with them. In 2011, about 910,700
children aged 0 to 14 (16.3% of the total) lived
with common-law parents, up from 12.8% in 2001
(Statistics Canada, 2012e). In both countries, the
pace of the increase in cohabitation has slowed some-
what since the rapid rise in the 1970s and 1980s.
Why has cohabitation increased so much? Re-
searchers have offered several explanations, includ-
ing increased uncertainty about the stability of
marriage, the erosion of the stigma associated with
cohabitation and sexual relations outside of
marriage, the wider availability of reliable birth
control, economic changes, and increased individ-
ualism and secularization (Bianchi et al., 2012;
Cherlin, 2009). Youths reaching adulthood in the
past two decades are much more likely to have wit-
nessed their parents’ divorce than any generation
before them. Some have argued that cohabitation
allows a couple to experience the benefits of an
intimate relationship without committing to mar-
riage. If a cohabitating relationship is not success-
ful, one can simply move out; if a marriage is not
successful, one suffers through a sometimes
lengthy and difficult divorce.
Nevertheless, most adults in the United States
eventually do marry. In 2011, 90% of women aged
50 to 54 had been married at least once (U.S. Census
Bureau, 2011h). An estimated 88% of U.S. women
born in the 1960s will eventually marry; however,
considerable differences exist by race/ethnicity
(Raley, 2000). For example, 88% of African
American women reaching adulthood in the 1960s
would eventually marry, compared with only 66%
coming of age in the 2000s. The meaning and per-
manence of marriage may be changing, however.
Marriage used to be the primary demographic
event that marked the formation of new house-
holds, the beginning of sexual relations, and the
birth of a child. Marriage also implied that an
individual had one sexual partner, and it theoreti-
cally identified the two individuals who would par-
ent any child born of the union. The increasing
social acceptance of cohabitation outside marriage
has meant that these linkages can no longer be
assumed. Couples began to set up households that
might include the couple’s children, as well as chil-
dren from previous marriages or other relation-
ships (Casper & Bianchi, 2002). Similarly, what it
meant to be single was no longer always clear, as
the personal lives of unmarried couples began to
resemble those of their married counterparts.
Cohabitating households can pose unique
challenges for health care providers, especially in
the United States. Because cohabitating relation-
ships are not legally sanctioned in most states,
partners may not have the right to make health
care decisions on behalf of each other or of the
other’s children (Casper & Haaga, 2005). Cohab-
itating couples report poorer health and have
lower incomes than do married couples, on aver-
age (Waite & Gallagher, 2000). Thus, although
they are more likely to need health care services,
they may be less likely to have the financial ability
to secure them.
44 Foundations in Family Health Care Nursing
3921_Ch02_033-066 05/06/14 10:55 AM Page 44
Same-Sex Couples
The number of same-sex couples has increased sub-
stantially in North America over the past couple of
decades. A conservative estimate shows that the num-
ber of same-sex couples in the United States grew by
80% from 358,390 in 2000 to 646,464 in 2010
(Lofquist, Lugaila, O’Connell, & Feliz, 2012). In
Canada, the number of same-sex couples increased
by 42.4% from 45,345 in 2006 to 64,575 in 2011, of
which nearly a third were married couples (Statistics
Canada, 2012e). The vast majority of same-sex cou-
ples live in common-law or cohabitating relation-
ships. Before 2000, same-sex marriage was not legally
recognized. In 2005, however, after the Netherlands
and Belgium, Canada became the third country to
legalize same-sex marriage. Following legalization,
the number of same-sex married couples in Canada
almost tripled from 7,465 in 2006 to 21,015 in 2011
(Statistics Canada, 2012e). In the United States, fed-
eral law provides each state with autonomy to grant
marriage recognition and legal rights to same-sex
couples. In 2004, Massachusetts became the first state
to legalize same-sex marriage; since then, a number
of states and jurisdictions have followed suit. Never-
theless, same-sex marriage is still not legally
recognized in most states.
Although the division of labor for parenting and
household chores in same-sex families tends to be
more egalitarian than among opposite-sex couples,
same-sex couples are not as “genderless” as has
been previously suggested. This equality often
changes as couples transition to parenthood, when
one of the partners usually becomes more involved
in child rearing, assumes more responsibility for
housework, and often becomes the partner in
charge of caring for the health of the children and
seeking health services for them.
PARENTING
Even with the increase in divorce and cohabita-
tion, postponement of marriage, and decline in
childbearing, most North American adults have
children, and most children live with two parents.
In 2011, 64% of families with children were two-
parent, married families and an additional 5%
were two-parent, unmarried families (U.S. Census
Bureau, 2011a). In Canada, in 2011, the level was
comparable: 62% of Canadian families with chil-
dren were married two-parent families, 14% were
two-parent common-law families, and 24% were
lone-parent (single-parent) families (authors’
calculations from Statistics Canada, 2011c). In
2011, 26% of American families were mother-
only families and only 4% were father-only fami-
lies. “Lone-parent families” in Canada increased
from 9% of all families (including those with
no children) in 1971 to about 16% in 2011, in-
cluding 13% lone mothers and 3% lone fathers.
The changes in marriage, cohabitation, and non-
marital childbearing over the past few decades
have had a profound effect on North American
families with children and are changing our
images of parenthood.
This section discusses individuals’ and couples’
transitions into parenthood, beginning with cur-
rent trends in fertility, the increased use of assisted
reproductive technologies (ARTs) to achieve par-
enthood, and trends and patterns in adoption. As
individuals become parents, different types of fam-
ily forms emerge. The section explores single
motherhood, fathering, and child rearing within
cohabitation and same-sex couple families. The
section concludes with a discussion of the impor-
tant role grandparents are playing in rearing and
caring for grandchildren.
Fertility
In the United States and Canada, fertility has ex-
hibited a trend of long-term decline for more than
a century, interrupted by the baby-boom period
and other small fluctuations. In recent decades, fer-
tility rates in most developed countries have fallen
below the level required to replace the population.
Replacement-level fertility refers to the required
number of children each woman in the population
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-
ity rates. This threshold is set slightly above 2 in
order to account for a negligible rate of childhood
mortality and a small proportion of individuals who
do not survive to their reproductive age (Preston,
Heuveline, & Guillot, 2001).
The U.S. fertility decline has not been very dras-
tic; thus, the United States is an atypical case
among developed countries. Figure 2-1 shows the
trends in fertility rates since the 1930s for the
United States and Canada, respectively. As this
graph shows, both countries experienced a post-
WWII baby boom during the 1950s and 1960s,
Family Demography: Continuity and Change in North American Families 45
3921_Ch02_033-066 05/06/14 10:55 AM Page 45
after which fertility began to decline again. Since
the 1980s, the United States has exhibited fertility
rates close to replacement level. In 2010, the total
U.S. fertility rate was 1.93 children per woman
(Martin et al., 2012). In Canada, however, the fer-
tility decline has been of greater magnitude; in
2010, the fertility rate was 1.63 (Statistics Canada,
2012a). Persistent levels of below replacement fer-
tility have raised concerns regarding population
shrinkage. Fewer births also imply a subsequent
contraction of the working-age population that,
coupled with increases in life expectancy, reduces
the tax base that supports health care and retire-
ment benefits for the aging population (Lee, 2003).
In the United States and Canada, a significant pro-
portion of population growth during recent
decades has come from immigration.
Fertility varies by demographic characteristics.
In the United States, except for Asians, immigrants
tend to exhibit higher fertility rates than the native-
born population. In 2010, native-born women had
on average 1.8 children, whereas foreign-born
women had 2.2 children (U.S. Census Bureau,
2010d). Fertility also varies by race and ethnicity.
In 2010 in the United States, fertility was the high-
est among Hispanic women (2.3), followed by
African Americans (2.0), and the lowest rate was
observed among white and Asian women (1.80)
(U.S. Census Bureau, 2010d). The differences are
greater by educational level. Women with less than
a high school education had on average 2.56 births,
whereas women with a graduate or professional de-
gree had only 1.67 births (U.S. Census Bureau,
2010d).
The causes behind the secular trends in fertility
decline can be grouped into socioeconomic, ideolog-
ical, and institutional factors. Among socioeconomic
factors are the increase in women’s opportunity
costs and the rising cost of rearing children. The
socioeconomic position of women has drastically
changed since the 1960s. Economic changes have
also made it more difficult to maintain a family on
the income of a single earner. Women’s education
and labor force participation increased considerably
during this period. In addition, changes in laws and
civil rights have reduced discriminatory practices
against women. All of these changes have resulted in
increases in women’s wages, although they have not
yet reached parity with men’s. As women’s incomes
and career opportunities have improved, women’s
opportunity costs of not participating in the labor
market have increased, thus reducing women’s fer-
tility intentions. At the same time, higher educational
expectations for children and rising living standards
have substantially increased the costs of raising chil-
dren (Lino, 2012).
Cultural and ideological changes, such as the
growth in individualism and the desire for self-
realization, have decreased the appeal of long-term
commitments, including childbearing (Bianchi
et al., 2012; Cherlin, 2009). The accentuation of
individual autonomy and the rise of feminism have
increased the desirability for more symmetrical
gender roles. However, institutions dealing with
family life still exhibit high levels of gender in-
equality. Equal opportunities for women in educa-
tion and employment are often curtailed within
families as women continue to pay a penalty for
having children in the form of reduced career in-
volvement and income prospects. This asymmetry
accentuates the incompatibility of childbearing and
labor force participation (McDonald, 2000).
In addition, in the 1960s more effective birth con-
trol methods became available, providing couples
with better means to control their fertility. More-
over, favorable attitudes toward nonmarital sex and
cohabitation have also weakened the link between
sex, marriage, and childbearing (Casper & Bianchi,
2002). Thus, most developed countries have experi-
enced a considerable rise in nonmarital births to sin-
gle and cohabitating mothers. In 2010, 41% of all
births in the United States were to unmarried
women, of which 58% were to cohabitating women
(Martin et al., 2012). In Canada, births to unmarried
women have also increased, representing 27.3% of
all births in 2007 (U.S. Census Bureau, 2012).
46 Foundations in Family Health Care Nursing
1930 1940 1950
Replacement
level
1960 1970
Total Fertility Rate for the U.S. and Canada:
1930–2010
1980 1990
U.S.
Canada
2000 2010
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
FIGURE 2-1 Total fertility rate for the United States
and Canada: 1930–2010. (Data from Martin et al., 2012;
Statistics Canada, 2011d.)
3921_Ch02_033-066 05/06/14 10:55 AM Page 46
Family Demography: Continuity and Change in North American Families 47
The birth rate for teenagers has decreased sub-
stantially in both countries, although in the United
States this rate is more than twice that observed in
Canada. In Canada in 2008, only 4% of all births
were to women ages 15 to 19, compared with 9%
in the United States in 2010. The birth rate for
teenagers in Canada was 14.3 births per 1,000
women in 2008, down from 26.1 in 1981 (Milan,
2011). The U.S. teenage birth rate for women ages
15 to 19 was 34.3 births per 1,000 women in 2010,
down from 52.2 in 1981 (Martin et al., 2012). The
United States still exhibits one of the highest rates
of teenage pregnancy in the industrialized world.
Nonetheless, women increasingly have been
delaying childbearing since the 1960s; thus, the av-
erage age at first birth has risen in both countries.
In 2010, the average age at first birth in the United
States was 25.4 (Martin et al., 2012). In 2008 in
Canada, the average age at first birth was 28.1, up
from 23.5 in the mid-1960s (Milan, 2011). How-
ever, the onset of fertility varies by race/ethnicity
in the United States. Whereas the average age at
first birth for African American and Hispanic
women was slightly above 23 years in 2010, for
white women it was 26.3. Asian and Pacific Is-
landers exhibited the highest average age at first
birth at 29.1 (Martin et al., 2012). Thus, childbear-
ing for middle-class whites and Asians is increas-
ingly becoming concentrated in the late twenties
and early thirties.
Overall, these trends imply not only that
women are having fewer children, but also that
they are increasingly having children at older
ages. Nurses are more likely to encounter more
educated and mature mothers and pregnant
women. However, as women wait longer to have
their first child, complications in pregnancies and
deliveries will become more common. Moreover,
age-related infertility will be more likely to affect
these women, increasing the rate of involuntary
infertility. As delays in fertility continue, a larger
pool of women approaching the end of their
reproductive years will seek the services of as-
sisted reproductive technology.
Assisted Reproductive
Technologies (ARTs)
Although various definitions have been used for
assisted reproductive technologies (ARTs), the cur-
rent definition used by the U.S. Centers for Dis-
ease Control and Prevention (CDC) is based on the
1992 Fertility Clinic Success Rate and Certification
Act. According to this definition, ARTs include
all fertility treatments in which both eggs and
sperm are handled. In general, ART procedures in-
volve surgically removing eggs from a woman’s
ovaries, combining them with sperm in the labora-
tory, and returning them to the woman’s body or
donating them to another woman. According to
this definition, treatments in which only sperm are
handled are not included (i.e., intrauterine—or
artificial—insemination), nor are procedures in
which a woman takes medications only to stimulate
egg production without the intention of having
eggs retrieved (U.S. Centers for Disease Control
and Prevention, 2012).
ARTs have been used in the United States since
1981 to help women become pregnant, most com-
monly through the transfer of fertilized human
eggs into a woman’s uterus (in vitro fertilization).
Deciding whether to undergo this expensive and
time-consuming treatment can be difficult. World-
wide, an estimated 9% of couples meet the defini-
tion of infertility, with 50% to 60% of them
seeking care (Boivin, Bunting, Collins, & Nygren,
2007). In the United States, approximately 7% of
married couples reported at least 12 months of un-
protected intercourse without conception, while
2% of women reported having visited an infertility-
related clinic within the past year (Chandra,
Martinez, Mosher, Abma, & Jones, 2005). In
Canada, the estimated percentage of couples expe-
riencing infertility in 2010 ranged from 11.5% to
15.7%, depending on the definition of infertility
used. Infertility treatment costs sum up to well over
three billion dollars annually in the United States
(Myers et al., 2008). As women wait longer to have
their first child, the likelihood of age-related infer-
tility increases. Although there is some controversy
about whether the proportion of the population
with self-reported infertility is increasing, stable, or
decreasing, there has been a clear increase in the
use of ARTs (Stephen & Chandra, 2006; Sunderam
et al., 2012).
The number of in vitro fertilization (IVF) cycles
performed in the United States increased from ap-
proximately 30,000 in 1996 (Myers et al., 2008) to
over 147,000 in 2010, resulting in 47,090 live births
(deliveries of one or more living infants) and 61,564
infants (U.S. Centers for Disease Control and Pre-
vention, 2012). Over this time, the proportion of
deliveries in the United States resulting from ARTs
has increased from 0.37% in 1996 to 0.94% in
3921_Ch02_033-066 05/06/14 10:55 AM Page 47
48 Foundations in Family Health Care Nursing
2005. In 2009, ARTs accounted for 1.4% of U.S.
births (Sunderam et al., 2012). In Canada 3,428 ba-
bies were born through ARTs in 2007 (Assisted
Human Reproduction Canada, 2011). ARTs often
result in multiple births, such as twins, triplets, and
so on, which increases health risks for children and
mothers. In the United States and Canada, nearly
30% of all ART births result in multiple births.
Due to high costs and increased health risks, the
Assisted Human Reproduction Canada (AHRC)
agency has set as a goal to reduce the rate of mul-
tiple births resulting from ARTs (AHRC, 2011).
A growing number of same-sex couples seeking
to become parents are also turning to ARTs to
achieve this goal: in the case of lesbians, usually
through the use of a sperm donor and artificial in-
semination; and in the case of gay men, through the
use of an egg donor and/or a surrogate. It is worth
noting that male same-sex couples face greater
challenges than female same-sex couples to become
parents, not only because fertility centers are less
likely to accept male gay patients, but also because
the procedure is more expensive as it involves ob-
taining both an oocyte donor and a gestational sur-
rogate, that is, a woman who will carry the zygote
and take the pregnancy to term (Greenfeld, 2007).
Although data on psychological outcomes of
women who become pregnant after infertility treat-
ment are quite limited, the available data suggest
that women have outcomes as good as, and perhaps
better than, women who get pregnant from spon-
taneous conception. Based on the available litera-
ture, there are no differences in parenting skills
when comparing singleton pregnancies resulting
from ART to spontaneous conceptions (Myers
et al., 2008). In fact, mothers of infants resulting
from ART appear to have better outcomes. By con-
trast, there is some evidence that fathers may do
worse on some scales. The multiple gestations and
preterm births that frequently result with ART
significantly increase stress and depressive symp-
toms, especially for mothers of infants with chronic
disabilities.
Births resulting from ART are more likely to in-
volve multiple births, pregnancy complications,
preterm delivery, and low birth weight, all of which
may pose substantial risks to the health of mothers
and infants. Additionally, children born as a result
of ART experience relatively worse neurodevelop-
mental outcomes, higher rates of hospitalization,
and more surgeries than other children. There is
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.
Adoption
Accurate trends on adoption in the United States
are difficult to obtain, but U.S. Census Bureau data
3921_Ch02_033-066 05/06/14 10:55 AM Page 48
indicate that the number of adopted children
increased in the 1990s from about 1.6 million in
1991 to 2.1 million in 2004 and then decreased to
1.4 million in 2009 (Kreider & Ellis, 2011a). Other
data show that in 2007 there were approximately
1.7 million adopted children living in the United
States (Vandivere, Malm, & Radel, 2009). Box 2-2
illustrates the three primary forms of adoption in
the United States: foster care adoption, private
domestic adoption, and international adoption.
According to the U.S. Administration for Chil-
dren and Families, the number of adoptions from
foster care has ranged from 50,000 to 57,000 an-
nually between 2002 and 2011, with some fluctua-
tions and no clear trend (U.S. Department of
Health and Human Services, 2011). In 2007,
661,000 children were adopted from foster care,
representing 37% of all adopted children. Of foster
care–adopted children, 23% were adopted by rela-
tives, 40% were adopted by someone who knew
them before the adoption (including relatives), and
69% were adopted by someone who was previously
their foster parent (Vandivere et al., 2009). Because
these children were removed from their homes due
to abuse or neglect, they are more likely than other
children, and even than those adopted through dif-
ferent means, to have special health care needs—in
2007 54% had special needs.
In 2007, about 677,000 or 38% of adopted chil-
dren were adopted privately from sources other
than foster care. Of these, 41% were adopted by
relatives and 44% were adopted by someone who
knew them before the adoption (including rela-
tives). Almost one-third of these children have spe-
cial health care needs. The majority of children
adopted privately in the United States were placed
with their adoptive family as newborns or when
they were younger than 1 month old (62%).
International adoptions increased from about
15,700 in 1999 to about 23,000 children in 2004.
Since 2004, they have been steadily decreasing to
9,300 in 2011 due to stricter laws and regulations
Family Demography: Continuity and Change in North American Families 49
BOX 2-2
Three Primary Forms of Adoption in the United States
Foster Care Adoption
Children adopted from foster care are those who were
removed from their families due to their families’ inability
or unwillingness to provide appropriate care and were
placed under the protection of the state by the child
protective services system. Public child welfare agencies
oversee such adoptions, although they sometimes
contract with private adoption agencies to perform
some adoption functions.
Private Domestic Adoption
These children were adopted privately from within the
United States and were not part of the foster care system
at any time before their adoption. Such adoptions may
be arranged independently or through private adoption
agencies.
International Adoption
This group includes children who originated from coun-
tries other than the United States. Typically, adoptive
parents work with private U.S. adoption agencies, which
coordinate with adoption agencies and other entities in
children’s countries of origin. Changes in international
adoption laws have made it more difficult to adopt
children from abroad. Starting in 2008, the Hague
Convention on Protection of Children and Co-operation
in Respect of Intercountry Adoption has been regulating
adoptions from several countries. Its purpose is to protect
children and to ensure that placements made are in the
best interests of children. For adoptions from countries
not part of the Hague Convention, U.S. law dictates that
children have to be orphans in order to immigrate into
the United States. The Hague Convention seems to have
contributed to the decrease in international adoptions.
For example, in 2007 24% of all international adoptions
of children under age 18 were from Guatemala, but in
March 2008, the U.S. Department of State announced
that it would not process Guatemalan adoptions until fur-
ther notice, due to concerns about the country’s ability to
adhere to the guidelines of the Hague Convention. Addi-
tionally, in 2008, Guatemala stopped accepting any new
adoption cases (U.S. Department of State, 2011).
Other countries have also implemented stricter regula-
tions for international adoptions. For example, as of May
2007, China enacted a rigorous policy requiring adoptive
parents be married couples between the ages of 30 and
50 with assets of at least $80,000 and in good health
(including not being overweight). In November 2012 a
bilateral adoption agreement between the United States
and Russia increased safeguards for and monitoring of
Russian children adopted by U.S. parents (U.S. Department
of State, 2011). In addition, China and other countries,
such as Russia and Korea, are attempting to promote
domestic rather than international adoption (Lee, 2007;
Voice of Russia World Service in English, 2007).
3921_Ch02_033-066 05/06/14 10:55 AM Page 49
(U.S. Department of State, 2011). Internationally
adopted children make up the smallest group, num-
bering about 444,000 or 25% of all adopted chil-
dren. Of these adopted children, 29% have special
health care needs. More than 7 in 10 adopted chil-
dren in 2011 came from just five countries—China
(28%), Ethiopia (19%), Russia (10%), South Korea
(8%), and the Ukraine (7%). In Canada, interna-
tional adoptions have also slightly decreased from
an average of 2,000 adoptions per year during the
1990s and early 2000s. In 2010, 1,946 children were
adopted from abroad. In the same year, nearly 6 in
10 international adoptions to Canada came from
China (24%), Haiti (9%), the United States (8%),
Vietnam (7%), Ethiopia (6%), and Russia (5%)
(Hilborn, 2011).
Since 2008, the Hague Convention on Protec-
tion of Children and Co-operation in Respect of
Intercountry Adoption has been regulating adop-
tions from approximately 75 countries. The stricter
law adopted by the Hague Convention has proba-
bly contributed to the decline in international
adoption (see Box 2-2). In the past several years,
many countries have changed their adoption re-
quirements, thus making it harder to adopt. All
of these legal changes have reduced the number of
international adoptions in the United States.
Social and demographic changes coupled with
changing laws have altered the context of adoption.
Recent developments in reproductive medicine,
such as intrauterine insemination and in vitro fer-
tilization, seem to have contributed to the decline
in adoption in recent years by reducing the demand
for adoption. At the same time, never-married
mothers have become less likely to put their infants
up for adoption—in 1973, 9% of births were placed
for adoption compared to just 1% in the 1990s and
2000s, reducing the supply of infants for domestic
adoptions (Jones, 2008).
According to a recent study conducted at the
U.S. Department of Health and Human Services,
overall, 87% of adopted children have parents who
said they would “definitely” make the same deci-
sion to adopt their child, knowing everything then
that they now know about their child. More than
90% of adopted children ages 5 and older have par-
ents who perceived their child’s adoption experi-
ence as “positive” or “mostly positive” (Vandivere
et al., 2009).
According to this study, overall, 40% of the
adopted children are in transracial adoptions; either
one or both adoptive parents are of a different race,
culture, or ethnicity than their child. The majority
of adopted children have non-Hispanic white par-
ents but are not themselves non-Hispanic white.
Transracial adoptions are most common for chil-
dren whose families adopted internationally. Over-
all, about half of adopted children are male
(49%)—33% of internationally adopted children
are male, while 57% of children adopted from fos-
ter care are male (Vandivere et al., 2009). Adopted
children are less likely than biological children in
the general population to live in households below
the poverty line (12% compared with 18%). How-
ever, nearly half of children adopted from foster
care (46%) live in households with incomes no
higher than two times the poverty threshold. Over
two-thirds of adopted children (69%) live with two
married parents; they are just as likely to do so
as children in the general population (Vandivere
et al., 2009).
The majority of adoptive children engage in en-
richment activities with their families, and in fact
they are more likely to have some of these positive
experiences than all children in the population
(Vandivere et al., 2009). As youngsters, adopted
children are more likely than all children to be read
to every day (68% compared with 48%), to be sung
to or told stories every day (73% compared with
59%), and to participate in extracurricular activities
as school-age children (85% compared with 81%).
A small percentage of adopted children have par-
ents who report parental aggravation (for example,
feeling the child was difficult to care for, or feeling
angry with the child). Parental aggravation is more
common among parents of adopted children than
among all parents (11% compared with 6%).
This socioeconomic and demographic portrait
of adopted children has implications for family
nursing. First, although most adoptive children
fare well with regard to health, educational
achievement, and social and cognitive develop-
ment, those who are adopted through foster care
are disproportionately disadvantaged. Second, be-
cause most parents of adopted children do not
share with them their genetic endowment and be-
cause the medical histories of the biological par-
ents are often unknown, diagnosis for these
children can be more challenging than for biolog-
ical children. Third, the substantial proportion of
transracial adoptive families requires special atten-
tion. For decades, adoptive parents who were of a
50 Foundations in Family Health Care Nursing
3921_Ch02_033-066 05/06/14 10:55 AM Page 50
different race than their child were taught to be
color blind regarding their adoptive children and
to raise them according to the culture of the par-
ent. More recently, adoption social workers have
encouraged adoptive parents to embrace the
child’s culture of origin and to help their children
develop positive racial and ethnic identities. As
most of these parents are white, however, they may
be unaware of the nuances of the culture the child
is coming from and may not have the capacity to
teach their children how to deal with bias and dis-
crimination (Shiao, Tuan, & Rienzi, 2004). Nurses
should be sensitive to these differences and help
guide the parents in understanding how to help
their children.
Finally, unlike biological families, many adoptive
families emerge out of loss for all members—for
example, foster parents who are not able to have bi-
ological children; biological parents who are relin-
quishing their children; and adoptive children who
are losing or have lost their biological parents. This
unique family form requires an adjustment period
for all of those involved. Separations of adoptive
children from biological parents at birth deprive
children of the bioregulatory channels that exist be-
tween a mother and her baby—from breathing, to
respiration, to heart rate and blood pressure. Tak-
ing away a baby at birth cuts off this regulation and
may cause children to cry more often, become
angry or confused, or behave badly simply because
they do not understand the separation (Verrier,
1993). Nurses should be aware that unusual behav-
iors such as these among adoptive children may not
stem from illness or health-related causes.
Single Mothers
How many single mothers are there? This turns
out to be a more difficult question to answer from
official statistics than it would first appear. Over
time, it is easiest to calculate the number of single
mothers who maintain their own residence. In the
United States between 1950 and 2011, the number
of such single-mother families increased from
1.3 million to 8.7 million (U.S. Census Bureau,
2011c). These estimates do not include single
mothers living in other persons’ households but do
include single mothers who are cohabitating with
a male partner. The most dramatic increase was
during the 1970s, when the number of single-
mother families was increasing at 8% per year. The
average annual rate of increase slowed considerably
during the 1980s and was near 0% after 1994 (Casper
& Bianchi, 2002). By 2011, single mothers who
maintained their own households accounted for 25%
of all families with children, up from 6% in 1950
(U.S. Census Bureau, 2011c). Almost 1.4 million
more single mothers lived in someone else’s house-
hold, bringing the total number of single mothers to
over 10 million (U.S. Census Bureau, 2011c). In
2011 in Canada, there were 1.2 million lone mothers
and 328,000 lone fathers with children of any age liv-
ing with them (Statistics Canada, 2012e).
Single mothers with children at home face a
multitude of challenges. They usually are the pri-
mary breadwinners, disciplinarians, playmates, and
caregivers for their children. They must manage
the financial and practical aspects of a household
and plan for the family’s future. Many mothers
cope remarkably well, and many benefit from
financial support and help from relatives and from
their children’s fathers.
Women earn less than men, on average, and be-
cause single mothers are usually younger and less
educated than other women, they are often at the
lower end of the income curve. Never-married sin-
gle mothers are particularly disadvantaged; they are
younger, less well educated, and less often em-
ployed than are divorced single mothers and mar-
ried mothers. Single mothers often must curtail
their work hours to care for the health and well-
being of their children.
Despite the fact that the majority of American
single mothers are not poor, they are much more
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
mother with two children translates into an annual
income of less than $18,123 in 2011. Overall, 20%
of U.S. children lived in poverty in 2009. Children
in two-parent families had the lowest rate at 13.3%,
followed by children living in father-only families
at 19.9%. Children in mother-only families had the
highest poverty rate at 38.1%. Poverty and family
structure are highly correlated with race in the
United States. Children in black and Hispanic
single-mother families exhibit the highest poverty
rate at about 45% compared with white children in
two-parent families, who have the lowest rate at
8.6% (Kreider & Ellis, 2011a).
The family income of children who reside with a
never-married single mother is less than one-fourth
Family Demography: Continuity and Change in North American Families 51
3921_Ch02_033-066 05/06/14 10:55 AM Page 51
that of children in two-parent families (Bianchi &
Casper, 2000). Almost three of every five children
who live with a never-married mother are poor.
Mothers who never married are much less likely to
get child support from the father than are mothers
who are divorced or separated. Whereas 43% of di-
vorced mothers with custody of children younger
than 21 received some child support from the chil-
dren’s father, fewer than 25% of never-married
mothers reported receiving regular support from
their child’s father (U.S. Census Bureau, 2010c).
Children who live with a divorced mother tend
to be much better off financially than are children
of never-married mothers. Divorced mothers are
substantially better educated and more often em-
ployed than are mothers who are separated or who
never married. Even so, the average incomes of
families headed by divorced mothers is less than
half that of two-parent families.
In 2010, three million Canadians lived in low
income and about 546,000 or 8.1% of children
younger than 18 lived in low-income families
(Statistics Canada, 2012c). Canadian lone-parent
families with children younger than 18 are much
more likely to have low incomes, and thus, more
likely to be poor (First Call: BC Child and Youth
Advocacy Coalition, 2011). Among children living
in female lone-parent families, 187,000, or 21.8%,
were low income, whereas the incidence of low
income was 5.7% among children living in two-
parent families (Statistics Canada, 2012c).
In the United States, single mothers with children
in poverty are particularly affected by major welfare
reform legislation, such as the Personal Responsibil-
ity and Work Opportunity Reconciliation Act
(PRWORA) (Box 2-3). President Clinton claimed in
his 1993 State of the Union Address that the 1996
law would “end welfare as we know it,” and the
changes embodied in PRWORA—time limits on
welfare eligibility and mandatory job-training re-
quirements, for example—seemed far-reaching
(Hays, 2003). Some argued that this legislation would
end crucial support for poor mothers and their chil-
dren; several high-level government officials resigned
because of the law. Others heralded PRWORA as
the first step toward helping poor women gain con-
trol of their lives and making fathers take responsi-
bility for their children. Many states had already
begun to experiment with similar reforms. The suc-
cess of this program is open to dispute because it has
been and continues to be such a political issue.
Why have mother-child families increased in
number and as a percentage of North American
families? Explanations tend to focus on one of two
trends. First is women’s increased financial inde-
pendence. More women entered the labor force and
women’s incomes increased relative to those of men,
and welfare benefits for single mothers expanded
during the 1960s and 1970s. Women today are less
dependent on a man’s income to support themselves
and their children, and many can afford to live in-
dependently rather than stay in an unsatisfactory
relationship. Second, the job market for men has
tightened, especially for less-educated men. As the
North American economy experienced a restructur-
ing in the 1970s and 1980s, the demand for profes-
sionals, managers, and other white-collar workers
expanded, whereas wages for men in lower-skilled
jobs declined in real terms (Casper & Bianchi, 2002).
Over the past two decades, this pattern has contin-
ued due to technological advances and outsourcing
displacing manufacturing and other lower-skilled
jobs (Bianchi et al., 2012). Men still earn more than
women, on average, but the earnings gap narrowed
steadily between the 1970s and 2000 as women’s
earnings increased and men’s earnings remained flat
or declined. In the past decade, the gender-earnings
gap has been relatively constant because both men’s
and women’s average earnings have stagnated.
In 2011 in the United States, full-time, year-round
female workers earned 77 cents for every dollar
earned by full-time, year-round male workers
(DeNavas-Walt, Proctor, & Smith, 2012).
In the early years of the 20th century, higher mor-
tality rates made it more common for children to live
with only one parent (Uhlenberg, 1996). As declining
death rates reduced the number of widowed single
parents, a counterbalancing increase in single-parent
families occurred because of divorce. For example, at
the time of the 1960 Census, almost one-third of
American single mothers living with children
younger than 18 were widows (Bianchi, 1995). As di-
vorce rates increased precipitously in the 1960s and
1970s, most single-parent families were created
through divorce or separation. Thus, at the end of
the 1970s, only 11% of American single mothers
were widowed and two-thirds were divorced or sep-
arated. In 1978, about one-fifth of single American
mothers had never married but had a child and were
raising that child on their own (Bianchi & Casper,
2000). By 2011, 46.5% of single mothers had never
married (U.S. Census Bureau, 2011k).
52 Foundations in Family Health Care Nursing
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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
low-income families have been transformed during the
past two decades. The 1996 PRWORA was the legislative
milestone at the federal level.
■ PRWORA replaced the Aid to Families With Dependent
Children program, an entitlement for poor families, with
a program of block grants to the states called Temporary
Assistance to Needy Families (TANF).
■ It requires states to impose work requirements on at
least 80% of TANF recipients.
■ It forbids payments to single mothers younger than 18
unless they live with an adult or in an adult-supervised
situation.
■ It set limits of 60 months on TANF for any individual
recipient (and 22 states have used their option to
impose shorter lifetime limits).
■ It gives states more latitude to let TANF recipients earn
money or get child support payments without reduction
of benefits and to use block grants for child care.
Welfare-reform proponents often supported efforts to
“make work pay,” as well as to discourage long-term de-
pendence on welfare. The Earned Income Tax Credit, for
example, was expanded several times during the 1980s
and 1990s and now provides twice as much money
to low-income families, whether single- or two-parent
families. Funding for child care was also expanded during
the decade, though child care remains a problem for
low-income working families in most places.
PRWORA accelerated a decline in welfare caseloads
throughout the country. Because of a concern that former
welfare recipients entering the workforce would lose in-
surance coverage through Medicaid for their children, the
1997 Balanced Budget Act set up the new State Child
Health Insurance Program (SCHIP), providing federal
money to states in proportion to their low-income
population and recent success in reducing the proportion
of uninsured children.
Lack of health insurance remains an important concern
for children in the United States, however. The Census
Bureau estimated that in 2011 about 1 of every 10 chil-
dren in the United States was not covered by any health
insurance (and one in five adults between ages 18 and
64 were uninsured) (DeNavas-Walt et al., 2012).
In 1996, Congress also made the following state-
ments: (1) Marriage is the foundation of a successful
society. (2) Marriage is an essential institution of a suc-
cessful society which promotes the interests of children.
To support healthy marriage, in conjunction with TANF,
the Deficit Reduction Act of 2005 was implemented pro-
viding $150 million per year of funding to support healthy
marriage and responsible fatherhood promotion. The goal
of the Healthy Marriage Initiative (HMI) is to help couples,
“who have chosen marriage for themselves, gain greater
access to marriage education services, on a voluntary
basis, where they can acquire the skills and knowledge
necessary to form and sustain a healthy marriage”
(U.S. Department of Health and Human Services, 2012).
Key requirements of the law specify that HMI funds
may be used for competitive research and demonstra-
tion projects to test promising approaches to encourage
healthy marriages and promote involved, committed,
and responsible fatherhood by public and private entities
and also for providing technical assistance to states and
tribes:
■ Applicants for funds must commit to consult with
experts in domestic violence; applications must describe
how programs will address issues of domestic violence
and ensure that participation is voluntary.
■ Healthy marriage promotion awards must be used for
eight specified activities, including marriage education,
marriage skills training, public advertising campaigns,
high school education on the value of marriage, and
marriage mentoring programs.
Not more than $50 million each year may be used
for activities promoting fatherhood, such as counseling,
mentoring, marriage education, enhancing relationship
skills, parenting, and activities to foster economic stability
(U.S. Department of Health and Human Services, 2012).
The remarkable increase in the number of single-
mother households with women who have never
married was driven by a dramatic shift to childbear-
ing outside marriage. The number of births to
unmarried women grew from less than 90,000
per year in 1940 to nearly 1.6 million per year in
2010 (Martin et al., 2012). Less than 4% of all
births in 1940 were to unmarried mothers com-
pared with 41% in 2010. The rate of nonmarital
births—the number of births per 1,000 unmarried
women—increased from 7.1 in 1940 to 47.6 in
2010. The nonmarital birth rate peaked in 1994 at
46.2, leveled out in the latter 1990s, and has in-
creased slightly since the mid-2000s (Bianchi &
Casper, 2000; Martin et al., 2012). Births to unmar-
ried women have increased in Canada as well, from
12.8% in 1980 to 27.3% of all births in 2007 (U.S.
Census Bureau, 2012).
3921_Ch02_033-066 05/06/14 10:55 AM Page 53
The proportion of births that occur outside mar-
riage is even higher in some European countries
than in the United States and Canada. But unmar-
ried parents in European countries and Canada are
more likely to be living together with their biolog-
ical children than are unmarried parents in the
United States (Heuveline, Timberlake, & Fursten-
berg, 2003). In the United States, the tremendous
variation in rates of unmarried childbearing among
population groups suggests that there may be a con-
stellation of factors that determine whether women
have children when they are not married. In 2010,
the percentage of births to unmarried mothers was
the highest for blacks at 73%, followed by Native
Americans (66%), Hispanics (53%), and white non-
Hispanics (29%). Asian and Pacific Islanders re-
ported the lowest percentage at 17% (Martin et al.,
2012, Tables 13 and 14). Overall, 25% of all family
groups with children under 18 are maintained by
single mothers. The percentage of mother-only
family groups is much higher for African American
families (52%) than for Hispanic (28%), white
non-Hispanic (19%), and Asian (12%) families
(U.S. Census Bureau, 2011m).
Single-mother families present challenges for
family health care nurses providing care to this vul-
nerable group. Single mothers today are younger and
less educated than they were a few decades ago. This
presents problems because these mothers have less
experience with the health care system and are likely
to have more difficulty reading directions, filling out
forms, communicating effectively with doctors and
nurses, and understanding their care instructions. In
the U.S., these mothers are also more likely to be
poor and uninsured, making it less likely they will
seek care and more likely they will not be able to pay
for it. Consequently, when the need arises, these
women are more likely to resort to emergency rooms
for noncritical illnesses and injuries. Time is also in
short supply for single mothers. With the advent of
welfare reform in the United States, more of them are
working, which conceivably reduces the time they
used in the past to care for themselves and their chil-
dren (see Box 2-3). Moreover, although many of these
mothers can rely on their families for help, they are
apt to have tenuous ties with their children’s fathers.
Fathering
A new view of fatherhood emerged out of the fem-
inist movement of the late 1960s and early 1970s.
The new ideal father was a co-parent who was
responsible for and involved in all aspects of his
children’s care. The ideal has been widely accepted
throughout North American society; people today,
as opposed to those in earlier times, believe that
fathers should be highly involved in caregiving
(Hernandez & Brandon, 2002). In the U.S. and
Canada, although mothers still spend nearly twice
as much time caring for children than fathers do,
fathers are spending more time with their children
and are doing more housework than in earlier
decades. In 1998, married fathers in the United
States reported spending an average of 4 hours per
day with their children, compared with 2.7 hours
in 1965 (Bianchi, 2000). In 2010, in Canada, fathers
spent on average 24.4 hours per week (3.5 hours
per day) taking care of children (Statistics Canada,
2012f). These estimates vary by employment status
of both parents and by the children’s age. Fathers
spend more time caring for children when mothers
are employed and when children are young.
At the same time, other trends increasingly re-
move fathers from their children’s lives. When the
mother and father are not married, for example, ties
between fathers and their children often falter. Fa-
thers’ involvement with children differs by marital
status and living arrangements. Among fathers re-
siding with their children, biological married
fathers spend more time with their children, fol-
lowed by fathers in cohabitating relationships. Step-
fathers exhibit the lowest level of involvement
among all resident fathers. Nonresidential fathers
exhibit the lowest involvement in child rearing.
They also provide less financial support to their
children (Hofferth, Pleck, Stueve, Bianchi, & Sayer,
2002). Family demographer Frank Furstenberg
(1998) used the label “good dads, bad dads” to de-
scribe the parallel trends of increased commitment
to children and child rearing on the part of some
fathers at the same time that there seems to be less
connection to and responsibility for children on the
part of other fathers.
Fathers’ involvement is associated with improved
child well-being, including better cognitive devel-
opment, fewer behavioral problems, and better emo-
tional health. However, fathers’ involvement and
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 &
McLanahan, 2010). As a result, union disruption not
only hurts children’s cognitive and emotional well-
being, but also reduces children’s contact with
54 Foundations in Family Health Care Nursing
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fathers, decreasing the parental and financial re-
sources available to children (Amato & Dorius,
2010). Nonetheless, when fathers re-partner and ac-
quire stepchildren, they usually assume new respon-
sibilities and provide for their stepchildren, a fact
that is often overlooked when assessing fathers’
involvement (Hernandez & Brandon, 2002).
How many years do men spend as parents? De-
mographer Rosalind King (1999) estimated the
number of years that American men and women will
spend as parents of biological children or stepchil-
dren younger than 18 if the parenting patterns of the
late 1980s and early 1990s continue throughout
their lives; her estimations have not been refuted to
date. Almost two-thirds of the adult years will be
“child-free” years in which the individual does not
have biological children younger than 18 or respon-
sibility for anyone else’s children. Men will spend,
on average, about 20% of their adulthood living with
and raising their biological children, whereas women
will spend more than 30% of their adult lives, on av-
erage, raising biological children. Whereas women,
regardless of race, spend nearly all of their parenting
years rearing their biological children, men are more
likely to live with stepchildren or a combination of
their own children and stepchildren. Among men in
the United States, white men will spend about twice
as much time living with their biological children as
African American men.
One of the new aspects of the American family
in the last 50 years has been an increase in the num-
ber of single fathers. Between 1950 and 2011, the
number of households with children that were
maintained by an unmarried father increased from
229,000 to 2.2 million (U.S. Census Bureau, 2011c).
During the 1980s and 1990s, the percentage of
single-father households nearly tripled for white
and Hispanic families and doubled for African
American families (Casper & Bianchi, 2002). Re-
cent demographic trends in fathering have changed
the context of family health care nursing. The
growth in single fatherhood and joint custody, to-
gether with the increased tendency for fathers to
perform household chores, means that family health
care nurses are more likely today than in decades
past to be interacting with the fathers of children.
Unmarried Parents Living Together
In the United States, changes in marriage and co-
habitation tend to blur the distinction between one-
parent and two-parent families. The increasing
acceptance of cohabitation as a substitute for mar-
riage, for example, may reduce the chance that a
premarital pregnancy will lead to marriage before
the birth (Casper & Bianchi, 2002). Greater shares
of children today are born to a mother who is not
currently married than in previous decades. Some
of those children are born to cohabitating parents
and begin life in a household that includes both
their biological parents. Data from the 2006–2010
National Survey of Family Growth show that 58%
of recent nonmarital births were to cohabitating
women (Martin et al., 2012). Cohabitation in-
creased for unmarried mothers in all race and ethnic
groups, but especially among whites. Cohabitating
couples account for up to 13% of all single-parent
family groups. In 2011, 13% of white single parents
were actually cohabitating compared with 9% of
black, 13% of Asian, and 19% of Hispanic single
parents (U.S. Census Bureau, 2011d). In 2011 in
Canada, 17% of all families consisted of common-
law couples, and among families with children
under age 14, 14% were common-law families
(Statistics Canada, 2012e).
Same-Sex Couple Families
An increasing number of same-sex couples are now
raising children. In the United States, nearly 17%
of same-sex couples had children in 2010 (author’s
own calculations based on Lofquist et al., 2012). In
Canada, 9.4% of same-sex couples were raising chil-
dren in 2011 (Statistics Canada, 2012e). Same-sex
couples, especially gay male couples, face consider-
able obstacles and need to overcome negative public
attitudes to become parents (Biblarz & Savci, 2010).
Female couples are more likely than male couples
to be parents (Statistics Canada, 2012e). Many
same-sex couples bring children into their house-
holds from previous heterosexual relationships; oth-
ers become parents through the use of assisted
reproductive technology and surrogacy, yet an in-
creasing number of them become parents through
adoption as same-sex couples obtain legal adoption
rights (Biblarz & Savci, 2010; Greenfeld, 2007).
Although some people have raised concerns
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
that, for the most part, the parental skills of same-
sex couples are comparable to if not better than
those of heterosexual couples (Biblarz & Savci,
2010). This finding is partly explained by the fact
Family Demography: Continuity and Change in North American Families 55
3921_Ch02_033-066 05/06/14 10:55 AM Page 55
that although many same-sex couples are very
eager to become parents, they face several obstacles
that require them to invest more time, money, and
effort to achieve this goal. Their higher initial in-
vestments make them more likely to devote a great
deal of time to their children when they finally
become parents (Biblarz & Savci, 2010).
Research on children’s outcomes has focused on
different dimensions of well-being, including psy-
chological well-being, emotional development, so-
cial behavior, and school performance. Overall,
these studies have found that children of same-sex
parents fare relatively as well, if not better, com-
pared with children raised by heterosexual couples.
The gender of the child is an important moderat-
ing factor. Sons of same-sex couples are more likely
to experience disapproval from their peers and face
greater homophobic teasing than girls; boys may
be at greater risk of experiencing emotional dis-
tress. This effect seems to depend on the level of
social tolerance in their surrounding environments
(Biblarz & Savci, 2010).
Nurses and health workers should be aware that
same-sex couples often face particular challenges
to safeguarding their well-being and that of their
children. Although children raised by same-sex
couples generally exhibit similar outcomes and lev-
els of well-being, these children may be more sen-
sitive to judgmental attitudes of individuals with
whom they interact, including health workers.
Stepfamilies
Stepfamilies are formed when parents bring to-
gether children from a previous union. By contrast,
remarriages or cohabitating unions in which nei-
ther partner brings children into the marriage are
conceptualized and measured similarly to first mar-
riages. The U.S. Census Bureau uses the term
blended families to denote families with children that
are formed when remarriages occur or when chil-
dren living in a household share only one or no
biological parents. The presence of a stepparent,
stepsibling, or half-sibling designates a family as
blended; these families can include adoptive chil-
dren who are not the biological child of either par-
ent if there are other children present who are not
related to the adoptive child. In 2009, 13.3% of
households with children under 18 were blended-
family households, numbering 5.3 million (Kreider
& Ellis, 2011a). Almost 16% of U.S. children
(11.7 million) lived in blended families in 2009.
Blended families were the least common among
Asian children (7%) and the most common among
black and Hispanic children (17% each). Although
the number of children living in blended families
has increased by almost 2 million since 1991, the
percentage increase has been negligible (from 15%
to 16%) (Furukawa, 1994; Kreider & Ellis, 2011a).
In 2011, the Census of Population in Canada iden-
tified stepfamilies for the first time. Nearly 13% of
couple families with children were stepfamilies, and
almost 10% of children aged 14 and under were
living in stepfamilies in 2011 (Statistics Canada,
2012g).
Parental and financial responsibilities for biolog-
ical parents are upheld by law, customs, roles, and
rules that provide a cultural map of sorts for parents
to follow in raising their children. Because no such
map is available for stepfamilies, stepparents’ roles,
rules, and responsibilities must be defined, negoti-
ated, and renegotiated by stepparents. Through
these negotiations, many different types of step-
families are formed, resulting in a variety of con-
figurations and different patterns of everyday
living. The ambiguity surrounding roles in step-
families and the lack of a shared family history and
kinship system provide opportunities to build new
traditions and family rituals; however, they also
open the door for greater conflict. Consider the
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
and agree upon who is in their family. By contrast,
members within stepfamilies often do not share a
common definition of who is included in their fam-
ily. Common omissions include stepchildren, bio-
logical children not living in the household,
biological parents not living in the household, and
stepparents (Furstenberg & Cherlin, 1991). Even
biological siblings can have different ideas regarding
who they consider to be family members depending
on the degree of closeness they feel toward steppar-
ents, biological parents, biological siblings, half-
siblings, and stepsiblings, especially if the biological
siblings are living in different households; a girl liv-
ing with her biological mother and stepfather may
consider her brother living with his biological father
and a stepmother as a separate family.
Negotiations must occur with ex-spouses or ex-
partners, as well as with former in-laws. Researchers
56 Foundations in Family Health Care Nursing
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have found that the ex-spouse relationship can play
an important role in the well-being of stepfamilies
(Golish, 2003) and may affect the relationship be-
tween the new stepparents, especially in the begin-
ning of the relationship. Couples’ relationships
in stepfamilies and remarriages are informed and
shaped by experiences in previous unions, leading
to increased expectations in the remarriage. Remar-
ried women expect and have more say in decision
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,
Epstein, & Rankin-Esquer, 2001).
Step-relationships in particular are often weak
or ambivalent, and stress arises around various is-
sues such as perceptions of playing favorites, or
jealousy among biological children, of former
spouses, and of stepchildren toward stepparents.
These tensions arise because in some families step-
parents are not viewed by stepchildren as real par-
ents (Furstenberg & Cherlin, 1991). The level of
conflict also depends on the age of children, in-
creasing as children approach adolescence. Unlike
in biological families where the role of parent
emerges with the birth of the child (ascribed), step-
parent roles must be earned (achieved). As a result,
discipline in stepfamilies is often a problem. Addi-
tionally, it is more difficult to be a stepparent than
a biological parent because new family cultures are
being developed.
Like children growing up in single-parent fam-
ilies, children with stepparents have lower levels of
well-being than children growing up with biologi-
cal parents (Coleman, Ganong, & Fine, 2000).
Thus, it is not simply the presence of two parents,
but the presence of two biological parents that
seems to promote children’s healthy development.
Despite these challenges, positive changes can
occur when stepfamilies are formed. For example,
a stepfather’s income can compensate for the neg-
ative economic slide that tends to occur for di-
vorced mothers, and a stepparent can alleviate the
demands of single parenting (Smock, Manning, &
Gupta, 1999).
Because stepfamilies comprise a significant pro-
portion of families with children, nurses are likely
to deal with parents whose roles and responsibili-
ties are not well defined and with children who
have behavioral problems, especially among re-
cently formed blended families. Obtaining legal
authorization for medical procedures can be chal-
lenging when legal obligations are unclear. Family
nurses should take care to identify which parent(s)
have legal responsibility for medical decision mak-
ing. Health care workers should be aware that they
may also need to notify nonresidential parents
when their children require medical attention as
these parents may share the legal right to make
medical decisions.
Grandparents
One moderating factor in children’s well-being in
single-parent families can be the presence of grand-
parents in the home. Although the image of single-
parent families is usually that of a mother living on
her own and trying to meet the needs of her young
child or children, many single mothers live with
their parents. For example, in the United States in
2011, about 12% of children of single mothers
lived in the homes of their grandparents compared
with 8% of children of single fathers (U.S. Census
Bureau, 2011g). An additional 5.2% of children of
single mothers had a grandparent living with them
compared with 4.7% of children of single fathers.
This is a snapshot at one point in time, however. A
much higher percentage of single mothers (36%)
live in their parents’ home at some point before their
children are grown. African American single moth-
ers with children at home are more likely than are
others to live with a parent at some time.
Several studies have shown that the presence
of grandparents has beneficial effects on chil-
dren’s outcomes and can buffer some of the dis-
advantages of living in a single-parent family
(DeLeire & Kalil, 2002). This beneficial effect,
however, seems to be more pronounced among
whites than among African Americans, probably
because white grandparents in the United States
have more education and resources than black
grandparents (Dunifon & Kowaleski-Jones, 2007).
The involvement of grandparents in the lives of
their children has even become an issue for court
cases, as there have been several rulings in recent
years on grandparents’ visitation rights. The 2000
U.S. Census included a new set of questions on
grandparents’ support of grandchildren. Children
whose parents cannot take care of them for one
reason or another often live with their grandpar-
ents. In 1970, 2.2 million, or 3.2% of all American
children, lived in their grandparents’ households.
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3921_Ch02_033-066 05/06/14 10:55 AM Page 57
By 2011, this number increased to nearly 5 million,
or 6.6% of all American children (U.S. Census
Bureau, 2011f). Since the Great Recession in
2008 the number of children living with grand-
parents increased by 14%, from 4.3 million in
2008 to nearly 5 million in 2011. In 2011 in
Canada, 4.8% of children aged 0 to 14 resided
with at least one grandparent, up from 3.3% in
2001 (Statistics Canada, 2012e). In addition, in
2010 in the United States, grandparents were the
regular child care providers for 15% of grade-
schoolers and 23% of preschoolers (U.S. Census
Bureau, 2010a, 2010b).
The prevalence of grandparent families is a re-
sult of demographic factors, socioeconomic con-
ditions, and cultural norms. Increases in life
expectancy have expanded the supply of potential
kin support across generations, resulting in more
multigenerational households. At the same time,
changes in work and family life have increased par-
ents’ need for child care, which, coupled with
pressing economic circumstances, has made multi-
generational households a strategic symbiotic
arrangement, especially among single-mother,
low-income, and immigrant families (Glick & Van
Hook, 2002). Grandparents often provide finan-
cial, emotional, child care, and residential support
and, in turn, receive emotional and physical sup-
port (Bengtson, Giarrusso, Mabry, & Silverstein,
2002). Nonetheless, after practical and economic
factors are taken into account, racial and ethnic
differences in the prevalence of grandparent
households remain. Strong kinship ties and family
norms also seem to explain the prevalence of
grandparent households, especially among African
American, Native American, Hispanic, and immi-
grant families (Florian & Casper, 2011; Haxton &
Harknett, 2009). Thus, norms stressing familial
obligations may also be an important factor ex-
plaining differences in the formation of grandpar-
ent families.
Emerging research reveals that grandparents
play an important role in multigenerational house-
holds, which is at odds with the traditional image of
grandparents as family members who themselves
require financial and personal support. Although
early studies assumed that financial support flowed
from adult children to their parents, more recent
research suggests that the more common pattern is
for parents to give financial support to their adult
children (Bengtson, 2001; Bianchi et al., 2008). In
multigenerational households, it is more common
for adult children and grandchildren to move into
a house that grandparents own or rent. In 2007 in
the United States, 64% of multigenerational house-
holds were headed by grandparents (Florian &
Casper, 2011). Nearly 37% of all the grandparent-
maintained families were skipped generation, that
is, grandparents living with their grandchildren
without the children’s parents (authors’ calculations
based on data from U.S. Census Bureau, 2011f).
Nearly 3.1% or 413,490 of all households in
Canada contained a grandparent in 2011. Of these
households, 53% also contained both parents, 32%
contained a lone parent (mostly the mother), and
12% were skipped-generation households com-
prised of children residing with their grandparents
without a parent (Statistics Canada, 2012e).
Grandparents who own or rent homes that in-
clude grandchildren and adult children are younger,
healthier, and more likely to be in the labor force
than are grandparents who live in a residence owned
or rented by their adult children. Grandparents who
maintain multigenerational households are also bet-
ter educated (more likely to have at least a high-
school education) than are grandparents who live in
their children’s homes (Casper & Bianchi, 2002).
Nevertheless, supporting grandchildren can drain
grandparents’ resources. A recent study indicated
that grandfathers who are primary caretakers of
grandchildren are at higher risk of experiencing
poverty if they are in a skipped-generation house-
hold, are ethnic minorities, or are not married
(Keene, Prokos, & Held, 2012).
The structure of grandparent households differs
by nativity. Although co-residential grandparent
families are more common among immigrant fam-
ilies, immigrant grandparent families are less likely
to be maintained by grandparents and less likely to
be skipped generation. Thus, while the flow of sup-
port in native-born multigenerational families
more often runs from older to younger genera-
tions, in immigrant grandparent families support
more often flows from adult children to their older
parents (Florian & Casper, 2011).
Parents who support both dependent children
and dependent parents have been referred to as the
“sandwich” generation, because they provide eco-
nomic and emotional support for both the older
and younger generations. Although grandparents
in parent-maintained households tend to be older,
in poorer health, and not as likely to be employed,
58 Foundations in Family Health Care Nursing
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many are in good health and are, in fact, working
(Bryson & Casper, 1999). These findings suggest
that, at the very least, the burden of maintaining a
co-residential “sandwich family” household may be
somewhat overstated in the popular press. Many
of the grandparents who are living in the houses of
their adult children are capable of contributing
to the family income and helping with the supervi-
sion of children.
Many grandparents step in to assist their chil-
dren in times of crisis. Some provide financial
assistance or child care, whereas others are the pri-
mary caregivers for their grandchildren. Although
grandmothers comprise the majority of grandpar-
ent caregivers, a sizable number of grandfather
caregivers exist who are likely to experience more
challenges than grandmothers as primary care-
givers (Keene et al., 2012).
The recent increase in the numbers of grand-
parents raising their grandchildren is particularly
salient to health care providers because both
grandparents and grandchildren in this situation
often suffer significant health problems (Casper
& Bianchi, 2002). Researchers have documented
high rates of asthma, weakened immune systems,
poor eating and sleeping patterns, physical dis-
abilities, and hyperactivity among grandchildren
being raised by their grandparents (Kelley, Whitley,
& Campos, 2011; Minkler & Odierna, 2001).
Grandparents raising grandchildren tend to be in
poorer health than their counterparts. They have
higher levels of stress, higher rates of anxiety and
depression, poorer self-rated health, and more
multiple chronic health problems, especially if the
grandchildren exhibit behavioral problems
(Leder, Grinstead, & Torres, 2007). Other studies
suggest, however, that these negative outcomes
may not necessarily be a result of caring for
grandchildren; instead, they may reflect grandpar-
ents’ preexisting health conditions and economic
circumstances before they began to raise their
grandchildren (Hughes, Waite, LaPierre, & Luo,
2007). It is important to keep in mind that, al-
though many of the grandparents who live in their
adult children’s homes are in good health, some
of these grandparents require significant care.
Nurses should also be aware that there are also
adult children who provide care for their parents
who are not living with them. Adults who provide
care for both generations are likely to face both
time and money concerns.
SUMMARY
Families change in response to economic conditions,
cultural change, and shifting demographics, such as
the aging of the population and immigration. North
America has gone through a particularly tumultuous
period in the last few decades, resulting in rapid
changes in family structure, functions, and processes.
Families have grown more diversified.
■ More single-mother families, single-father
families, same-sex parent families, and fami-
lies with both parents in the labor force exist
today than in the past. This translates into
less time for parents to take care of the health
needs of family members.
■ Single mothers may find it particularly chal-
lenging to meet the health care needs of their
families because they tend to have the least
time and money to do so.
■ More fathers are taking responsibility for
being primary caretakers of their children
and will be more likely than in the past to be
the parent with whom nurses will interact.
■ Changes in childbearing behaviors have also
altered family life.
■ Persistent levels of below replacement fertil-
ity in Canada have raised concerns about the
future contraction of the population, which
would reduce the tax base to support children
and the growing number of senior citizens.
■ As more couples delay childbearing, they are
more likely to seek assistance to conceive
from health care providers.
■ The growing number of same-sex couples
who aspire to become parents has further
increased the demand for assisted reproduc-
tive technology.
■ Nurses should be aware that this is a stressful
time in families’ lives, as more adults and
children live in nontraditional family forms.
■ Nurses also should be aware that the roles of
parents and responsibility for children in
these households may be ambiguous.
■ Many North American families adopt
children. These children are likely to face a
period of adjustment and are also more likely
than other children to have special health
care needs.
■ More grandparents are raising their grand-
children, and these grandchildren may suffer
Family Demography: Continuity and Change in North American Families 59
3921_Ch02_033-066 05/06/14 10:55 AM Page 59
from more health problems compared with
other children.
■ Many families maintained by grandparents
are in poverty, and many of the grandparents
in these families suffer from poor health
themselves. Nurses will increasingly be likely
to provide care to grandparent families, and
they should be aware of the unique health
and financial challenges these families face.
■ As mortality rates at older ages continue to
improve, and as baby boomers move into
their retirement years, the proportions of the
population of elderly persons will continue to
increase. This demographic shift will in-
crease the need for nurses who specialize in
caring for elderly persons.
■ More adults will have children and parents
for whom they must care, increasing the
need for care in both directions, that of the
younger and the older.
■ Working with health care needs of both gen-
erations will be a challenge for health care
professionals, especially nurses who are on
the front line in most health care systems.
■ Today, more North Americans come from
other countries than in the past.
■ Health care providers will be serving a more
ethnically and culturally diverse population.
■ Many of these individuals speak a language
other than English.
■ Economics and family relationships remain
intertwined. Family issues growing in impor-
tance include balancing paid work with child
rearing, income inequality between men and
women, fathers’ parenting roles, the expected
increase in the number of frail elderly persons,
and intergenerational relationship changes
due to the increase in life expectancy.
■ The Great Recession has put economic strain
on many families, increasing the likelihood of
stress-related illness and decreasing the abil-
ity to afford appropriate care.
Families have been amazingly adaptive and re-
silient in the past; one would expect them to be so
in the future.
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2012. Washington, DC: U.S. Government Printing Office.
Jacobs, J., & Gerson, K. (2004). The time divide: Work, family, and
gender inequality. Cambridge, MA: Harvard University Press.
Kennedy, S., & Bumpass, L. (2008). Cohabitation and children’s
living arrangements: New estimates from the United States.
Demographic Research, 19(47), 1663–1692.
McLanahan, S. (2004). Diverging destinies: How children are
faring under the second demographic transition. Demography,
41(4), 607–627.
McLanahan, S. (2009). Fragile families and the reproduction of
poverty. Annals of the American Academy of Political and Social
Science, 621, 111–131.
National Center for Health Statistics. (2001). Healthy people 2000
final review. Hyattsville, MD: Public Health Service.
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policy, and economic inequality in twenty-one countries. New York,
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Contacts
■ Child Trends: www.childtrends.org
■ Designing New Models for Explaining Family Change and
Variation: www.soc.duke.edu/~efc/
■ Federal Interagency Forum on Aging-Related Statistics:
www.agingstats.gov
■ Federal Interagency Forum on Child and Family Statistics:
www.childstats.gov
■ Fragile Families and Child Wellbeing Study: www.fragilefamilies.
princeton.edu/
■ Kaiser Commission on Medicaid and the Uninsured: www.kff.org
■ Kids Count: The Annie E. Casey Foundation: www.aecf.org/
kidscount
64 Foundations in Family Health Care Nursing
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■ National Center for Health Statistics, U.S. Department of Health
and Human Services, Centers for Disease Control and Prevention:
www.cdc.gov/nchs
■ National Institute on Aging, National Institutes of Health:
www.nia.nih.gov
■ National Center for Marriage and Family Research: ncfmr.bgsu.edu/
■ National Institute of Child Health and Human Development,
National Institutes of Health: www.nichd.nih.gov
■ The National Longitudinal Study of Adolescent Health:
www.cpc.unc.edu/projects/addhealth
■ Population Reference Bureau: www.prb.org
■ Statistics Canada/Statistique Canada: www.statcan.gc.ca
■ U.S. Census Bureau: www.census.gov
■ Welfare, Children, & Families: A Three City Study:
web.jhu.edu/threecitystudy/index.html
Family Demography: Continuity and Change in North American Families 65
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67
Theoretical Foundations
for the Nursing of Families
c h a p t e r 3
Joanna Rowe Kaakinen, PhD, RN
Shirley May Harmon Hanson, PhD, PMHNP/ARNP, FAAN, CFLE, LMFT
C r i t i c a l C o n c e p t s
■ 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
prepared to think creatively and critically about
how health events affect the family client. The re-
ciprocal or interactive relationship between theory,
practice, and research is that each aspect informs
the other, thereby expanding knowledge and nurs-
ing interventions to support families. Theories and
models extend thinking to higher levels of under-
standing problems and circumstances that may be
affecting families and, thereby, offer more choice
and options for nursing interventions.
Currently, no single theory, model, or concep-
tual framework adequately describes the complex
relationships of family structure, function, and
process. Nor does one theoretical perspective give
nurses a sufficiently broad base of knowledge and
understanding to guide assessment and interven-
tions with families. No one theoretical perspective
3921_Ch03_067-104 05/06/14 10:56 AM Page 67
is better, more comprehensive, or more correct
than another (Doane & Varcoe, 2005; Kaakinen &
Hanson, 2010). The goal for nurses is to have a
deep understanding of the stresses that families ex-
perience when their family clients have a health
event and to support and implement family inter-
ventions based on theoretical perspectives that best
match the needs identified by the family.
Many theoretical approaches exist to under-
standing families. The purpose of this chapter is to
demonstrate how families who have members
experiencing a health event are conceptualized dif-
ferently depending on the theoretical perspective.
In this chapter, nurses seek different data depending
on which theory is being used, both to understand
the family experience and to determine the inter-
ventions offered to the family to help bring them
back to a state of stability.
RELATIONSHIP BETWEEN THEORY,
PRACTICE, AND RESEARCH
In nursing, the relationship of theory to practice
constitutes a dynamic feedback loop rather than a
static linear progression. Theory, practice, and re-
search are mutually interdependent. Theory grows
out of observations made in practice and is tested
by research; then tested theory informs practice,
and practice, in turn, facilitates the further refine-
ment and development of theory. Figure 3-1
depicts the dynamic relationship between theory,
practice, and research.
Theories do not emerge all at once; they build
slowly over time as data are gathered through prac-
tice, observation, and analysis of evidence. Relating
together the various concepts that emerge from
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-
stract, general ideas that are subject to rules of
68 Foundations in Family Health Care Nursing
This chapter begins with a brief review of the
components of a theory and how the components
contribute to the nursing of families. It then pres-
ents five theoretical approaches for working with
families, ranging from a broader to a more specific
perspective:
■ Family Systems Theory
■ Developmental and Family Life Cycle Theory
■ Bioecological Theory
■ Chronic Illness Framework
■ Family Assessment and Intervention Model
The chapter utilizes a case study of a family with
a member who is experiencing progressive multiple
sclerosis (MS) to demonstrate these five different
theoretical approaches to nursing care.
THEORY
(Generalities)
PRACTICEInductive
Reasoning
RESEARCH
(Specifics)
Deductive
Reasoning
FIGURE 3-1 Relationship between theory, practice, and
research. (Adapted from Smith, S. R., Hamon, R. R., Ingoldsby,
B. B., & Miller, J. E. [2008]. Exploring family theories [2nd ed.].
New York, NY: Oxford University Press.)
3921_Ch03_067-104 05/06/14 10:56 AM Page 68
organization. Theories provide a general frame-
work for understanding data in an organized way,
as well as showing us how to intervene. We live in
a time when tremendous amounts of information
are readily available and quickly accessible in mul-
tiple forms. Therefore, theories provide ways to
transform this huge volume of information into
knowledge and to integrate/organize the informa-
tion to help us make better sense of our world
(White, 2005). Ideally, nursing theories represent
logical and intelligible patterns that make sense of
the observations nurses make in practice and en-
able nurses to predict what is likely to happen to
clients (Polit & Beck, 2011). Theories can be used
as a level of evidence on which to base nursing
practice (Fawcett & Desanto-Madeya, 2012). The
major function of theory in family nursing is
to provide knowledge and understanding that
improves nursing services to families.
Most important, theories explain what is hap-
pening; they provide answers to “how” and “why”
questions, help to interpret and make sense of phe-
nomena, and predict or point to what could happen
in the future. All scientific theories use the same
components: concepts, relationships, and propositions.
We will discuss hypotheses and conceptual models
as well.
Concepts, the building blocks of theory, are words
that create mental images or abstract representa-
tions of phenomena of study. Concepts, or the
major ideas expressed by a theory, may exist on a
continuum from empirical (concrete) to abstract
(Powers & Knapp, 2010). The more concrete the
concept, the easier it is to figure out when it applies
or does not apply (White & Klein, 2008). For ex-
ample, one concept in Family Systems Theory is
that families have boundaries. A highly abstract
aspect of this concept is that the boundary reflects
the energy between the environment and the sys-
tem. A more concrete aspect of this concept is that
families open or close their boundaries in times of
stress.
Propositions are statements about the relationship
between two or more concepts (Powers & Knapp,
2010). A proposition might be a statement such as
the following: Families as a whole influence the
health of individual family members. The word
influence links the two concepts of “families as a
whole” and “health of individual family members.”
Propositions denote a relationship between the
subject and the object. Propositions may lead to
hypotheses. Theories are generally made up of sev-
eral propositions that emphasize the relationships
among the concepts in that specific theory.
A hypothesis is a way of stating an expected rela-
tionship between concepts or an expected proposi-
tion (Powers & Knapp, 2010). The concepts and
propositions in the hypothesis are derived from and
driven by the original theory. For example, using
the concepts of family and health, one could hy-
pothesize that there is an interactive relationship
between how a family is coping and the eventual
health outcome of family members. In other words,
the family’s ability to cope with stress affects the
health of individual family members and, in turn,
the health of this individual family member influ-
ences the family’s ability to cope. This hypothesis
may be tested by a research study that measures
family coping strategies and family members’ health
over time and that uses statistical procedures to look
at the relationships between the two concepts.
A conceptual model is a set of general propositions
that integrate concepts into meaningful configura-
tions or patterns (Fawcett & Desanto-Madeya,
2012). Conceptual models in nursing are based on
the observations, insights, and deductions that com-
bine ideas from several fields of inquiry. Conceptual
models provide a frame of reference and a coherent
way of thinking about nursing phenomena. A con-
ceptual model is more abstract and more compre-
hensive than a theory. Like a conceptual model, a
conceptual framework is a way of integrating con-
cepts into a meaningful pattern, but conceptual
frameworks are often less definitive than models.
They provide useful conceptual approaches or ways
in which to look at a problem or situation, rather
than a definite set of propositions.
In this chapter, the terms conceptual model or
framework and theory or theoretical framework are
often used interchangeably. In part, that is because
no single theoretical base exists for the nursing of
families. Rather, nurses typically draw from many
theoretical conceptual foundations using a more
pluralistic and eclectic approach. The interchange-
able use of these various terms reflects the fact that
there is considerable overlap among ideas in
the various theoretical perspectives and conceptual
models/frameworks and that many “streams of
influence” are important for family nurses to incor-
porate into practice. As might be expected, a
substantial amount of cross-fertilization among
disciplines has occurred, such as between social
Theoretical Foundations for the Nursing of Families 69
3921_Ch03_067-104 05/06/14 10:56 AM Page 69
science and nursing, and concepts originating in
one theory or discipline have been translated into
similar concepts for use in another discipline. Cur-
rently, no one theoretical perspective gives nurses
a sufficiently broad base of knowledge and under-
standing to guide assessment and interventions
with families.
THEORETICAL AND CONCEPTUAL
FOUNDATIONS FOR THE NURSING
OF FAMILIES
Nursing is a scientific discipline; thus, nurses are
concerned about the relationships between ideas
and data. Nurse scholars explain empirical observa-
tions by creating theories, which can be used as
evidence in evidence-based practice (Fawcett &
Garity, 2008). Nurse researchers investigate and
test the models and relationships. Nurses in practice
use theories, models, and conceptual frameworks to
help clients achieve the best outcomes (Kaakinen &
Hanson, 2010). In nursing, evidence, in the form of
theory, is used to explain and guide practice. The
theoretical foundations, theories, and conceptual
models that explain and guide the practice of nurs-
ing families have evolved from three major tradi-
tions and disciplines: family social science theories,
family therapy theories, and nursing models and
theories. Figure 3-2 shows the theoretical frame-
works that influence the nursing of families.
Family Social Science Theories
Of the three sources of theory, family social science
theories are the best developed and informative
about family phenomena; examples of such theo-
ries include the following: family function, the
environment-family interchange, interactions and
dynamics within the family, changes in the family
over time, and the family’s reaction to health and
illness. Table 3-1 summarizes the basic family
social science theories and provides some classic
references where these theories originate. It is
somewhat challenging to use the purist form of
family social science theories as a basis for nursing
assessment and intervention because of their ab-
stract nature. Despite this challenge, in recent
years, nursing and family scholars have made
strides in extrapolating and morphing these theo-
ries for use in clinical work (Fine & Fincham,
2012; Kaakinen & Hanson, 2010).
Family Therapy Theories
Family therapy theories are newer than and not as
well developed as family social science theories.
Table 3-2 lists these theories and the names of
some foundational scholars who first developed
them. These theories emanate from a practice dis-
cipline of family therapy, rather than from an aca-
demic discipline of family social science. Family
therapy theories were developed to work with trou-
bled families and, therefore, focus primarily on
family pathology. Nevertheless, these conceptual
models describe family dynamics and patterns that
are found, to some extent, in all families. Because
these models are concerned with what can be done
to facilitate change in “dysfunctional” families, they
are both descriptive and prescriptive. That is, they
not only describe and explain observations made in
practice but also suggest treatment or intervention
strategies.
Nursing Conceptual Frameworks
Finally, of the three types of theories, nursing con-
ceptual frameworks are the least developed “theories”
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,
1980), both of which were based on family social
science theories, the majority of the classic nursing
70 Foundations in Family Health Care Nursing
NURSING
MODELS/THEORIES
FAMILY THERAPY THEORIES
FAMILY SOCIAL
SCIENCE THEORIES
EMERGING
FAMILY NURSING
THEORIES
FIGURE 3-2 Theoretical frameworks that influence the
nursing of families.
3921_Ch03_067-104 05/06/14 10:56 AM Page 70
theorists from the 1970s focused on individual pa-
tients and not on families as a unit of care/analysis.
The nursing models, in large part, represent a
deductive approach to the development of nursing
science (general to specific). Although they embody
an important part of our nursing heritage, these
nursing conceptual frameworks and their deductive
approach are viewed more critically today. As the
science of nursing has evolved, more inductive
approaches to nursing theory development (specific
to the general) are now being advocated.
Table 3-4 shows the differences between family
social science theories, family therapy theories, and
nursing models/theories as they inform the practice
of nursing with families. The following case study
is used to demonstrate how the five different theo-
retical approaches may inform a nurse’s work with
one particular family.
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)
Friedman, Bowden, & Jones (2003)
Nye & Berardo (1981)
Symbolic Interaction Theory
Hill & Hansen (1960)
Nye (1976)
Rose (1962)
Turner (1970)
Developmental Theory and
Family Life Cycle Theory
Carter & McGoldrick (2005)
Duvall (1977)
Duvall & Miller (1985)
Family Systems Theory
von Bertalanffy (1950, 1968)
Family Stress Theory
Hill (1949, 1965)
McCubbin & McCubbin (1993)
McCubbin & Patterson (1983)
Change Theory
Maturana (1978)
Maturana & Varela (1992)
Watzlawick, Weakland, & Fisch (1974)
Wright & Leahey (2013)
Wright & Watson (1988)
Transition Theory
White (2005)
White & Klein (2008)
The focus is on families as an institution and how they function to maintain family
and social network.
The focus is on the interactions within families and the symbolic communication.
The focus is on the life cycle of families and representing normative stages of
family development.
The focus is on the circular interactions among members of family systems, which
result in functional or dysfunctional outcomes.
The focus is on the analysis of how families experience and cope with stressful life
events.
The focus is on how families remain stable or change when there is change within
the family structure or from outside influences.
The focus is on understanding and predicting the transitions families experience
over time by combining Role Theory, Family Development Theory, and Life
Course Theory.
3921_Ch03_067-104 05/06/14 10:56 AM Page 71
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)
Minuchin & Fishman (1981)
Minuchin, Rosman, & Baker (1978)
Nichols (2004)
International Family Therapy Theory
Jackson (1965)
Satir (1982)
Watzlawick, Beavin, & Jackson (1967)
Family Systems Therapy Theory
Freeman (1992)
Kerr & Bowen (1988)
Toman (1961)
This systems-oriented approach views the family as an open sociocultural system
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,
boundaries, and coalitions, as well as family transactional patterns and covert rules.
This approach views the family as a system of interactive or interlocking behaviors
or communication processing. Emphasis is on the here and now rather than on
the past. Key interventions focus on establishing clear, congruent communication
and clarifying and changing family rules.
This approach focuses on promoting differentiation of self from family and pro-
moting differentiation of intellect from emotion. Family members are encouraged
to examine their processes to gain insight and understanding into their past and
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
Nightingale (1859)
Rogers’s Science of Unitary
Human Beings
Casey (1996)
Rogers (1970, 1986, 1990)
Roy’s Adaptation Model
Roy (1976)
Roy & Roberts (1981)
Johnson’s Behavioral
Systems Model for Nursing
Johnson (1980)
King’s Goal Attainment Theory
King (1981, 1983, 1987)
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.
The family is viewed as a constant open system energy field that is ever-changing in its
interactions with the environment.
The family is seen as an adaptive system that has inputs, internal control, and feedback
processes and output. The strength of this model is understanding how families adapt
to health issues.
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.
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.
3921_Ch03_067-104 05/06/14 10:56 AM Page 72
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)
Orem’s Self-Care Deficit
Theory
Gray (1996)
Orem (1983a, 1983b, 1985)
Parse’s Human Becoming
Theory
Parse (1992, 1998)
Friedemann’s Framework
of Systemic Organization
Friedemann (1995)
Denham’s Family Health
Model
Denham (2003)
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.
The family is seen as the basic conditioning unit in which the individual learns culture,
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.
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.
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.
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
Discipline focus
Target population
Descriptive and explana-
tory (academic models);
to explain family function-
ing and dynamics.
Interdisciplinary (although
primarily sociological).
Primarily “normal” families
(normality-oriented).
Descriptive and prescriptive
(practice models); to explain
family dysfunction and guide
therapeutic actions.
Marriage and family therapy;
family mental health; new
approaches focus on family
strengths.
Primarily “troubled” families
(pathology-oriented).
Descriptive and prescriptive
(practice models); to guide
nursing assessment and
intervention efforts.
Nursing focus.
Primarily families with health
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.
3921_Ch03_067-104 05/06/14 10:56 AM Page 73
74 Foundations in Family Health Care Nursing
age 39, but he is described as “a blessing.” Linda and
Robert are devout Baptists, but they did discuss abortion
in light of the fact that Linda’s illness could progress signifi-
cantly after the birth of Travis. Their faith and personal
beliefs did not support abortion. They made the decision
to continue with Linda’s pregnancy, knowing the risk that it
might exacerbate and speed up her MS. Linda had an
uncomplicated pregnancy with Travis. She felt well until
3 months postpartum with Travis when she noted a
significant relapse of her MS.
Over the last 4 years, Linda has experienced develop-
ment of progressive relapsing MS, which is a progressive
disease from onset with clear, acute relapses without full
recovery after each relapse. The periods between her re-
lapses are characterized by continuing progression of the
disease. She now has secondary progressive multiple scle-
rosis because of her increased weakness. Robert and Linda
are having sexual issues with decreased libido and painful
intercourse for Linda. Both are experiencing stress in their
marital roles and relationship.
Currently, Linda has had a serious relapse of her MS.
She is hospitalized for secondary pneumonia from aspi-
ration. She has weakness in all limbs, left foot drag, and
increasing ataxia. Linda will be discharged with a wheel-
chair (this aid is new as she has used a cane up until
this admission). She has weakness of her neck muscles
and cannot hold her head steady for long periods. She
has difficulty swallowing, which probably caused her
Family Case Study: Jones Family
Setting: Inpatient acute care hospital
Nursing Goal: Work with the family to assist them in
preparation for discharge that is planned to occur in the
next 2 days.
Family Members:
The Jones family is a nuclear family. The Jones family
genogram and ecomap are illustrated in Figures 3-3 and 3-4.
• Robert: 48 years old; father, software engineer, full-time
employed.
• Linda: 43 years old; mother, stay-at-home homemaker,
has progressive multiple sclerosis, which recently has
worsened significantly.
• Amy: 19 years old; oldest child, daughter, freshman at
university in town 180 miles away.
• Katie: 13 years old: middle child, daughter, sixth grade,
usually a good student.
• Travis: 4 years old: youngest child, son, just started
attending an all-day preschool because of his mother’s
illness.
Jones Family Story:
Linda was diagnosed with multiple sclerosis (MS) at age 30
when Katie was 3 months old. After she was diagnosed
with MS, Linda had a well-controlled, slow progression of
her illness. Travis was a surprise pregnancy for Linda at
Elise
70 yr
Amy
19 yr
Freshman at
university 180
miles away
Healthy
Sixth grade
Healthy
Usually a good
student, now
showing some
difficulty noted
by teachers
Preschool, just
moved to full day
Healthy
Katie
13 yr
Travis
4 yr
Full-time
software
engineer
Healthy Full-time
employed
teacher,
high school
Tom
64 yr
Sally
63 yr
Full-time
employed
secretary
Multiple sclerosis;
progressive and
relapse
UTI
Constipation
Difficulty swallowing
Requires
supplemental O2
Uses wheelchair
Robert
48 yr
Ralph
Linda
43 yr
FIGURE 3-3 Jones family genogram.
3921_Ch03_067-104 05/06/14 10:56 AM Page 74
Theoretical Foundations for the Nursing of Families 75
aspiration. She has numbness and tingling of her legs
and feet. She has severe pain with flexion of her neck.
Her vision is blurred. She experiences vertigo at times
and has periodic tinnitus. Constipation is a constant
problem, together with urinary retention that causes
periodic urinary tract infections.
Health Insurance:
Robert receives health insurance through his work that cov-
ers the whole family. Hospitalizations are covered 80/20,
so they have to pay 20% of their bills out of pocket. Al-
though Robert is employed full-time, this cost adds heavily
to the financial burden of the family. Robert has shared
with the nurses that he does not know whether he should
take his last week of vacation when his wife comes home,
or whether he should save it for a time when her condition
worsens. Robert works for a company that offers family
leave, but without pay.
Family Members:
Robert reports being continuously tired from caring for his
wife and children, as well as working full-time. He asked the
doctor for medication to help him sleep and decrease his
anxiety. He said he is afraid that he may not hear Linda in
the night when she needs help. He is open to his mother
moving in to help care for Linda and the children. He began
counseling sessions with the pastor in their church.
Amy is a freshman at a university that is 180 miles
away in a different town. Her mother is proud of Amy
going to college on a full scholarship. Amy does well in
her coursework but travels home weekends to help the
Travis’s P.E.
school teacher Hospital socialworker
MS support
group
Pastor
Woman’s
church group
Linda’s
parents
Paternal
grandmother,
Elise
Neurology
team
CNS
Neurology
RN case
manager
Family
insurance
Robert’s work
Katie’s middle
school teacher
R
TKA
Weak relationship
Strong relationship
Tense relationship
Direction of
energy flow
L
FIGURE 3-4 Jones family ecomap.
(continued)
3921_Ch03_067-104 05/06/14 10:56 AM Page 75
76 Foundations in Family Health Care Nursing
family and her mother. Amy is considering giving up her
scholarship to transfer home to attend the local commu-
nity college. She has not told her parents about this
idea yet.
Katie is in the sixth grade. She is typically a good stu-
dent, but her latest report card showed that she dropped
a letter grade in most of her classes. Katie is quiet. She
stopped having friends over to her home about 6 months
ago when her mother began to have more ataxia and slur-
ring of speech. Linda used to be very involved in Katie’s
school but is no longer involved because of her illness.
Katie has been involved in Girl Scouts and the youth group
at church.
Travis just started going to preschool 2 months ago for
full days because of his mother’s illness. This transition to
preschool has been difficult for Travis because he had been
home full-time with Linda until her disease worsened. He is
healthy and developmentally on target for his age.
Linda’s parents live in the same town. Her parents,
Tom and Sally, both work full-time and are not able to
help. Robert’s widowed mother, Elise, lives by herself in
her own home about 30 minutes out of town and has
offered to move into the Jones’ home to help care for
Linda and the family.
Discharge Plans: Linda will be discharged home in 2 days.
THEORETICAL PERSPECTIVES
AND APPLICATION TO FAMILIES
The case of the Jones family is used throughout the
rest of this chapter to demonstrate how assess-
ments, interventions, and options for care vary
based on the particular theoretical perspective
chosen by nurses caring for this family.
Family Systems Theory
Family Systems Theory has been the most influential
of all the family social science frameworks (Kaakinen
& Hanson, 2010; Wright & Leahey, 2013). Much
of the understanding of how a family is a system de-
rives from physics and biology perspectives that or-
ganisms are complex, organized, and interactive
systems (Bowen, 1978; von Bertalanffy, 1950, 1968).
Nursing theorists who have expanded the concept
of systems theory include Hanson (2001), Johnson
(1980), Neuman (1995), Neuman and Fawcett
(2010), Parker and Smith (2010), Walker (2005),
and Wilkerson and Loveland-Cherry (2005).
The Family Systems Theory is an approach
that allows nurses to understand and assess fami-
lies as an organized whole and/or as individuals
within family units who form an interactive and
interdependent system (Kaakinen & Hanson,
2010). Family Systems Theory is constructed
of concepts and propositions that provide a
framework for thinking about the family as a
system. Typically, in family nursing, we look
at three-generational family systems (Goldenberg
& Goldenberg, 2012).
One of the major assumptions of Family Sys-
tems Theory is that family system features are de-
signed to maintain stability, although these features
may be adaptive or maladaptive. At the same time,
families change constantly in response to stresses
and strains from both the internal and external en-
vironments. Family systems increase in complexity
over time and increase their ability to adapt and to
change (Smith & Hamon, 2012; White & Klein,
2008). The family systems theoretical perspective
encourages nurses to see individual clients as
participating members of a larger family system.
Figure 3-5 depicts a mobile showing how family
systems work. Any change in one member of the
family affects all members of the family. As it
applies to the Jones family, nurses who are using
this perspective would assess the impact of Linda’s
illness on the entire family, as well as the effects of
family functioning on Linda. The goal of nurses is
to help maintain or restore the stability of the fam-
ily, to help family members achieve the highest
level of functioning that they can. Therefore,
emphasis should be on the whole, rather than on
any given individual. Some of the concepts of sys-
tems theory that help nurses working with families
are explained in the following sections.
Concept 1: All Parts of the System
Are Interconnected
What influences one part of the system influences
all parts of the system. When an individual in a
family experiences a health event, all members are
affected because they are connected. The effect
on each family member varies in intensity and
3921_Ch03_067-104 05/06/14 10:56 AM Page 76
quality. In the Jones case study, all members of the
Jones family are touched when Linda’s health
condition changes, requiring her to be hospital-
ized. Linda takes on the role of a sick person and
must give up some of her typical at-home mother
roles; she is physically ill in the hospital. She feels
guilty about not being at home for her family.
Robert is affected because he has to assume the
care of Katie and Travis. These tasks require get-
ting them ready for school, transporting them to
school and other events, and making lunches.
Katie gives up some after-school activities to help
Travis when he gets home from preschool. Travis
misses the food his mother prepared for him, his
afternoon alone time with his mother when they
read a story, and being tucked into bed at night
with songs and a back rub. Amy, who is a fresh-
man in college, finds it difficult to concentrate
while reading and studying for her college classes.
The formal and informal roles of all these family
members are affected by Linda’s hospitalization.
What affects Linda affects all the members of the
Jones family in multiple ways.
Concept 2: The Whole Is More Than
the Sum of Its Parts
The family as a whole is composed of more than the
individual lives of family members. It goes beyond
parents and children as separate entities. Families
are not just relationships between the parent-child
but are all relationships seen together. As we look
at the Jones family, it is a nuclear family—mother,
father, and three children. They are a family system
that is experiencing the stress of a chronically ill
mother who is deteriorating over time; each of them
is individually affected, but so is the family as a
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
change in their family tradition and beliefs. Thus,
the family loss is larger than individual loss of this
tradition.
Concept 3: All Systems Have Some Form
of Boundaries or Borders Between the
System and Its Environment
Families control the in-flow of information and
people coming into its family system to protect in-
dividual family members or the family as a whole.
Boundaries are physical or abstract imaginary lines
that families use as barriers or filters to control the
impact of stressors on the family system (Smith &
Hamon, 2012; White & Klein, 2008). Family
boundaries include levels of permeability in that
they can be closed, flexible, or too open to infor-
mation, people, or other forms of resources. Some
families have closed boundaries as exemplified by
statements such as, “We as a family pull together
and don’t need help from others,” or “We take care
of our own.” For example, if the Jones family were
to have a closed boundary, they would not want to
meet with the social worker or, if they did, they
would reject the idea of a home-health aide and
respite care.
Some families have flexible boundaries, which they
control and selectively open or close to gain bal-
ance or adapt to the situation. For example, the
Jones family welcomes a visit from the pastor but
turns down visits from some of the women in
Linda’s Bible study group. Some families have too
open boundaries in which they are not discriminating
about who knows their family situation or the num-
ber of people from whom they seek help. Open
boundaries can invite chaos and unbalance if the
family is not selective in the quantity or quality of
resources. If the Jones family were to have truly
open boundaries, it may reach out to the larger com-
munity for resources and have different church
Theoretical Foundations for the Nursing of Families 77
FIGURE 3-5 Mobile depicting family system.
3921_Ch03_067-104 05/06/14 10:56 AM Page 77
members come stay with the children every
evening. The permeability of boundaries resides on
a continuum and varies from family to family.
Concept 4: Systems Can Be Further
Organized Into Subsystems
In addition to conceptualizing the family as a
whole, nurses can think about the subsystems of the
family, which may include husband to wife, mother
to child, father to child, child to child, grandparents
to parents, grandparents to grandchildren, and so
forth. These subsystems take into account the three
dimensions of families discussed in Chapter 1:
structure, function (including roles), and processes
(interconnection and dynamics). By understanding
these three dimensions, family nurses can stream-
line interventions to achieve specific family out-
comes. For example, the Jones family has the
following subsystems: parents, siblings, parent-
child, a daughter subsystem, an in-law subsystem,
and a grandparent subsystem. The nurse may work
to decrease family stress by focusing on the marital
spouse subsystem to help Linda and Robert con-
tinue couple time, or the nurse may focus on the
sibling subsystem of Katie and Travis and their
after-school activities.
Application of Family Systems Theory
to the Jones Family
The focus of the nurses’ practice from this perspec-
tive is family as the client. Nurses work to help
families maintain and regain stability. Assessment
questions of family members are focused on the
family as a whole. While planning for Linda’s dis-
charge that is scheduled in the next couple of days,
a nurse would ask questions such as the following
to explore with Linda or with Linda and Robert:
■ Who are members of your family? (See
Concept 1.)
■ How do you see your family being involved
in your care once you go home? (See
Concept 1.)
■ Who in your family will experience the most
difficulty coping with the changes, especially
now that you will be using a wheelchair?
(See Concept 1.)
■ How are the members of your family
meeting their personal needs at this time?
(See Concept 1.)
■ The last time your condition worsened, what
helped your family the most? (See Concept 2.)
■ The last time your condition worsened,
what was the least help to your family?
(See Concept 2.)
■ Who outside of your immediate family do
you see as being a potential person to help
your family during the next week when you
go home? (See Concept 3.)
■ How do you feel your family would react to
having a home-health aide come to help you
twice a week? (See Concept 3.)
■ Are there some friends, church members,
or neighbors who might be able to help with
some of the everyday management issues,
such as carpooling to school, or providing
some after-school care for Travis so Katie
could go to her after-school activities?
(See Concepts 3 and 4.)
■ What are your thoughts about how the
children will react to having Grandma Elise
here to help the family? (See Concept 4.)
Interventions by family nurses must address in-
dividuals, subsystems within the family, and the
whole family all at the same time. One strategy
would be to assess family process and functioning
and then offer intervention strategies to assist the
family in its everyday functioning. Nurses could ask
the following types of questions about functioning:
■ Linda and Robert, from what you have told
me, it appears that your oldest daughter,
Amy, has been able to help take on some of
the parental jobs in the family by being the
errand runner, chauffeur, and grocery shop-
per. Now that Amy is off to college, which
of your family roles will need to be covered
by someone else for a while when you and
Linda first come home: cooking, laundry,
chauffeur, cleaning the house?
■ Because you both shared with me that your
family likes to go bowling on family night
out, how do you envision how Linda being in
a wheelchair might affect family night out?
■ Robert and Linda, have the two of you dis-
cussed legal durable power of attorney for
health care so Robert can make health care
decisions when the time comes that Linda
may not be able to do this for herself? Linda,
who would you prefer to make health care
decisions for you, should you not be able to
do so? Let’s discuss what those health care
decisions might involve.
78 Foundations in Family Health Care Nursing
3921_Ch03_067-104 05/06/14 10:56 AM Page 78
■ Tell me about your personal/sexual relation-
ship that you, Linda, are experiencing now
that you are more disabled.
The goal of using a family systems perspective
is to help the family reach stability by building on
their strengths as a family, using knowledge of the
family as a social system, and understanding how
the family is an interconnected whole that is adapt-
ing to the changes brought about by the health
event of a given family member.
Strengths and Weaknesses of Family
Systems Theory
The strengths of the general systems framework
are that this theory covers a large array of phe-
nomena and views the family and its subsystems
within the context of its suprasystems (the larger
community in which it is embedded). Moreover, it
is an interactional and holistic theory that looks at
processes within the family, rather than at the con-
tent and relationships between the members. The
family is viewed as a whole, not as merely a sum of
its parts. Another strength of this approach is that
it is an excellent data-gathering method and assess-
ment strategy, such as using a family genogram to
gather a snapshot of the family as a whole or other
family system assessment instruments discussed in
Chapter 4.
Systems theory also has its limitations (Smith &
Hamon, 2012). Because this theoretical orientation
is so global and abstract, it may not be specific
enough for beginners to define family nursing in-
terventions. It is important for family nurses to be
able to understand conceptually how important the
family as a whole is to the practice of family nurs-
ing. As health care systems continue to emphasize
the autonomy of the individual, it takes time and
practice to develop ways to deeply understand how
a family, as a whole, is greater than the members
of the family.
Developmental and Family Life Cycle
Theory
Developmental Theory provides a framework for
nurses to understand normal family changes and
experiences over the members’ lifetimes; the the-
ory assesses and evaluates both individuals and
families as a whole. Developmental stages for in-
dividuals have been detailed by psychologists and
sociologists, such as Erikson, Piaget, and Bandura.
Families are seen as a system in that what happens
at one level has powerful ramifications at other lev-
els of the system. Families are seen as the basic
social unit of society and as the optimal level of
intervention.
The family developmental theories are specifi-
cally geared to understanding families and not in-
dividuals (Smith & Hamon, 2013; White & Klein,
2008). Families, like individuals, are in constant
movement and change throughout time—the fam-
ily life cycle. Family developmental theorists who
inform the nursing of families include Duvall
(1977); Duvall and Miller (1985); and McGoldrick,
Carter, and Garcia-Preto (2010). The original
work of Duvall (1977), and later Duvall and Miller
(1985), examined how families were affected or
changed cognitively, socially, emotionally, spiritu-
ally, and physically when all members experienced
developmental changes. The relationships among
family members are affected by changes in individ-
uals, and changes in the family as a whole affected
the individuals within the family. These theorists
recognized that families are stressed at common
and predictable stages of change and transition and
need to undergo adjustment to regain family
stability. This early theoretical work was primarily
based on the experiences of white Anglo middle-
class nuclear families, with a married couple,
children, and extended family.
McGoldrick et al. (2010) expanded on the orig-
inal Developmental and Family Life Cycle Theory
because they recognized the dramatically chang-
ing landscape of family structure, functions, and
processes that was making it increasingly difficult
to determine normal predictable patterns of change
in families. They replaced the concept of “nuclear
family” with “immediate family,” which takes into
consideration all family structures, such as stepfam-
ilies, gay families, and divorced families. Instead of
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.
Concept 1: Families Develop and Change
Over Time
According to Family Developmental Theory, fam-
ily interactions among family members change
over time in relation to structure, function (roles),
and processes. The stresses created by these
changes in family systems are somewhat pre-
dictable for different stages of family development.
Theoretical Foundations for the Nursing of Families 79
3921_Ch03_067-104 05/06/14 10:56 AM Page 79
The first way to view family development is
to look at predictable stresses and changes as they
relate to the age of the family members and
the social norms the individuals experience
throughout their development. The classic tradi-
tional work of Duvall (1977) and Duvall and
Miller (1985) identified overall family tasks that
need to be accomplished for each stage of family
development, as related to the developmental tra-
jectory of the individual family members. It starts
with couples getting married and ends with one
member of the couple dying. Refer to Table 3-5
for a detailed list of the traditional family life
cycle stages and developmental tasks. McGoldrick
et al. (2010) expanded the traditional develop-
mental and family life cycle theory to address
changes in the family that undergoes a divorce.
Table 3-6 outlines the emotional process of a
family undergoing a divorce and describes the
developmental tasks the family deals with at dif-
ferent stages.
According to this theory, families have a pre-
dictable natural history. The first stage involves the
simple husband-wife pairing, and the family group
becomes more complex over time with the addition
of new members. When the younger generation
leaves home to take jobs or marry, the original fam-
ily group becomes less complex again.
The second way to view family development is
to assess the predictable stresses and changes in
families based on the stage of family development
and how long the family is in that stage. For ex-
ample, suppose each of the following couples have
made a choice to be childless: a newly married
couple, a couple who have been married for
3 years, and a couple who have been married for
80 Foundations in Family Health Care Nursing
Table 3-5 Traditional Family Life Cycle Stages and Developmental Tasks
Stages of Family Life Cycle Family Developmental Tasks
Married couple
Childbearing families with infants
Families with preschool children
Families with school-age children
Families with adolescents
Families with young adults: launching
Middle-aged parents
Aging families
Establishing relationship as a married couple.
Blending of individual needs, developing conflict-and-resolution approaches,
communication patterns, and intimacy patterns.
Adjusting to pregnancy and then infant.
Adjusting to new roles, mother and father.
Maintaining couple bond and intimacy.
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.
Working out authority and socialization roles with school.
Supporting child in outside interests and needs.
Determining disciplinary actions and family rules and roles.
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.
After member moves out, reallocating roles, space, power, and communication.
Maintaining supportive home base.
Maintaining parental couple intimacy and relationship.
Refocusing on marriage relationship.
Ensuring security after retirement.
Maintaining kinship ties.
Adjusting to retirement, grandparent roles, death of spouse, and living alone.
3921_Ch03_067-104 05/06/14 10:56 AM Page 80
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
Divorce
The decision to divorce
Planning the breakup of
the system
Separation
The divorce
Postdivorce Family
Single parent (custodial
household or primary
residence)
Single parent
(noncustodial)
Acceptance of inability to resolve marital
tensions sufficiently to continue
relationship.
Supporting viable arrangements for all
parts of the system.
a. Willingness to continue cooperative
co-parental relationship and joint financial
support of children.
b. Work on resolution of attachment to
spouse.
More work on emotional divorce:
overcoming hurt, anger, guilt, among
other emotions.
Willingness to maintain financial responsi-
bilities, continue parental contact with
ex-spouse, and support contact of chil-
dren with ex-spouse and his or her family.
Willingness to maintain financial
responsibilities and parental contact with
ex-spouse, and to support custodial
parent’s relationship with children.
Acceptance of one’s own part in the failure
of the marriage.
a. Working cooperatively on problems of
custody, visitation, and finances.
b. Dealing with extended family about the
divorce.
a. Mourning loss of intact family.
b. Restructuring marital and parent-child
relationships and finances; adaptation to
living apart.
c. Realignment of relationships with
extended family; staying connected with
spouse’s extended family.
a. Mourning loss of intact family.
b. Retrieval of hopes, dreams, expectations
from the marriage.
c. Staying connected with extended
families.
a. Making flexible visitation arrangements
with ex-spouse and family.
b. Rebuilding own financial resources.
c. Rebuilding own social network.
a. Finding ways to continue effective
parenting.
b. Maintaining financial responsibilities to
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
couple experiences from this decision would be
different.
Concept 2: Families Experience Transitions
From One Stage to Another
Disequilibrium occurs in the family during the
transitional periods from one stage of development
to the next stage. When transitions occur, families
experience changes in kinship structures, family
roles, social roles, and interaction. Family stress is
considered to be greatest at the transition points as
families adapt to achieve stability, redefine their
concept of family in light of the changes, and re-
align relationships as a result of the changes
(McGoldrick et al., 2010). For example, marriage
changes the status of all family members, creates
new relationships for family members, and joins
two different complex family systems.
Family developmental theorists explore whether
families make these transitions “on time” or “off
time” according to cultural and social expectations
3921_Ch03_067-104 05/06/14 10:56 AM Page 81
(Smith & Hamon, 2012; White & Klein, 2008). For
example, it is “off time” for a couple in their forties
to have their first child. It is still considered “on
time” in North America to have a couple be married
before the birth of a child, but that norm may be
changing given the increased numbers of babies
born to couples who are not married but cohabitate.
Even though some family developmental needs
and tasks must be performed at each stage of the
family life cycle, developmental tasks are general
goals, rather than specific jobs that must be com-
pleted at that time. Achievement of family devel-
opmental tasks enables individuals within families
to realize their own individual tasks. According to
family developmental theory, every family is
unique in its composition and in the complexity
of its expectations of members at different ages
and in different roles. Families, like individuals,
are influenced by their history and traditions and
by the social context in which they live. Further-
more, families change and develop in different
ways because their internal/external demands and
situations differ. Families may also arrive at simi-
lar developmental levels using different processes.
Despite their differences, however, families have
enough in common to make it possible to chart
family development over the life span in a way
that applies to most, if not all families (Friedman,
Bowden, & Jones, 2003). Families experience
stress when they transition from one stage to the
next. The predictable changes that are based on
these family developmental steps are called nor-
mative changes. When changes occur in families
out of sequence, “off time,” or are caused by a dif-
ferent family event, such as illness, they are called
nonnormative.
In contrast with the Duvall (1977) and later
Duvall and Miller’s (1985) traditional develop-
mental approach, Carter and McGoldrick (1989)
and McGoldrick et al. (2010) built on this work
by approaching family development from the per-
spective of family life cycle stages. They explored
what happens within families when family mem-
bers enter or exit their family group; they focus
on specific family experiences, such as disruption
in family relationships, roles, processes, and fam-
ily structure. Examples of a family member leav-
ing would be divorce, illness, a miscarriage, or
death of a family member. Examples of family
members entering would include birth, adoption,
marriage, or other formal union.
Today, the Developmental and Family Life
Cycle Theory remains useful as long as it is viewed
generally for use with families, despite all the cur-
rent variations of families. McGoldrick et al. (2010)
recently expanded the Family Life Cycle to incor-
porate the changing family patterns and broaden
the view of both development and the family.
Application of Developmental and Family
Life Cycle Theory to the Jones Family
In conducting family assessments using the devel-
opmental model, nurses begin by determining the
family structure and where this family falls in the
family life cycle stages. Using the developmental
tasks outlined in the developmental model, the
nurse has a ready guide to anticipate stresses the
family may be experiencing or to assess the devel-
opmental tasks that are not being accomplished.
Family assessment would also entail determining
whether the family is experiencing a “normative”
or “nonnormative” event in the family life cycle.
According to Duvall and Miller (1985), the
Jones family is in the Families With Young Adults:
Launching Phase because Amy left home and is now
a freshman at a college. She is living away from
home for the first time. Regardless of the fact that
the Jones family is experiencing a nonnormative
event (unexpected, developmental stressor) because
Linda, the mother, is now in the hospital, the fam-
ily is also experiencing the normative or expected
challenges for a family when the oldest child leaves
home. This is a good example of where major in-
dividual and whole family events coincide and pres-
ent challenges for families. Questions to explore
with the family might include the following:
1. How has the family addressed the realloca-
tion of family household physical space since
Amy left for school? (For example, the allo-
cation of bedrooms or the arrangement of
space within the bedroom if Katie and Amy
shared the bedroom).
2. How has Amy developed as an indirect
caregiver (such as calling home to chat with
dad and see how he is doing, talking with
the siblings and teasing or supporting their
efforts, or sharing with parents her school
life to reduce their worry about her
adjustment)?
3. How have family roles changed since Amy
left for school? What roles did Amy perform
82 Foundations in Family Health Care Nursing
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for the family that someone else needs to
pick up now? For example, who will per-
form such roles as chauffeur, grocery shop-
per, errand runner, and babysitter now
that Linda is not able and Amy is gone?
4. How has the power structure of the family
shifted now that Katie is more responsible
for the care of Travis?
5. How has the parents’ couple time changed
since Amy went off to college?
With the developmental approach, nursing
interventions may include helping the family to un-
derstand individual and family developmental tasks.
Interventions could also include helping the family
understand the normalcy of disequilibrium during
these transitional periods. Another intervention is
to help the family mitigate these transitions by cap-
italizing on family rituals. Family rituals serve to
decrease the anxiety of changes in that they help
link the family to other family members and to the
larger community (Imber-Black, 2005).
Family nurses must recognize that every family
must accomplish both individual and family devel-
opmental tasks for every stage of the Developmental
and Family Life Cycle. Events at one stage of the
cycle have powerful effects at other stages. Helping
families adjust and adapt to these transitions is an
important role for family nurses. It is important for
nurses to keep in mind the needs and requirements
of both the family as a whole and the individuals
who make up the family.
Strengths and Weaknesses of the
Developmental and Family Life Cycle
A major strength of the developmental approach is
that it provides a systematic framework for predict-
ing what a family may be experiencing at any stage
in the family life cycle. Family nurses can assess a
family’s stage of development, the extent to which
the family has achieved the tasks associated with
that stage of family development, and problems
that may or may not exist. It is a superb theoretical
approach for assisting nurses who are working with
families on health promotion. Family strengths and
available resources are easier to identify because
they are based on assisting families to achieve
developmental milestones.
A primary criticism of family development the-
ory is that it best describes the trajectory of intact,
two-parent, heterosexual nuclear families. The
original eight-stage model was based on a nuclear
family, assumed an intact marriage throughout the
life cycle of the family, and was organized around
the oldest child’s developmental needs. It did not
take into account divorce, death of a spouse, remar-
riage, unmarried parents, childless couples, or co-
habitating or gay and lesbian couples. It normalized
one type of family and invalidated others (Smith &
Hamon, 2012). Today’s families vary widely in
their makeup and in their roles. The traditional
view of families moving in a linear direction from
getting married, tracking children from preschool
to launching, middle-aged parents, and aging fam-
ilies is no longer so clear-cut and applicable. Carter
and McGoldrick (1989, 2005), Carter (2005), and
McGoldrick et al. (2010) expanded the family
developmental model to include stresses in the re-
married family. As family structures continue to
change in response to the culture and ecologic sys-
tem, trajectories of families likely will not fit within
the traditional developmental framework (White
& Klein, 2008).
Bioecological Systems Theory
Urie Bronfenbrenner was one of the world’s lead-
ing scholars in the field of developmental psychol-
ogy (Bronfenbrenner, 1972a, 1972b, 1979, 1981,
1986, 1997; Bronfenbrenner & Morris, 1998). He
contributed greatly to the ecological theory of
human development, which concentrated on the
interaction and interdependence of humans—as
biological and social entities—with the environ-
ment. Originally this idea was called the Human
Ecology Theory, then it was changed to Ecological
Systems Theory, and it finally evolved into the
Bioecological Systems Theory (Bronfenbrenner &
Lerner, 2004). The Bioecological System is the
combination of children’s biological disposition
and environmental forces coming together to
shape the development of human beings. This
theory combines both Developmental Theory
and Systems Theory to understand individual and
family growth.
Before Bronfenbrenner, child psychologists
studied children, sociologists examined families,
anthropologists analyzed society, economists scru-
tinized the economic framework, and political sci-
entists focused on political structures. Through
Bronfenbrenner’s groundbreaking work in “human
ecology,” environments from the family to larger
Theoretical Foundations for the Nursing of Families 83
3921_Ch03_067-104 05/06/14 10:56 AM Page 83
economic/political structures have come to be
viewed as part of the life course from childhood
through adulthood. This “bioecological” approach
to human development crosses over barriers among
the social sciences and builds bridges among the
disciplines, allowing for better understanding to
emerge about key elements in the larger social
structure that are vital for optimal human develop-
ment (both individual and family) (Boemmel &
Briscoe, 2001).
The human ecology framework brings together
other diverse influences. From evolutionary theory
and genetics comes the view that humans develop
as individual biological organisms with capacities
limited by genetic endowment (ontogenetic develop-
ment) that lead to hereditary familial characteristics.
From population genetics comes the perspective
that populations change by means of natural selec-
tion. For the individual, this means that individuals/
families demonstrate their fitness by adapting to
ever-changing environments. From ecological the-
ories come the notion that human and family de-
velopment is “contextualized” and “interactional”
(White & Klein, 2008, p. 247). All of this leads to
the never-ending debate related to the dual nature
of humans as constructions of both biology and
culture, hence the argument nature versus nurture.
Although this debate has never been resolved, sci-
entists have moved beyond debate to the realization
that the development of most human traits depends
on a nature/nurture interaction rather than on one
versus the other (White & Klein, 2008). Thus,
Bronfenbrenner moved his own theory and ideas
from the concept and terminology of ecology (en-
vironment) to bioecology (both genetics and soci-
ety) as a way of embracing two developmental
origins for this theory. His Bioecological Systems
Theory emphasizes the interaction of both the
biological/genetics (ontologic/nature) and the so-
cial context (society) characteristics of development
(Smith & Hamon, 2012; White & Klein, 2008).
The human bioecological perspective consists of
a framework of four locational/spatial contexts and
one time-related context (Bengtson, Acock, Allen,
Dilworth-Anderson, & Klein, 2005). A primary fea-
ture of this theory is the premise that individual and
family development is contextual over time. Accord-
ing to Bronfenbrenner, individual development is
affected by five types or levels of environmental sys-
tems (Figure 3-6) (Emory University, 2008). Family
Bioecological Theory describes the interactions and
influences on the family from systems at different
levels of engagement.
Microsystems are the settings in which individuals/
families experience and create day-to-day reality.
They are the places people inhabit, the people with
whom they live, and the things they do together.
In this level, people fulfill their roles in families,
with peers, in schools, and in neighborhoods where
they are in the most direct interaction with agents
around them.
Mesosystems are the relationships among major
microsystems in which persons or families actively
participate, such as families and schools, families
and religion, and families to peers. For example,
how does the interaction between families and
school affect families? Can the relationship
between families and their religious/spiritual com-
munities be used to help families?
Exosystems are external environments that influ-
ence individuals and families indirectly. The person
may not be an active participant within these sys-
tems, but the system has an effect on the persons/
families. For example, a parent’s job experience
affects family life, which, in turn, affects the chil-
dren (parent’s job’s travel requirements, job
stress, salary). Furthermore, governmental funding
to other microsystems environments—schools, li-
braries, parks, health care, and day care—affect the
experiences of children and families.
Macrosystems are the broad cultural attitudes, ide-
ologies, or belief systems that influence institutional
environments within a particular culture/subculture
in which individuals/families live. Examples include
the Judeo-Christian ethic, democracy, ethnicity,
and societal values. Mesosystems and exosystems
are set within macrosystems, and together they
are the “blueprints” for the ecology of human and
family development.
Chronosystems refer to time-related contexts where
changes occur over time and have an effect on the
other four levels/systems of development mentioned
earlier. Chronosystems include the patterning of
environmental events and transitions over the life
course of individuals/families. These effects are cre-
ated by time or critical periods in development and
are influenced by sociohistorical conditions, such as
parental divorce, unexpected death of a parent, or a
war. Individuals/families have no control over the
evolution of such external systems over time.
Within each one of these levels are roles,
norms, and rules that shape the environment.
84 Foundations in Family Health Care Nursing
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Theoretical Foundations for the Nursing of Families 85
CHRONOSYSTEM
Cha
nges
in person
s or environment over time
U
ne
xp
ec
te
d
de
at
h
of
p
ar
en
t B
roa
d i
de
olo
gy,
law
s, an
d cust
oms of one’s culture, subculture, or social class
MACROSYSTEM
Extended Family
EXOSYSTEM
MESOSYSTEM
MI
CRO
SYSTEM
Friends
of
family
Neighbors
Mass
media
Family Day-care
center
Community health
and
welfare services
Doctor’s office
Child
Legal
services
Workplace
Church,
synagogue Peers
School
board
Sociohistorical Conditions
D
isasters W
ar
s
Critical events (e.g., parental divorce)
School Neighborhood
play area
Church
School
FIGURE 3-6 Bioecological Systems Theory Model.
Bronfenbrenner’s model of human/family devel-
opment acknowledges that people develop not in
isolation, but rather in relation to their larger en-
vironment: families, home, schools, communities,
and society. All of these interactive, ever-changing,
and multilevel environments over time are key to
understanding human/family development.
Bronfenbrenner uses the term bidirectional to
describe the influential interactions that take place
between children and their relationships with
parents, teachers, and society. All relationships
among humans/families and their environment are
bidirectional or interactional. The environment in-
fluences us as individuals or families, but, in turn,
individuals/families influence what happens in their
own environments. This kind of interaction is also
basic to family systems theory.
In the bioecological framework, what happens
outside family units is as important as what hap-
pens inside individual members and family units.
3921_Ch03_067-104 05/06/14 10:56 AM Page 85
Developing families are on center stage as an ac-
tive force shaping their social experiences for them-
selves. The ecological perspective views children/
families and their environments as mutually shap-
ing systems, each changing and adapting over time
(again, a systems perspective). The bioecological
approach addresses both opportunities and risks.
Opportunities mean that the environment offers
families material, emotional, and social encourage-
ment compatible with their needs and capacities.
Risks to family development are composed of direct
threats or the absence of opportunities.
Application of the Bioecological Systems
Theory to the Jones Family
Assessment consists of looking at all levels of the
system when interviewing the family in a health
care setting. Assessment of the microsystem reveals
that the Jones family consists of five members: two
parents and three children. They live in a two-story
home with four bedrooms in an older suburban
section of the town. Mother Linda had been a full-
time homemaker before experiencing health prob-
lems related to her diagnosis of MS. The mesosystem
assessment for the family consists of identifying the
schools the children attend, neighborhood/friends,
extended family, and religious affiliation. The old-
est daughter is a college student who travels home
on weekends to help the family. The second daugh-
ter is in a local middle school and can walk back
and forth to her school. The youngest child, a boy,
attends an all-day preschool and is transported by
his parents or other parents from the preschool.
The family has attended a Protestant church in the
neighborhood. The family lives in a house in an
older established neighborhood, and has made
friends through the schools, church, and neighbor-
hood contacts. Part of the extended family (grand-
parents) live nearby, and all of the family members
get together for the holidays; neither parent has
siblings who live nearby. The exosystem assessment
shows that father Robert works 40 hours a week for
an industrial plant at the edge of town, and he
drives back and forth daily. The father has some
job stress, because he is in a middle-management
position. His salary is average for middle-class fam-
ilies in the United States. State and county funding
to the area schools, libraries, and recreational facil-
ities are always a struggle in this community. The
town has physicians/clinics of all specialties and has
one community hospital. An assessment of the
macrosystem shows that this community is largely
white, with only 10% of residents from ethnic
backgrounds. Most people in the community em-
brace a Christian ethic.
The value system includes a family focus and a
strong work ethic. Many of the people prefer the
Democratic Party. In terms of the time-related
contexts of the chronosystem, a few things are no-
table. These time-related events put more stress on
the family than usual nonnormative events. Linda’s
disease process with MS has exacerbated in recent
times, placing additional strain on the family sys-
tem. Robert’s own dad died in the past year, leaving
him extra responsibility for his widowed mother in
addition to his responsibility for his own children
and now ill wife. The economy in the country and
region is going through a recession, leading people
to feel some fear about their economic futures.
Robert had hoped that his wife could go to work
part-time when their youngest child went to
school, but that no longer seems to be a possibility.
The family assessment would include how the fam-
ily at each of the earlier-mentioned levels is influ-
enced by the changes brought about by Linda’s
progressing debilitative disease and recent hospi-
talization. The family is experiencing disturbance
at many of these levels.
Interventions include the following possibilities.
In general, nurses can also look for additional sys-
tems with which the family could interact to help
support family functioning during this family ill-
ness event. Nurses could make home visits to assess
the living arrangements of the family and to deter-
mine how the home could be changed to accom-
modate a wheelchair/walker. The nurses should
talk with the parents about their relationship to the
schools, church, and extended family support sys-
tems. The parents might be advised to inform the
school(s), church, workplace, and grandparents of
what is happening to their family. The nurses could
make suggestions relative to Travis’s current be-
havior with having to go to all-day preschool. The
nurses also could explore with the family the larger
external environment, including community re-
sources (e.g., Multiple Sclerosis Society, visiting
nurse service, or counseling services). The nurses
should contact the medical doctor(s) and discharge
planning nurse at the hospital to obtain informa-
tion to interpret the diagnosis, prognosis, and treat-
ment of MS to the family. The nurses might talk
to the family about how their faith can be of help
86 Foundations in Family Health Care Nursing
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during these tough times and what their primary
concerns are as a family. The nurses should get in
touch with the social workers at the hospital to co-
ordinate care and social well-being strategies for
the posthospitalization period, as well as in the
future. Strategies may involve application to social
security for the disabled. A family care planning
meeting should be set up to involve as many care-
takers and stakeholders as possible.
Evaluation of the interventions would consist
of follow-up with the family through periodic
home visits and telephone contact. The nurses
would be interested in how the family is adapting
to its situation, how the father is dealing with the
extra responsibility, how the children are coping,
and the physical and mental health of the mother.
Because MS is a chronic progressive relapsing dis-
order, a plan would be put into place for periodic
evaluations that might involve changing the plan
of care.
Strengths and Weaknesses of
the Bioecological Systems Theory
The strength of the bioecological perspective is that
it represents a comprehensive and holistic view of
human/family development—a bio/psycho/socio/
cultural/spiritual approach to the understanding of
how humans and families develop and adapt to the
larger society. It includes both the nature (biological)
and nurture (environmental contexts) aspects of
growth and development for both individuals and
families. It directs our attention to factors that
occur within, as well as to the layered influences of
factors that occur outside individuals and families.
The bioecological perspective provides a valuable
complement to other theories that may offer
greater insight into how each aspect of the holistic
approach affects individuals and families over time.
The strength of this theory is also part of the
weakness of this approach. The different systems
show nurses what to think about that may affect the
family, but the direction of how the family adapts is
not specifically delineated in this theory. In other
words, the bio/psycho/socio/cultural/spiritual as-
pects of human/family growth and development are
not detailed enough to define how individuals/
families can accomplish or adapt to these contextual
changes over time. Aspects of the theory require
further delineation and testing, that is, the influence
of biological and cognitive processes and how they
interact with the environment.
Chronic Illness Framework
The Chronic Illness Framework was proposed by
Rolland (1987, 1994) to help foster understanding
of how chronic illness affects the family. Chronic
illness is a complex concept that has vast implica-
tions for the individual and the family. Rolland’s
conceptual framework has evolved over time and
helps nurses think about multiple factors of the ill-
ness and how these influence family functioning.
This framework, sometimes called the Family Sys-
tems and Chronic Illness Framework (Rolland,
1987), has three major elements:
■ Illness types
■ Time phases of the illness
■ Family functioning
The illness types include the following aspects
of chronic illness: onset of the illness, the course
of the disease, the outcome of the illness, and the
degree of incapacitation of the family member.
The aspect of time addresses how issues facing
families and individuals vary depending on the
timing in the course of the illness, such as initial
diagnosis, long chronic illness day-to-day adjust-
ment phase, or terminal phase. All of these factors
influence the third major concept of family func-
tioning. Family functioning includes the demands
of managing the illness and the family strengths
and vulnerabilities. All of these aspects of the
Chronic Illness Framework are detailed in the fol-
lowing section. Figure 3-7 depicts the different
factors that influence how the family experiences
the chronic illness of a family member. The over-
arching factor for families living with chronic ill-
ness is the degree of uncertainty about how the
illness will present and affect the family. According
to the Chronic Illness Framework, it is possible to
have at a minimum 24 different configurations of
the factors that influence chronic illness and family
systems (Rolland, 1987).
Illness Types
Onset of Illness: Gradual or Acute
When chronic illness has an acute onset (e.g.,
a spinal cord injury, a traumatic brain injury, or
an amputation), the family reacts by rapid mobi-
lization of crisis mode strategies to manage the
situation. These strategies include short-term
role flexibility, accessing previously used problem-
solving approaches in other crises, and the ability
Theoretical Foundations for the Nursing of Families 87
3921_Ch03_067-104 05/06/14 10:56 AM Page 87
to use outside resources. As the acute phase of a
chronic condition morphs into a chronic illness—or
if a chronic illness has a gradual onset, such as
multiple sclerosis, Parkinson’s disease, or renal
failure—the family adaptation occurs over a pro-
longed period of time.
Course of Illness: Progressive, Constant,
or Relapsing/Episodic
The issues families manage are affected by the
course of the illness. Chronic disease, however, is
seldom a pure typology and over time it often
changes from one course to another. When indi-
vidual family members have a progressive chronic
illness, the disability occurs in a stepwise fashion.
It requires families to make gradual changes in
their roles to adapt to the losses and needs of the
family member as the illness progresses in severity.
The families must address perpetual symptoms,
which requires continual adaptation mixed with
minimal periods of relief. Thus, families usually
experience exhaustion from the demands of the
illness. As the disease progresses, new family roles
develop and family caregiving tasks evolve over
time. Examples of a progressive chronic illness are
amyotrophic lateral sclerosis (ALS), Huntington’s
disease, and Parkinson’s disease.
Chronic illness is considered constant when,
after the initial chaos and stress caused by the acute
illness/injury, it evolves into a semipermanent
change in condition that is stable and somewhat
predictable. The potential for family stress and
exhaustion are present, but to a lesser degree than
in a progressive chronic illness. Examples of a con-
stant chronic illness are spinal cord injuries, cere-
brovascular stroke, and myocardial infarction.
With a relapsing/episodic chronic illness, fam-
ilies alternate between stable low symptomology
periods and periods of exacerbation with flare-up.
Families are strained by both the frequency of the
transition between stable and unstable crisis
modes of functioning and the ongoing uncer-
tainty of when the remission and exacerbation
will occur. The uncertainty and unpredictability
of relapsing is very taxing on families. Examples
88 Foundations in Family Health Care Nursing
Initial/crisis Mid Terminal
Illness Types
Family Functioning Time Phases
Demands of
illness
Family strengths
and vulnerabilities
Chronic Illness Framework
(Rolland, 1987)
Non-fatal
Unpredictable
Fatal
Incapacitating
Non-incapacitating
Progressive
Constant
Relapsing
Gradual
Acute
FIGURE 3-7 Family systems and illness model.
3921_Ch03_067-104 05/06/14 10:56 AM Page 88
of relapsing/episodic chronic illness are multiple
sclerosis, bipolar disorder, schizophrenia, and lupus.
Outcome: Trajectory of Illness
The trajectory of the illness and the possible out-
come affect family functioning. Stress is constant
and adaptation strained when the chronic illness has
a fatal outcome that results in a shortened life span,
such as metastatic cancers, ALS, Huntington’s
disease, or cystic fibrosis. Other chronic illnesses
do not shorten the individual’s life span, so they
do not generate the same amount of family adjust-
ment as other outcomes. Types of chronic illness
that do not shorten a person’s life span are arthri-
tis, chronic fatigue syndrome, and gluten intoler-
ance. Some chronic illnesses both shorten the life
span of the individual and have the potential for
sudden death. Examples of these types of chronic
illness include congestive heart failure and auto-
nomic dysreflexia with a high spinal cord injury.
These types of chronic illness present with a dif-
ferent set of family stressors and adaption needs
than either of the two other possible outcomes or
trajectories.
Outcome: Incapacitation
The extent and kind of incapacitation of the illness
places different stressors on the family and the in-
dividual living with chronic illness. Incapacitation
can present in a variety of ways, such as cognitive
(Alzheimer’s disease, Parkinson’s disease), energy
production or expenditure (congestive heart failure,
chronic obstructive pulmonary disease), impaired
mobility (stroke, multiple sclerosis, cerebral palsy),
disfigurement (amputation, scars), or social stigma
(mental health disorders or HIV).
Time Phases
The stress responses and needs of the family
change depending on the time phase of the illness.
The needs of the family when a chronic illness is
newly diagnosed are different than when a person
adjusts and lives with the illness over time. The
needs change again when ill family members enter
the terminal phase of their chronic illness. Specific
family stressors or needs for each time phase are
outlined below.
Initial/Crisis Time Phase
When family members are first diagnosed with a
chronic illness they must (1) establish a positive
working relationship with health care providers,
(2) gather information about the diagnosis, and
(3) accept the diagnosis (Danielson, Hamel-Bissell,
& Winstead-Fry, 1993). All diagnoses have the po-
tential to create stress. The diagnostic process cre-
ates stress and uncertainty in families. Families
vary in their ability to seek resources or informa-
tion and to understand the ramifications of the
diagnosis. For some families, the diagnosis is un-
expected and can put the family in a crisis mode.
For other families, the diagnosis is confirmation of
their observations and concerns and so may result
in relief. Families may or may not accept the diag-
nosis. Some families may deny the diagnosis, and
others will question the diagnosis and seek other
opinions. Once a medical diagnosis is given to
families, the diagnosis becomes public knowledge,
which means that everyone who knows the diag-
nosis has a reaction and response. Families may
choose to keep the information within their family
unit or be discriminating about whom they tell.
Nurses have a central role in providing informa-
tion to families with new diagnoses and helping
them navigate the health care system. Family
education is critical to the health outcomes, specif-
ically integrating the medical treatment plan into
family life and family roles.
Mid–Time Phase
The mid–time phase is considered the “long haul”
of chronic illness (Rolland, 1987, 2005a). Rolland
(2005a) outlined the salient issues in this phase:
(1) pacing and avoiding burnout, (2) minimizing
relationship skew between the patient and other
family members, (3) sustaining autonomy for
all members of the family, (4) preserving or
redesigning individual and family development
goals within the constraints of the illness, and
(5) sustaining intimacy in the face of threatened
loss. According to Danielson, Hamel-Bissell, and
Winstead-Fry (1993), this time phase also includes
the following challenges: (1) accept the treatment
plan, (2) reorganize family roles, and (3) maintain
a positive relationship with health care providers.
Once families accept the diagnosis, they move into
what Danielson et al. (1993) called “illness career,”
which is a way that families adapt and adjust to the
illness on a day-by-day basis. The major challenge
of the family is to redefine what is a normal bal-
anced family life while also facing uncertainty
about the future (Rolland, 2005a, 2005b). During
this phase, families are constantly adjusting to the
situation caused by the illness. Families vary in
Theoretical Foundations for the Nursing of Families 89
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their ability to adjust to the illness situation—the
more problems adjusting, the more stress families
will experience. Family role stress, role strain, and
role overload can occur when the family lives with
illness over a long period.
Family tasks in this phase are to redefine normal,
adjust to social stigma or altered relationships
caused by the disability or illness, continue to main-
tain positive relationships with the health care
team, and successfully grieve the loss caused by the
disability or chronic condition. The family must
adjust continually to the remission and exacerba-
tions of the illness. One of the major tasks is to bal-
ance the needs of the family and the needs of ill
family members (Danielson et al., 1993).
Families must adapt to the demands of the
chronic condition; thus, a whole body of informa-
tion has evolved around family coping and family
adaptation with medical regimens. How do families
promote the recovery of ill members while preserv-
ing their energy to nurture other family members
and perform other family functions? An example of
an appropriate intervention would be to help fam-
ilies find respite care for family caregivers so that
caregivers do not “burn out.” The family relation-
ship with the health care provider(s) is a critical
component of this phase. Families expect that they
will be active members of the treatment team.
Terminal Time Phase
The nursing tasks in the terminal time phase con-
sist of working with the family through the dying
of the family member, through the grieving
process, to integrating the loss into the family and
family life. Nurses can work with families to change
focus from managing the illness to comfort care
strategies and working on the concept of “letting
go” (Rolland, 2005a). During this time, an impor-
tant nursing role is to help families with the cascade
of decisions that occur in the terminal phase. Each
family member will respond differently to the loss,
and the family will be forever changed by the loss.
The loss requires the family to adjust and adapt
to the finality and to develop or generate a different
sense of identity of family without the person
(see Chapter 10).
Family Functioning
Families, as a whole, experience health events.
When family members become ill, it triggers a
stress response in the family to adapt to the needs
of the individual and the family member. As
presented earlier in the chapter, the demands of the
illness can take multiple forms, depending on the
illness type and the time phases of the illness. As
each family is unique in its strengths and vulnerabil-
ities, the ways in which families adapt to the chal-
lenge of chronic illness are vast and too numerous
to list, which reinforces the opening statements of
this chapter that nurses who bring knowledge of a
variety of models, theories, and conceptual frame-
works to their practice tailor their practice to the
family needs by building on the strength of families
in creative ways.
Application of the Chronic Illness
Framework to the Jones Family
The Jones family is living with, adjusting to, and
stressed and influenced by Linda’s chronic illness
of multiple sclerosis (MS). The course of MS is a
gradual onset of symptoms. Linda was diagnosed
after the birth of her second child, Katie; therefore,
the Jones family has been living with her chronic
illness for 13 years. The course of illness for Linda is
typical of many individuals with MS. For the first
10 years, or in the Jones’ case 13 years, of the dis-
ease, the most common type of MS is relapsing MS
(RMS), which is characterized by exacerbation
(relapses and attacks) followed by partial recovery
periods (remission) and no disease progression be-
tween exacerbations. For most people with MS,
after this initial course of disease, the presentation
changes to progressive. At this point in time,
Linda’s illness has morphed to secondary progres-
sive MS (SPMS), which is characterized by a
steadily worsening disease course with or without
occasional exacerbations, minor partial recoveries,
or plateaus until death. Approximately 50% of
people with RMS will convert to SPMS within
10 years (Lewis, Dirksen, Heitkemper, Bucher, &
Camera, 2011). The Jones family remains in the
mid–time phase of the illness trajectory, but the
change in the course of Linda’s illness brings
with it increased incapacitation and an unpredictable
outcome.
The Jones family is constantly adjusting and
adapting to the course of Linda’s illness and in-
creasing incapacitation. The family is exhausted
with managing this change; solutions that have
worked for this family in the past are not working
now. The family roles need to be supported, rede-
fined, or renegotiated. Each of the members is ex-
periencing role stress and strain. Linda is having
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to “let go” of more of her mothering role and ac-
tions. Her self-concept regarding her illness has
been changed. Robert is having role overload with
all the changes in his life. The intimacy needs of
the couple are stressed by these changes. Amy is
thinking of staying home and not going to college
in another town. Katie is now a struggling student.
Travis is a full-day student in a preschool. Grand-
mother, Elise, will no longer be living independ-
ently as she moves into the Jones family home to
assume new roles as caretaker to the children and
Linda. All the role changes, and seeing Linda get
worse or more incapacitated, creates uncertainty
about the future for each member and the family
as a whole. Each family member experiences un-
certainty differently based on age, family roles,
role expectations, and the developmental needs of
each person.
Family functioning is of central concern for the
family nurse as he helps Linda and the family learn
to adapt to new treatment and regimen manage-
ment issues and establish a new normal day-to-day
long-haul balance. One aspect of family function-
ing the nurse can help with revolves around family
roles. The nurse can assist by exploring options for
care and potential future decisions the family may
face as Linda’s health continues to decline and the
time phase changes to terminal.
Strengths and Weaknesses of the Chronic
Illness Framework
The strength of this descriptive framework is that
it outlines how multiple factors of a chronic illness
can be grouped in a variety of ways that affect
family functioning. Rolland’s (1987, 1994) con-
ceptual framework depicts the complexity of
chronic illness and the diversity of potential family
responses to chronic illness. It may appear at first
glance that families have similar circumstances
given the same chronic illness, but on closer as-
sessment it becomes clear that families’ experi-
ences of the different components of this
framework result in different family stressors and
strengths.
The weakness of this model is the same as the
strengths in that the complexity of chronic illness is
not predictive. Because this framework depicts how
the individual’s illness progresses from more of a
medical model, it is easy for nurses to focus only on
that part of the framework and not think about the
overarching aspect of the family as a whole.
Family Assessment and Intervention
Model
The Family Assessment and Intervention Model,
originally developed by Berkey and Hanson
(1991), is based on Neuman’s Health Care Sys-
tems Model (Hanson, 2001; Hanson & Mischke,
1996; Kaakinen & Hanson, 2010). Neuman’s
model and theoretical constructs are based on
systems theory and were extended and modified
to focus on the family rather than on the individ-
ual (Neuman & Fawcett, 2010). Figure 3-8 de-
picts the Family Assessment and Intervention
Model.
According to the Family Assessment and Inter-
vention Model, families are viewed as a dynamic,
open system interacting with their environment.
One of the roles for families is to help buffer their
members, or protect the family as a whole, from
perceived threats to the family system. The core of
the family system comprises basic family structure,
function, processes, and energy/strength resources.
This basic family structure must be protected at all
costs, or the family ceases to exist. The family de-
velops normal lines of defense as an adapting mech-
anism and abstract flexible protective lines of
defense when the system is threatened by signifi-
cant stressors. Family systems are vulnerable to
tensions produced when stressors in the form
of problems or concerns penetrate the family’s lines
of defenses. Families also have lines of resistance to
help prevent penetration into the basic family core.
The lines of defense and resistance depicted in the
model (see Fig. 3-8) demonstrate how unexpected/
unwanted health status changes can affect the basic
family unit or core.
Families are subject to imbalance from normal
homeostasis when stressors (e.g., physical or mental
health problems) penetrate families’ flexible and
normal lines of defense. Furthermore, the stressors
can challenge the families’ lines of resistance, which
have been put in place to maintain stability and to
prevent penetration of the basic family defense sys-
tem. In other words, health events cause families to
react to stressors created by changes in the health
status of a family member. Families vary in their
response to the stressors and in their ability to
cope, depending on how deeply the stressors pen-
etrate the basic family unit and how capable or ex-
perienced the family is in adapting to maintain its
stability.
Theoretical Foundations for the Nursing of Families 91
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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
A
re
a
3:
R
es
to
ra
tio
n
of
fa
m
ily
s
ta
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lit
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d
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ily
fu
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tio
ns
a
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ev
el
s
of
p
re
ve
nt
io
n/
in
te
rv
en
tio
n
A
rea 2: Fam
ily’s reaction and instability at lines of defense and resistance
CORE
Basic family structure,
function, process,
and energy resources
Norm
al line of defense
N
orm
al line of defense
Se
co
nd
ar
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pr
ev
en
tio
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in
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/in
te
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Lines
of resistance
Lines of resistance
Te
rtia
ry
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Flexib
le line of defense
StressorsStre
ssor
s
F
lex
ib
le
lin
e o
f d
efense
Stre
sso
rs
Stressors
FIGURE 3-8 Family Assessment and Intervention Model.
Reconstitution or adaptation is the work the
family undertakes to preserve or restore family sta-
bility after stressors penetrate the family lines of
defense and resistance. This process alters the
whole of the family. The model addresses three
areas: (1) wellness–health promotion activities—
problem identification and family factors at lines of
defense and resistance, (2) family reaction and in-
stability at lines of defense and resistance, and
(3) restoration of family stability and family func-
tioning at levels of prevention and intervention.
The Family Assessment and Intervention Model
focuses specifically on what causes family stress and
how families react to this stress. One critical con-
cept is to build on the family’s strengths by helping
the family identify its problem-solving strategies.
The basic assumptions of this family-focused
model are listed in Box 3-1.
3921_Ch03_067-104 05/06/14 10:56 AM Page 92
Family Systems Stressor-Strength Inventory
Berkey and Hanson (1991) developed an assess-
ment, intervention, and measurement tool, the
Family Systems Stressor-Strength Inventory (FS3I),
to help guide nurses working with families who
are undergoing stressful health events and to
build on the strengths of the family. The FS3I is
divided into three sections: (1) family systems
stressor—general, (2) family stressors—specific,
and (3) family system strengths. The tool helps
nurses assess family stability by gathering infor-
mation on family stressors and strengths. The as-
sessment of general, overall stressors is followed
by an assessment of specific issues or problems,
such as birth of first child, automobile accident,
or family divorce. The tool helps to identify fam-
ily strengths to help determine potential or actual
problem-solving abilities of the family system.
Examples of family strengths could include sup-
portive extended family, health insurance, and
availability of family counseling.
The FS3I is intended for use with multiple fam-
ily members. Individual members of the family can
complete the FS3I, or the entire family can sit
together and complete the assessment. The nurse
meets with family members and interviews them to
clarify their perceived general stressors, specific
stressors, and family strengths as identified by the
family members.
After the interview, the nurse completes the
quantitative summary and enters each respondent’s
score on the graph. Recording individual scores on
the graph allows for a comparison of the family re-
sponses and visually shows the variability among
family members’ perceptions of general and specific
health stressors. The nurse synthesizes the inter-
view information gleaned from all the family par-
ticipants on the qualitative summary. Together, the
nurse and family develop a family care plan with in-
tervention strategies tailored to the individual fam-
ily needs and built on the strengths of the family.
A major benefit of using the FS3I for family as-
sessment and intervention planning is that both
quantitative and qualitative data are used to deter-
mine the level of prevention and intervention
needed: primary, secondary, or tertiary (Pender,
Murdaugh, & Parsons, 2006). Primary prevention
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
families have a common basic structure that is a com-
posite of common, known factors or innate characteris-
tics within a normal given range of response.
■ Family wellness is on a continuum of available energy
to support the family system in its optimal state.
■ The family, in both a state of wellness or illness, is a
dynamic composite of interrelationships of variables
(physiological, psychological, sociocultural, developmental,
and spiritual).
■ A myriad of environmental stressors can affect the fam-
ily. Each stressor differs in its potential for disturbing the
family’s stability level or normal line of defense. The
specific family interrelationships (physiological, psycho-
logical, sociocultural, developmental, and spiritual) af-
fect the degree to which a family is protected by its
flexible lines of defense against possible reactions to
the stressors.
■ Families evolve a normal range of response to the envi-
ronment, which is called a normal line of defense. The
normal line of defense is flexible or accordion-like as it
moves to protect the family.
■ When the flexible line of defense is no longer capable
of protecting the family or family system against the
environmental stressor, the stressor is said to break
through the normal line of defense.
■ Families have an internal resistance factor called the line
of resistance that functions to stabilize and return the
family to its usual wellness state (normal line of de-
fense), or possibly to a higher level of stability after an
environmental stressor reaction.
■ Primary prevention is general knowledge that is applied
in family assessment and intervention for identification
and mitigation of risk factors associated with environ-
mental stressors to prevent possible reaction.
■ Secondary prevention is symptomatology after reaction
to stressors, appropriate ranking of intervention priori-
ties, and treatment to reduce their noxious effects.
■ Tertiary prevention is the adjusting processes that take
place as reconstitution begins and maintenance factors
move the client back in the circular manner toward
primary prevention.
■ The family is in a dynamic, constant energy exchange
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.
3921_Ch03_067-104 05/06/14 10:56 AM Page 93
focuses on moving the individual and family to-
ward a state of improved health or toward health-
promotion activities. Primary interventions include
providing families with information about their
strengths, supporting their coping and functioning
capabilities, and encouraging movement toward
health through family education. Secondary inter-
ventions attain system stability after stressors or
problems have invaded the family core. Secondary
interventions include helping the family to handle
its problems, helping family members to find and
use appropriate treatment, and intervening in
crises. Tertiary prevention is designed to maintain
system stability through intervention strategies that
are initiated after treatment has been completed.
Coordination of care after discharge from the hos-
pital and postdischarge rehabilitation services are
examples of tertiary prevention.
The Family Assessment and Intervention Model
focuses on the family as client. The Family Systems
Stressor-Strength Inventory (FS3I) was developed to
provide a concrete, focused assessment and interven-
tion instrument that helps families identify current
family stressors and strengths and that assists nurses
and families in planning interventions to meet family
needs. The model and inventory represent a nursing
model made for nursing care of families. An updated
blank copy of the instrument, with instructions for
administration and a scoring guide, can be found in
Appendix A. A summary of a completed instrument
applied to the case study follows.
Application of the Family Assessment and
Intervention Model With the Jones Family
The FS3I was used to assess stressors (problems)
and strengths (resources) that the Jones family had
to cope with their situation. Robert and Linda were
interviewed together by the nurse, but each person
completed a separate FS3I. Scores were tallied
using the scoring guide for the FS3I. Amy was away
attending college, and Katie and Travis were too
young to complete the assessment instrument.
The general stressors were viewed similarly by
both Robert and Linda, and these stressors were
assessed as more serious by the nurse than by the
couple. Robert, Linda, and the nurse concurred
that the general stress level was high. The specific
stressors were perceived slightly differently by
Robert and Linda. The following figures summa-
rize information gained from the Jones family:
Figure 3-9, which applies the FS3I to the Jones
Family; Figure 3-10, which presents an FS3I quan-
titative summary of family system stressors, general
and specific, for the Jones family; Figure 3-11,
which lists FS3I family and clinician perception
scores of the Jones family; Figure 3-12, which is an
FS3I qualitative summary, family and clinician, of
the Jones family; and Figure 3-13, which provides
an FS3I family care plan for the Jones family.
The qualitative summary, family and clinician
form in Figure 3-12, serves as the groundwork for
the family care plan. This form synthesizes infor-
mation pertaining to general stressors, specific
stressors, family strengths, and the overall func-
tioning and physical and mental health of the fam-
ily members. The nurse completed this form using
her assessment skills with information obtained
from the verbal exchange and the FS3I.
The family members and the nurse perceived
that the chronic and debilitating diagnosis of MS
was the major general stressor. Linda’s specific
stressors included her growing inability to func-
tion as a wife and mother; her physical problems,
such as increasing physical weakness, swallowing
challenges, pain, vision impairment, vertigo/tinnitus,
constipation, urinary infections; and her mental
health issues, such as guilt, anxiety, and depression.
Specific stressors for Robert included his worry
about Linda’s health; loss of his life’s partner in
taking care of the family, household maintenance,
and raising children; fear of the unknown future
and health outcomes; loss of sexual expression with
his wife; and financial worries. The strengths of
the family were seen as communication between
the couple, religious faith, the social support net-
work of extended family, and the availability of
good health providers. The overall family func-
tioning was considered to be as good as could be
expected under the circumstances. Where the
mother’s physical health was compromised, the
father’s physical health was good. Both Linda
and Robert expressed mental health concerns.
Overall, the nurse perceived that this family
had the strengths it needed to deal with both the
general and specific stressors. After completing a
genogram (Fig. 3-3) and ecomap (Fig. 3-4) of this
family unit, the nurse concluded that the family
was being supported by community/family re-
sources. These social support systems are impor-
tant factors in coping with stress, and the nurse
concluded that this family could use assistance in
utilizing these resources.
94 Foundations in Family Health Care Nursing
3921_Ch03_067-104 05/06/14 10:56 AM Page 94
Theoretical Foundations for the Nursing of Families 95
The Family Systems Stressor-Strength Inventory (FS
3
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
noitacudE pihsnoitaleR ylimaF
Members in Family Age Marital Status (highest degree) Occupation
1. Robert Father 48 yr Married MS Software engineer
2. rekam emoHdeirraMry 34rehtoMadniL
3. Amy Daughter 19 yr Single
4. Katie Daughter 13 yr Single
5. Travis Son 4 yr Single
6.
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
permission.)
The family care plan for the Jones family was
developed by the nurse in concert with the family
members who completed the FS3I (see Fig. 3-13).
The family care plan addresses the diagnosis
of general and specific family systems stressors
and family systems strengths that support the
family care plan and the goals of the family
and the clinician(s): interventions/prevention
activities—primary/secondary/tertiary, and outcome/
evaluation/replanning proposed for this family.
The goal of this family care plan was to achieve a
restoration of optimum health that could provide
homeostasis and stability for this family, as well
as more positive health outcomes than the family
could reach at the beginning of their health
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.)
YLIMAF)LARENEG( SROSSERTS SMETSYS YLIMAF SYSTEMS STRESSORS (SPECIFIC)
SCORES FOR FAMILY MEMBER CLINICIAN SCORES FOR FAMILY MEMBER CLINICIAN
WELLNESS PERCEPTION PERCEPTION WELLNESS PERCEPTION PERCEPTION
AND STABILITY SCORE SCORE AND STABILITY SCORE SCORE
0.50.5
X8.48.4 √1
6.46.4
4.4
X
4.4
X
4.2
X√1
4.2
X√2
4.0 X√ 0.42
8.38.3
6.36.3
4.34.3
2.32.3
0.30.3
8.28.2
6.26.2
4.24.2
2.22.2
0.20.2
8.18.1
6.16.1
4.14.1
2.12.1
0.10.1
*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 3-10 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.)
FAMILY SYSTEMS STRENGTHS
SUM OF STRENGTHS
AVAILABLE FOR PREVENTION/ FAMILY MEMBER CLINICIAN
EROCS NOITPECREPEROCS NOITPECREPEDOM NOITNEVRETNI
5.0
4.8
4.6
4.4 X
4.2
√2
4.0
3.8
3.6
3.4 √1
3.2
3.0
2.8
2.6
2.4
2.2
2.0
1.8
1.6
1.4
1.2
1.0
3.2-0.1eniL elbixelF :edoM noitnevretnI/noitneverP YRAMIRP* √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
family.
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
and Specific Family
System Stressors
Dx of MS
weakness of
swallowing, pain,
vision impairment,
vertigo/tinnitus,
constipation,
urinary infections,
guilt/anxiety,
depression, sexual
dysfunction, over-
load for caregiver
father.
Couple
communication,
religious faith,
social support of
extended family,
good medical care.
Restoration of
stability and
homeostasis at
each level of
progressive
chronic illness.
Support of family
changes, connect
family with MS
family support
group, locate
part-time family
helper for home,
coordinate with
other medical
groups involved,
set up rehabilitation,
and physical
therapy.
Couple receives
counseling, pain
and symptom
management;
involve social
worker to look at
community agencies
to offer assistance.
Evaluation to be done
once plan
implemented.
Family Systems
Strengths Supporting
Family Care Plan
Primary, Secondary,
or Tertiary
Prevention/
Intervention Activities
Outcomes Evaluation
and Replanning
Goals for Family
and Clinician
FIGURE 3-13 Family care plan: Jones family.
section of the family care plan remains blank for
now because it is dependent on feedback from the
interventions proposed for the family, as well as
the physical and mental health status of the entire
family.
Strengths and Weaknesses
The strength of the FS3I approach is that both
quantitative and qualitative data are used to deter-
mine the level of prevention and intervention
needed: primary, secondary, or tertiary. The in-
strument is brief, is easy to administer, and yields
data to compare one family member with another
member and one family with another family. The
weakness of this model and instrument is that they
focus only on family strengths and stressors rather
than all the dimensions of the family as a unit. This
model and instrument hold much promise for nurs-
ing assessment of families, but more work needs to
be done on this approach. See Box 3-2 for a com-
parison of the approaches.
SUMMARY
By understanding theories and models, nurses are
better prepared to think creatively and critically
about how health events affect the family. This
chapter introduced nurses to the concept of theory-
guided, evidence-based family nursing practice.
It presented the relationship between theory,
practice, and research, and explained crucial as-
pects of theory. The chapter then explored five
theories and models for the nursing care of fami-
lies and applied the theories to the case study in
the chapter:
■ Family Systems Theory
■ Developmental and Family Life Cycle Theory
■ Bioecological Theory
■ Chronic Illness Framework
■ Family Assessment and Intervention Model
The chapter revealed how nurses can practice
family nursing differently with the Jones family ac-
cording to the different theoretical perspectives.
The following points highlight critical concepts
that are addressed in this chapter:
■ No single theory, model, or conceptual
framework adequately describes the complex
relationships of family.
■ No one theoretical perspective gives nurses
a sufficiently broad base of knowledge and
understanding to guide assessment and
interventions with all families.
■ No one theoretical perspective is better,
more comprehensive, or more correct than
another.
■ Nurses who draw from multiple theories
are more effective in tailoring their nursing
practice and family interventions. Using
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
Conceptual
Family is viewed as a whole. What happens to the family
as a whole affects each individual family member, and
what happens to individuals affects the totality of the fam-
ily unit. Focus is on the circular interactions among mem-
bers of the family system, resulting in functional or
dysfunctional outcomes.
Assessment
The family may be assessed together or individually.
Assessment questions relate to the interaction between
the individual and the family, and the interaction between
the family and the community in which the family lives.
Intervention Examples
■ Complete a family genogram to understand patterns
and relationships over several generations over time.
■ Complete family ecomap to see how individuals/family
relate to the community around them.
■ Collect data about the family as a whole and about
individual family members.
■ Conduct care-planning sessions that include family
members.
Strengths
Focus is on family as a whole or its subsystems, or both. It
is a generally understood and accepted theory in society.
Weaknesses
Theory is broad and general. It does not give definitive
prescriptions for interventions.
Application to Jones Family
All members of the Jones family are affected by the
mother’s progressive chronic health condition and
changes. Family structure, functions, and processes of the
family are influenced, changing family roles and dynamics.
Everyone in the family has his or her own concerns and
needs attention from health care professionals.
Family Developmental and Life Cycle Theory
Conceptual
Family is viewed as a whole over time. All families go
through similar developmental processes starting with the
birth of the first child to death of the parents. Focus is on
the life cycle of families and represents normative stages
of family development.
Assessment
The family may be assessed together or individually. As-
sessment questions relate to the normative predictable
events that occur in family life over time. It also includes
nonnormative, unexpected events.
Intervention Examples
■ Conduct family interview to determine where family is
in terms of cognitive, social, emotional, spiritual, and
physical development.
■ A family genogram and ecomap should be completed.
■ Determine the normative and nonnormative events that
have occurred to the family as a whole or to individuals
within the family.
■ Analyze how an individual’s growth and developmental
milestones may affect the family developmental trajectory.
Strengths
Focus is on the family as a whole. The theory provides a
framework for predicting what a family will experience at
any given stage in the family life cycle so that nurses can
offer anticipatory guidance.
Weaknesses
The traditional linear family life cycle is no longer the
norm. Modern families vary widely in their structure and
roles. Divorce, remarriage, gay parents, and never-married
parents have changed the traditional trajectory of growth
and developmental milestones. The theory does not
focus on how the family adapts to the transitions from
one stage to the other; rather, it simply predicts what
transitions will occur.
Application to Jones Family
The Jones family is in the stages of “families with adoles-
cents” and “launching young adults.” The nonnormative
health condition of the mother is changing the predictable
normative course of development for the individuals and
for the family as a whole. These health events will change
the cognitive, social, emotional, spiritual, and physical de-
velopment as the family shifts to integrate new roles into
their lives as family members.
Bioecological Systems Theory
Conceptual
Bioecological systems theory combines children’s biologi-
cal disposition and environmental forces that come to-
gether to shape the development of human beings. This
theory has a basis in both developmental theory and sys-
tems theory to understand individual and family growth.
It combines the influence of both genetics and environ-
ment from the individual and family with the larger eco-
nomic/political structure over time. The basic premise is
that individual and family development are contextual
over time. The different levels of the theory that apply to
the family at any one point in time vary depending on
what is happening at that time. Therefore, the interaction
of the systems vary over time as the situation changes.
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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
Assess all levels of the larger ecological system when
interviewing the family. Determine the microsystem,
mesosystem, exosystem, macrosystem, and chronosys-
tem of the individual and of the family as a whole.
Intervention Examples
■ Conduct a family interview to determine the family’s sta-
tus in relationship to four locational/spatial contexts and
one time-related context.
■ A family genogram and ecomap should be completed.
■ Determine how individuals are doing in relationship to
their entire environment, which includes immediate
family, extended family, home, school, and community.
■ Analyze the family in its smaller and larger contextual
aspects.
Strengths
Focus is on a holistic approach to human/family develop-
ment. A bio/psycho/socio/cultural/spiritual approach to
understanding how individuals and families develop and
change/adapt over time in their society is a more com-
plete approach.
Weaknesses
This holistic approach is not specific enough to define
contextual changes over time. Nor can the larger context
in which individuals/families are embedded be predicted
or controlled.
Application to Jones Family
■ Microsystem: The Jones family consists of school-age
children living at home. The parental roles have been
traditional until recent health events.
■ Mesosystem: Family has much interaction with schools,
church, and extended family.
■ Exosystem: Family influenced by father’s work at the fac-
tory and other institutions in the community.
■ Macrosystem: Family consistent with community culture,
attitudes, and beliefs. Their community is largely Cau-
casian, middle class, and Christian.
■ Chronosystem: At this time in the illness story of the
Jones family with the mother’s illness changing, the
family situation changes and moves between stability
and crisis.
Chronic Illness Framework
Conceptual
This is a conceptual framework and not a theory. There-
fore, each aspect of the framework represents several
fields of inquiry relative to chronic illness. The framework
has been built and data have been organized to provide a
coherent way of thinking about families when a member
has a chronic illness. The areas of inquiry that inform this
model are onset of the chronic illness, course of illness,
outcome or trajectory of the chronic illness, outcome rela-
tive to degree of incapacitation from the illness, time
phase of the illness, and family functioning.
Assessment
In this framework, it is important first to analyze the vari-
ous aspects of the specific type of chronic illness. Each
aspect presents a different type of stress or challenge for
the family based on the particular chronic illness. The last
aspect of the framework, family function, requires the
family nurse to explore how the specific chronic illness
affects this specific family based on the demands of the
illness and the family strengths and vulnerabilities.
Intervention Examples
■ Complete a family genogram and ecomap.
■ Implement a plan of care to help facilitate family adap-
tation and coping strategies.
■ Work with families by building on the family strengths to
adjust family roles to help the family with managing the
stressors identified in this specific chronic illness for this
specific family.
Strengths
The Chronic Illness Framework is designed to support
family-centered nursing care. Focus is on family strengths
and vulnerabilities through identified predictable stressors
experienced by families who are in that aspect of the
chronic illness. Anticipatory guidance can be provided as
the chronic illness may progress through typical trajecto-
ries or times phases.
Weaknesses
The model is not specific enough to identify precise ways
families adapt; rather, it is more of a guideline to typical
stressors and coping tasks that may happen when a fam-
ily member develops a chronic illness.
Application to Jones Family
The Jones family is struggling to adapt during the rocky
chronic illness phase. As the mother’s illness has changed
from being episodic to progressive in nature, the family is
stressed with adapting to the mother losing ambulation
and needing more physical support than in the past. The
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.
Family Assessment and Intervention Model
Conceptual
Families are viewed as dynamic, open systems in interac-
tion with their environment. A major role of family is to
Continued
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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
threaten the family’s inner core. The inner core of the
family consists of family structure, function, process, and
energy/strength resources and must be protected or the
family ceases to exist. Adaptation is the work the family
undertakes to preserve/restore family stability. This model
evolved out of nursing and builds on general systems
theory, stress theory, and change theory.
Assessment
Family may be assessed together, but all individuals
are asked to complete the measurement instrument. The
Family Systems Stressor-Strength Inventory (FS3I)
is administered to determine general family stressors, spe-
cific family stressors, and family system strengths. The
stressors that affect the balance of the family strengths are
analyzed to assist the family to achieve stability.
Intervention Examples
■ The FS3I is completed by all adult individuals in the
family. Scores are derived from the measurement scales
and then analyzed. Health care providers meet with
families to review results and provide different interven-
tion strategies based on the specific stressors, how the
family is coping, and what strengths are brought to the
situation.
■ A family genogram and ecomap should be completed.
Strengths
The model and instrument provide a structured approach
to family assessment and intervention based on both
quantitative and qualitative data. These data help deter-
mine the primary, secondary, and tertiary levels of preven-
tion and intervention. The focus on family strengths is
unique to this model and approach.
Weaknesses
This model is used specifically when families enter
the health care system. It is applicable when health
problems have come up that cause stressors. Although
the model per se is applicable to all families in terms
of life stressors and strengths, the administration of
the FS3I is specific to only these two aspects of the
health events.
Application to Jones Family
The adults in this family were interviewed together,
with each person completing the FS3I. General stressors
and specific stressors were rated similarly by each
member of the couple. The nurse also rated her per-
ceptions of the family stressors and strengths. Overall
family physical and mental functioning were also rated.
The nurse concluded that this family had the strengths
it needed to deal with both the general and specific
stressors.
likelihood that the family will be able to
achieve stability and health as a family unit.
■ Theories that inform the nursing of families
should be the “gold standard” of nursing
practice (Segaric & Hall, 2005); hence, family
nursing is a theory-guided, evidence-based
nursing practice.
This chapter presents ways of providing excel-
lent family health care nursing that is theory driven
and evidence based. By using different lenses to
view family care problems, different solutions and
options for care and interventions become avail-
able. Clearly, no one theoretical perspective gives
all nurses in all settings a sufficiently broad base of
knowledge on which to assess and intervene with
the complex health events experienced by families.
What is crucial is that nurses use multiple theoret-
ical perspectives to guide their practice with the
nursing care of families.
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105
Family Nursing Assessment
and Intervention
c h a p t e r 4
Joanna Rowe Kaakinen, PhD, RN
Aaron Tabacco, BSN, RN, Doctoral Candidate
C r i t i c a l C o n c e p t s
■ 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.
3921_Ch04_105-136 05/06/14 10:58 AM Page 105
Families are complex social systems. Therefore, the
use of logical, systematic approaches to assess and
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
of action, and (3) to offer multiple supports and re-
sources to the family. Nurses use a variety of as-
sessment models to collect information about
families. In concert with the family, this informa-
tion is used to develop the interventions families
use to manage their current health event. Some as-
sessment and intervention instruments are based
on theoretical models, and some are developed
using a psychometric approach to instrument de-
velopment. Built on the traditional nursing process
as visualized by Doenges, Moorhouse, and Murr
(2013) (Fig. 4-1) and combined with the Outcome
Present State Testing Model (Pesut & Herman,
1999), this chapter presents a dynamic systematic
critical reasoning method to conducting a family as-
sessment and tailoring interventions to meet family
needs (Fig. 4-2) and applies it to a case study. The
chapter explores assessment strategies, including
how to select assessment instruments, determine
the need for interpreters, assess for health literacy,
diagram family genograms, and develop family
ecomaps. Intervention strategies follow assessment
strategies to assist nurses and families in shared de-
cision making. The chapter concludes with a brief
introduction to three family assessment and inter-
vention models that were developed by nurses.
FAMILY NURSING ASSESSMENT
Central to the delivery of safe and effective family
nursing care is the nurse’s ability to make accurate
assessments, identify health problems, and tailor
plans of care. Each step of working with families,
whether applied to individuals within the family or
the family as a whole, requires a thoughtful, delib-
erate reasoning process. Nurses decide what data
to collect and how, when, and where those data are
collected. Nurses determine the relevance of each
new piece of information and how it fits into the
emerging family story. Before moving forward,
nurses decide whether they have obtained sufficient
information on problem and strength identifica-
tion, or whether gaps exist that require additional
data gathering.
Nurses must always be aware that “common” in-
terpretations of data may not be the “correct” in-
terpretation in any given situation, and that
commonly expected signs and symptoms may not
appear in every case or in the same data pattern
presentation. The ability of nurses to be open to
the unexpected and to be alert to unusual or differ-
ent responses is critical to determining the primary
106 Foundations in Family Health Care Nursing
NURSE
Int
er
ve
nti
on
Int
er
ve
nti
on
Int
er
ve
nti
on
E
valuation
E
valuation
E
valuation
Planning
Planning
Planning
Assessment Assessment
N
ur
si
ng
di
ag
no
si
s
N
ur
si
ng
di
ag
no
si
s
N
ur
si
ng
di
ag
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si
s
CLIENT
FIGURE 4-1 Nursing process model.
3921_Ch04_105-136 05/06/14 10:58 AM Page 106
needs confronting the family. Nurses should be
able to perceive that which is not obvious and to
understand how this family story is similar to or
different from other family stories.
The family nursing assessment includes the fol-
lowing steps:
■ Assessment of the family story: The nurse
gathers data from a variety of sources to see
the whole picture of the family experience.
■ Analysis of family story: The nurse clusters
the data into meaningful patterns to see how
the family is managing the health event. The
family needs are prioritized using a Family
Reasoning Web.
■ Design of a family plan of care: Together, the
nurse and family determine the best plan of
care for the family to manage the situation.
■ Family intervention: Together, the nurse and
family implement the plan of care incorporat-
ing the most family-focused, cost-effective,
and efficient interventions that assist the fam-
ily to achieve the best possible outcomes.
■ Family evaluation: Together, the nurse and
family determine whether the outcomes are
being reached, are being partially reached,
or need to be redesigned. Is the care plan
working well, does a new care plan need to
be put into place, or does the nurse/family
relationship need to end?
■ Nurse reflection: Nurses engage in critical,
creative, and concurrent reflection about them-
selves and their own family experiences, the
family client, and their work with the family.
Engaging Families in Care
Background and First Contact
Nurses encounter families in diverse health care
settings for many different kinds of problems and
circumstances. Every family has a story about how
the potential or actual health event influences its
individual members, family functioning, and man-
agement of the health event. Nurses are charged
with gathering, sifting, organizing, and analyzing
the data to craft a clear view of the family’s story.
Nurses filter data gathered in the story through dif-
ferent views or approaches, which affects how they
think about the family as a whole and each individ-
ual family member. For example, a family who is
faced with a new diagnosis of a chronic illness
would have different needs than a family who is
faced with a member dying of an end-stage chronic
Family Nursing Assessment and Intervention 107
FIGURE 4-2 Family nursing assessment model.
NURSE
Over Time
Fa
mi
ly
int
erv
en
tio
ns
Fa
mi
ly
int
er
ve
nti
on
s
Fam
ily evaluation
Fam
ily evaluation
Design
family plan
Design
family plan
Assess
family story
Nurse
Reflection
Nurse
Reflection
Assess
family story
A
na
ly
ze
fa
m
ily
s
to
ry
A
na
ly
ze
fa
m
ily
s
to
ry
FAMILY
3921_Ch04_105-136 05/06/14 10:58 AM Page 107
illness. Nurses might use different strategies if the
patient is in the acute hospital setting, is in an as-
sisted living center, or is living at home.
The underlying theoretical approach used by the
nurses working with families influences how they ask
questions and collect family data. For example, if the
family is worried about how their 2-year-old child
will react to a new baby, such as in the Bono family
case study presented later in this chapter, the nurse
may elect to base the assessment and interventions
on a family systems theoretical view, or the devel-
opmental family life cycle theoretical view. Refer to
Chapter 3 for a detailed discussion of working with
families from different theoretical perspectives.
Data collection, which is the first part of assess-
ment, involves both subjective and objective family
information that is obtained through direct obser-
vation, examination, or in consultation with other
health care providers. In all cases, family assess-
ment begins from the first moment that the family
is referred to the nurse. Following are some cir-
cumstances in which a family is referred to a nurse:
■ A family is referred by the hospital to a home
health agency for wound care on the feet of a
client with diabetes.
■ A couple seeks advice for managing their
busy life with three children as the mother
returns home from the hospital following an
unplanned cesarean section.
■ A family calls the Visiting Nurse Association
to request assistance in providing care to a
family member with increasing dementia.
■ A school nurse is asked by the school psy-
chologist to conduct a family assessment with
a family who is suspected of child neglect.
■ A physician requests a family assessment with
a child who has nonorganic failure to thrive.
■ A family with a member with critical care
needs is asked to make decisions about life-sus-
taining treatments in the intensive care unit.
Making Community-Based Appointments
As soon as a family is identified, the nurse begins
to collect data about the family story. Sources of
data that can be collected before contacting a fam-
ily for a home or clinic appointment are listed in
Box 4-1. Specifically, the nurse needs to know the
following information:
■ The reason for the referral or requested visit
■ The family knowledge of the visit or referral
■ Specific medical information about the
family member with the health problem
■ Strategies that have been used previously
■ Insurance sources for the family
■ Family problems identified by other health
providers
■ Family demographic data, when available,
such as the number of people and ages of
family members or basic cultural background
information
■ The need for an interpreter
Before contacting the family to arrange for the
initial appointment, the nurse decides whether the
most appropriate place to conduct the appointment
is in the family’s home or the clinic/office. The type
of agency where the nurse works may dictate this
decision. Advantages and disadvantages of a home
setting and a clinic setting are listed in Table 4-1.
Contacting the family for the appointment pro-
vides valuable information about the family. It is im-
perative that the nurse be confident and organized
when making the initial contact. Information that
is important for the nurse to note is whether the
family acts surprised that the referral was made,
shows reluctance in setting up a meeting, or ex-
presses openness about working together. The fam-
ily also gathers important information about the
nurse during the initial interaction. For example,
family members will notice whether the nurse takes
time to talk with them, uses a lot of words they do
not understand, or appears organized and open to
working with the family. To facilitate the best pos-
sible outcomes in engaging families for the first
time to learn about their health and illness story,
effective nurses consider the family and its needs
as central to starting a successful collaboration.
108 Foundations in Family Health Care Nursing
BOX 4-1
Sources of Pre-encounter Family Data
■ Referral source: includes data that indicated a problem
for this family, as well as demographic information
■ Family: includes family members’ views of the prob-
lem, surprise that the referral was made, reluctance to
set up the meeting, avoidance in setting up the ap-
pointment
■ Previous records: in the health care systems or that are
sent by having the client sign a release for information
form, such as process logs, charts, phone logs, or
school records
3921_Ch04_105-136 05/06/14 10:58 AM Page 108
This relationship of trust begins from the moment
of first contact with families. As a guide, Box 4-2
outlines steps to follow when making an appoint-
ment with a family.
Family Assessments in Acute Care Settings
Nurses in acute care settings encounter families of
their individual patients on a daily basis. The de-
gree to which nurses feel comfortable and to which
they demonstrate clinical competence engaging
families varies widely. Because cost (which is con-
strained) determines length of stay, and because of
the increasing population of people with chronic
illnesses who experience poor symptom manage-
ment, nurses in acute care settings often feel there
is little time to engage families effectively. Lack of
time, in fact, has been identified by nurses as the
primary barrier to engaging families, though there
are many other barriers as well, including nurse
bias, safety concerns, and negative nurse attitudes
about working with families (Duran, Oman, Abel,
Koziel, & Szymanski, 2007; Gurses & Carayon,
2007; Svavarsdottir, 2008). It is critical that nurses
gain skill and comfort with families in acute care
settings as families are the primary caregivers fol-
lowing the discharge of their family members.
Families need the help of nurses in order to learn
how to provide effective postdischarge care tasks;
engage in shared decision making with health care
providers; understand the current health status of
their ill family member; balance admission and
postdischarge family life demands; assist families
during critical events such as resuscitation; and
solve ethical dilemmas that arise in the care of their
loved one. With this extensive list of needs, it is es-
sential that nurses in acute care settings intention-
ally and effectively engage families.
Nurses in acute care settings encounter a num-
ber of challenges, including caring for several
acutely ill persons simultaneously, managing the
informational needs of interdisciplinary providers,
and coping with a host of distractions that often
keep nurses away from the bedside. Therefore,
Family Nursing Assessment and Intervention 109
Table 4-1 Advantages and Disadvantages of Home Visits Versus Clinic Visits
Home Visit
Advantages
• Opportunity to see the everyday family environment.
• Observe typical family interactions because the family
members are likely to feel more relaxed in their physical
space.
• More family members may be able to attend the meeting.
• Emphasizes that the problem is the responsibility of the
whole family and not one family member.
Disadvantages
• Home may be the only sanctuary or safe place for the
family or its members to be away from the scrutiny of others.
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.
Clinic Visit
• Conducting the family appointment in the office or clinic al-
lows for easier access to consultants.
• The family situation may be so strained that a more formal,
less personal setting will facilitate discussions of emotion-
ally charged issues.
• May reinforce a possible culture gap between the family
and the nurse.
BOX 4-2
Setting Up Family Appointments
■ Introduce yourself.
■ State the purpose of the requested meeting, including
who referred the family to the agency.
■ Do not apologize for the meeting.
■ Be factual about the need for the meeting but do not
provide details.
■ Offer several possible times for the meeting, including
late afternoon or evening.
■ Let the family select the most convenient time that
allows the majority of family members to attend.
■ Offer services of an interpreter, if required.
■ Confirm date, time, place, and directions.
3921_Ch04_105-136 05/06/14 10:58 AM Page 109
nurses seeking to engage families, complete family
assessments, and implement family interventions
must be highly efficient and creative. A number of
specific strategies and tools must be used to accom-
plish a meaningful and effective experience. For an
in-depth discussion of acute care family nursing
needs, refer to Chapter 14.
Using Interpreters With Families
It is critical for the nurse to determine whether an
interpreter is needed during the family meeting, be-
cause the number of families who do not speak Eng-
lish is increasing. For 55.4 million Americans,
English is not the primary language spoken in the
home, and 13.6 million of these people speak English
poorly or not at all (U.S. Census Bureau, 2010). Lan-
guage barriers have been found to complicate many
aspects of patient care, including comprehension and
adherence to plans of care. Furthermore, language
barriers have been found to contribute to adverse
health outcomes, compromised quality of care,
avoidable expenses, dissatisfied families, and in-
creased potential for medical mistakes (Flores, Abreu,
Barone, Bachur, & Lin, 2012; Schenker, Wang,
Selig, Ng, & Fernandez, 2007). Thus, it is essential
that nurses who are not bilingual use interpreters
when working with non–English-speaking families.
The types of interpreters that nurses solicit to
help work with families have the potential to influ-
ence the quality of the information exchanged and
the family’s ability to follow the suggested plan of
action. One of the most common types of inter-
preters used are bilingual family members or
friends, called ad hoc family interpreters. The prob-
lems with using family members as interpreters are
that they have been found to buffer information,
alter the meaning of the content, or make the de-
cision for the person for whom they are interpret-
ing (Flores et al., 2012; Ledger, 2002). The ad hoc
family member interpreter also has been found to
lack important language skills, especially when it
comes to medical interpretation (Flores et al., 2012;
Khwaja et al., 2006; Ledger, 2002). If the ad hoc
family member interpreter is a child, the informa-
tion that is being discussed may be frightening or
the topic may be too personal and sensitive
(Ledger, 2002). Using ad hoc family interpreters
also raises confidentially issues (Gray, Hilder, &
Donaldson, 2011). Therefore, it is not ideal for
nurses to use a family member for interpretation,
especially if another choice is available.
If a qualified medical interpreter cannot come to
the meeting in the family home, the nurse should
plan to use a speaker phone so that the professional
interpreter can be involved in the conversation with
the family. One of the problems with using an in-
terpreter on the phone is that interpreters do not
have the advantage of seeing the family members
in person and cannot observe nonverbal commu-
nication (Bethell, Simpson, & Read, 2006; Gray
et al., 2011; Herndon & Joyce, 2004). Also, the
nurse should be aware that using a telephone inter-
preter introduces another outside person into the
family setting, which may be perceived as imper-
sonal by the family (Bethell et al., 2006).
Family-Centered Meetings and Care
Conferences
Family-centered care (FCC) principles should be
applied in all interactions between nurses and fam-
ilies or other health care providers. According to
the Institute for Patient and Family Centered Care
(IPFCC) (2013), the core principles of FCC are re-
spect and dignity, information sharing, participa-
tion, and collaboration. The goal of FCC is to
increase the mutual benefit of health care provision
for all parties, with a focus on improving the satis-
faction and outcomes of health care for families
(IPFCC, 2013). By utilizing these principles in all
aspects of the family nursing approach from assess-
ment through intervention and evaluation, nurses
can facilitate exchanges of shared expertise, which
lead to better holistic health outcomes.
During the initial interaction with families, it is
critical for nurses to introduce themselves to the
family, meet all the family members present, learn
about the family members not present, clearly state
the purpose for working with the family, outline
what will happen during this session, and indicate
the length of time the meeting will last. Taking
these actions demonstrates respect for family mem-
bers and their unique story. To continue with this
precedent, the nurse needs to develop a systematic
plan for the first and all following family meetings.
This focus on respect, dignity, and collaboration in
initial meetings helps to establish relationships that
are therapeutic; effective, satisfying partnerships
between nurses and families are critical as they
work together toward health-related goals.
Nurses who use a therapeutic approach to
family meetings have found that their focus on
family-centered care increased, and that their
110 Foundations in Family Health Care Nursing
3921_Ch04_105-136 05/06/14 10:58 AM Page 110
communication skills with families became more
fluid with experience (Harrison, 2010; Martinez,
D’Artois, & Rennick, 2007). When nurses use
therapeutic communication skills with families, the
families report feeling a stronger rapport with the
nurse, an increased frequency of communication
between families and the nurse occurs, and families
perceive these nurses to be more competent
(Harrison, 2010; Martinez et al., 2007).
Conducting family meetings not only requires
skilled communication strategies but also requires
knowledge of family assessment and intervention
models. Nurses use a variety of data collection and
assessment instruments to help gather information
in a systematic and efficient manner. Therefore, it
is important that the instruments be carefully se-
lected so they are family friendly and render infor-
mation pertinent to the purpose of working with
the family.
FAMILY NURSING ASSESSMENT
MODELS AND INSTRUMENTS
Nurses practice family nursing using a variety of
tools. The following three family assessment
models have been developed by family nurses.
The Family Assessment and Intervention Model
and the FS3I were developed by Berkey-Mischke
and Hanson (1991). Friedman developed the
Friedman Family Assessment Model (Friedman
et al., 2003). The Calgary Family Assessment
Model (CFAM) and Calgary Family Intervention
Model (CFIM) were developed by Wright and
Leahey (2013). These three approaches vary in
purpose, unit of analysis, and level of data col-
lected. Table 4-2 has a detailed comparison of the
essential components of these three family assess-
ment models.
Family Nursing Assessment and Intervention 111
Table 4-2 Comparison of Family Assessment Models Developed by Family Nurses
Name of model
Citation
Purpose
Theoretical underpinnings
Level of data collected
Settings in which primarily
used
Units of analysis
Calgary Family Assessment
and Intervention Model
Wright & Leahey (2013)
Conceptual model and mul-
tidimensional approach to
families that looks at the fit
among family functioning,
affective, and behavioral
aspects
Systems:
Cybernetics Communica-
tion Change Theory
Qualitative:
Nominal
Outpatient
Community
Family as system
Friedman Family Assess-
ment Model
Friedman, Bowden, & Jones
(2003)
Concrete, global family as-
sessment interview guide
that looks primarily at fami-
lies in the larger community
in which they are embedded
Developmental
Structural-functional
Family stress-coping
Environmental
Qualitative:
Nominal
Outpatient
Community
Family as client
Family as component
of society
Family Assessment and In-
tervention Model and the
Family System Stressor-
Strength Inventory (FS3I)
Berkey-Mischke & Hanson
(1991)
Hanson (2001)
Concrete, focused measure-
ment instrument that helps
families identify current
family stressors and builds
interventions based on
family strengths
Systems:
Family systems
Neuman systems
Model:
Stress-coping theory
Quantitative:
Ordinal and interval
Qualitative:
Nominal
Inpatient
Outpatient
Community
Family as context
Family as client
Family as system
Family as component
of society
(continued)
3921_Ch04_105-136 05/06/14 10:58 AM Page 111
Family Assessment and Intervention
Model
The Family Assessment and Intervention Model,
originally developed by Berkey-Mischke and Hanson
(1991), is presented in greater detail in Chapter 3,
but is worth exploring in this context as well. The
Family Assessment Intervention Model is based on
Neuman’s health care systems model (Kaakinen &
Hanson, 2005).
According to the Family Assessment and Inter-
vention Model, families are subject to tensions
when stressed. The family’s reaction depends on
how deeply the stressor penetrates the family unit
and how capable the family is of adapting to main-
tain its stability. The lines of resistance protect the
family’s basic structure, which includes the family’s
functions and energy resources. The family core
contains the patterns of family interactions and
strengths. The basic family structure must be pro-
tected at all costs or the family ceases to exist. Re-
constitution or adaptation is the work the family
undertakes to preserve or restore family stability.
This model addresses three areas: (1) health pro-
motion, wellness activities, problem identification,
and family factors at lines of defense and resistance;
(2) family reaction and instability at lines of defense
and resistance; and (3) restoration of family stability
and family functioning at levels of prevention and
intervention.
The FS3I is the assessment and intervention tool
that accompanies the Family Assessment and In-
tervention Model. The FS3I is divided into three
sections: (1) family systems stressors—general; (2)
family stressors—specific; and (3) family system
strengths. An updated copy of the instrument, with
instructions for administration and a scoring guide,
can be found in Appendix A.
Nurses can assess family stability by gathering in-
formation on family stressors and strengths. The
nurse and family work together to assess the family’s
general, overall stressors, and then specific family
problems. Identified family strengths give an indi-
cation of the potential and actual problem-solving
abilities of the family system. A plus to the FS3I ap-
proach is that both quantitative and qualitative data
are used to determine the level of prevention and
intervention needed. The family is actively involved
in the discussions and decisions. Moreover, this as-
sessment and intervention approach focuses on
family stressors and strengths, and provides a theo-
retical structure for family nursing.
Friedman Family Assessment Model
The Friedman Family Assessment Model (Friedman
et al., 2003) is based on the structural-functional
framework and developmental and systems theory.
This assessment model takes a macroscopic approach
to family assessment by viewing families as subsystems
of the wider society, which includes institutions de-
voted to religion, education, and health. Family is
considered an open social system and this model fo-
cuses on family’s structure, functions (activities and
purposes), and relationships with other social systems.
The Friedman model is commonly used when the
family-in-community is the setting for care (e.g., in
community and public health nursing). This approach
enables family nurses to assess the family system as a
whole, as a subunit of the society, and as an interac-
tional system. Box 4-3 delineates the general assump-
tions of this model (Friedman et al., 2003, p. 100).
112 Foundations in Family Health Care Nursing
Table 4-2 Comparison of Family Assessment Models Developed by Family Nurses—cont’d
Strengths
Weaknesses
Conceptually sound
Not concrete enough to be
useful as a guideline unless
the provider has studied this
model and approach in detail
Comprehensive list of areas
to assess family
Large quantities of data
that may not relate to the
problem
No quantitative data
Short
Easy to administer
Yields data to compare
one family member with
another family member
Assess and measure
focused presenting
problem
Narrow variable
3921_Ch04_105-136 05/06/14 10:58 AM Page 112
Structure refers to how a family is organized and
how the parts relate to each other and to the whole.
The four basic structural dimensions are role sys-
tems, value systems, communication networks, and
power structure. These dimensions are interrelated
and interactive, and they may differ in single-par-
ent and two-parent families. For example, a single
mother may be the head of the family, but she may
not necessarily take on the authoritarian role that
a traditional man might in a two-parent family. In
turn, the value systems, communication networks,
and power structures may be quite different in the
single-parent and two-parent families as a result of
these structural differences.
Function refers to how families go about meet-
ing the needs of individuals and meeting the pur-
poses of the broader society. In other words, family
functions are what a family does. The functions of
the family historically are discussed in Chapter 1,
but the following specific family functions are con-
sidered in this approach:
■ Pass on culture, religion, ethnicity.
■ Socialize young people for the next genera-
tion (e.g., to be good citizens, to be able to
cope in society through education).
■ Exist for sexual satisfaction and reproduction.
■ Provide economic security.
■ Serve as a protective mechanism for family
members against outside forces.
■ Provide closer human contact and relations.
The Friedman Family Assessment Model form
consists of six broad categories of interview ques-
tions: (1) identification data, (2) developmental
stage and history of the family, (3) environmental
data, (4) family structure (i.e., role structure, family
values, communication patterns, power structure),
(5) family functions (i.e., affective functions, social-
ization functions, health care functions), and
(6) family stress and coping. Each category has sev-
eral subcategories (Friedman et al., 2003).
Friedman’s assessment was developed to provide
guidelines for family nurses who are interviewing
a family. The guidelines categorize family informa-
tion according to structure and function. Fried-
man’s Family Assessment Form exists in both a
long form and a short form. The long form is quite
extensive (13 pages), and it may not be possible to
collect all of the data in one visit. Moreover, all the
categories of information listed in the guidelines
may not be pertinent for every family. Like other
approaches, this model has its strengths and weak-
nesses. One problem with this approach is that it
can generate large quantities of data with no clear
direction as to how to use all of the information in
diagnosis, planning, and intervention. The strength
of this approach is that it addresses a comprehen-
sive list of areas to assess the family, and that a short
assessment form has been developed to highlight
critical areas of family functioning. The short form,
which is included in Appendix B, outlines the types
of questions the nurse can ask.
Calgary Family Assessment Model
The CFAM by Wright and Leahey (2013) blends
nursing and family therapy concepts that are
grounded in systems theory, cybernetics, commu-
nication theory, change theory, and a biology of
recognition. The following concepts from general
systems theory and family systems theory make up
the theoretical framework for this model (Wright
& Leahy, 2013, pp. 21–44):
■ A family system is part of a larger suprasys-
tem and is also composed of many subsys-
tems.
■ The family as a whole is greater than the sum
of its parts.
■ A change in one family member affects all
family members.
■ The family is able to create a balance be-
tween change and stability.
■ Family members’ behaviors are best under-
stood from a perspective of circular rather
than linear causality.
Family Nursing Assessment and Intervention 113
BOX 4-3
Underlying Assumptions of Friedman’s
Family Assessment Model
■ A family is a social system with functional require-
ments.
■ A family is a small group possessing certain generic
features common to all small groups.
■ The family as a social system accomplishes functions
that serve the individual and society.
■ Individuals act in accordance with a set of internalized
norms and values that are learned primarily through
socialization.
Source: Friedman, M. M., Bowden, V. R., & Jones, E. G. (2003).
Family nursing: Research, theory & practice (5th ed.). Upper
Saddle River, NJ: Prentice Hall/Pearson Education.
3921_Ch04_105-136 05/06/14 10:58 AM Page 113
Cybernetics is the science of communication
and control theory; therefore, it differs from sys-
tems theory. Systems theory helps change the focus
of one’s conceptual lens from parts to wholes. By
contrast, cybernetics changes the focus from sub-
stance to form. Wright and Leahey (2013) pull two
useful concepts from cybernetics theory:
■ Families possess self-regulating ability.
■ Feedback processes can simultaneously occur
at several system levels with families.
Communication theory in this model is based on
the work of Watzlawick and colleagues (Watzlawick,
Weakland, & Fisch, 1967, 1974). Communication
represents the way that individuals interact with
one another. Concepts derived from communica-
tion theory used in the CFAM are as follows
(Wright & Leahey, 2013):
■ All nonverbal communication is meaningful.
■ All communication has two major channels
for transmission: digital (verbal) and analogi-
cal (nonverbal).
■ A dyadic relationship has varying degrees of
symmetry (similarity) and complementarity
(divergence, contrast, or complementary
characteristics).
■ All communication has two levels: content
and relationship.
Helping families to change is at the very core of
family nursing interventions. Families need a bal-
ance between change and stability. Change is re-
quired to make things better, and stability is required
to maintain some semblance of order. A number of
concepts from change theory are important to this
family nursing approach (Wright & Leahey, 2013):
■ Change is dependent on the perception of
the problem.
■ Change is determined by structure.
■ Change is dependent on context.
■ Change is dependent on co-evolving goals
for treatment.
■ Understanding alone does not lead to change.
■ Change does not necessarily occur equally in
all family members.
■ Facilitating change is the nurse’s responsibility.
■ Change occurs by means of a “fit” or meshing
between the therapeutic offerings (interven-
tions of the nurse) and the bio-psycho-
social-spiritual structures of family members.
■ Change can be the result of a myriad of
causes.
Figure 4-3 shows the branching diagram of the
CFAM (Wright & Leahey, 2013, p. 48). The as-
sessment questions that accompany the model are
organized into three major categories: (1) struc-
tural, (2) developmental, and (3) functional. Nurses
examine a family’s structural components to answer
these questions: Who is in the family? What is the
connection between family members? What is the
family’s context? Structure includes family compo-
sition, sex, sexual orientation, rank order, subsys-
tems, and the boundaries of the family system.
Aside from interview and observation, strategies
recommended to assess structure include the
genogram and the ecomap.
The second major assessment category in the
Calgary approach is family development, which in-
cludes assessment of family stages, tasks, and at-
tachments. For example, nurses may ask, “Where
is the family in the family life cycle?” Understand-
ing the stage of the family enables nurses to assess
and intervene in a more purposeful, specific, and
meaningful way. There are no actual instruments
for assessing development, but nurses can use de-
velopmental tasks as guidelines.
The third area for assessment in the CFAM is
family functioning. Family functioning reflects how
individuals actually behave in relation to one an-
other, or the “here-and-now aspect of a family’s
life” (Wright & Leahey, 2013, p. 116). Aspects of
family functioning include activities of daily life,
such as eating, sleeping, meal preparation, and
health care, as well as emotional communication,
verbal and nonverbal communication, communica-
tion patterns (the way communication and re-
sponses are passed back and forth between
members), problem solving, roles, influence and
power, beliefs, and alliances and coalitions. Wright
and Leahey indicate that nurses may assess in all
three areas for a macroview of the family, or they
can use any part of the approach for a microassess-
ment. Wright and Leahey (2013) developed a com-
panion model to the CFAM, the CFIM. This
intervention model provides concrete strategies by
which nurses can promote, improve, and sustain
effective family functioning in the cognitive, affec-
tive, and behavioral domains. The strength of the
Calgary Assessment and Intervention Model is that
it is a conceptually sound model that incorporates
114 Foundations in Family Health Care Nursing
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multiple theoretical aspects into working with fam-
ilies. The strength of this approach is also its weak-
ness in that unless you are intimately knowledgeable
with the model and the interventions, it is difficult
to implement in acute care settings.
Family Assessment Instruments
Because there are approximately 1,000 family-
focused instruments that have been developed and
used in assessing family-related variables (Touliatos,
Perlmutter, & Straus, 2001), the selection of the ap-
propriate instrument can be complex. Sometimes,
a simple questionnaire or instrument can be com-
pleted in just a few minutes. One such example is
the Patient/Parent Information and Involvement
Assessment Tool (PINT), which is an instrument
that Sobo (2004) designed to assess the family’s per-
spective on shared decision making. Other times,
more comprehensive family assessment instruments
are necessary, such as the Family Systems Stressor-
Strength Inventory (FS3I) (Berkey-Mischke &
Hanson, 1991; Hanson, 2001; Kaakinen, Hanson,
& Denham, 2010). The FS3I is an instrument
designed by nurses to provide quantitative and qual-
itative data pertinent to family stressors, family
strengths, and intervention strategies (see Appendix
A). To select the most appropriate assessment in-
strument, be sure the instrument has the following
characteristics:
■ Written in uncomplicated language at a fifth-
grade level
■ Only 10 to 15 minutes in length
■ Relatively easy to score
Family Nursing Assessment and Intervention 115
Family composition
Gender
Sexual orientation
Rank order
Subsystems
Boundaries
Extended family
Larger systems
Ethnicity
Race
Social class
Religion and/or spirituality
Environment
Activities of daily living
Emotional communication
Verbal communication
Nonverbal communication
Circular communication
Problem-solving
Roles
Influence and power
Beliefs
Alliances/coalitions
Structural
Developmental
Stages
Tasks
Attachments
Instrumental
Expressive
Functional
Family
assessment
Internal
External
Context
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.)
3921_Ch04_105-136 05/06/14 10:58 AM Page 115
■ Offers valid data on which to base decisions
■ Sensitive to sex, race, social class, and ethnic
background
Regardless of which assessment/measurement in-
strument is used, families should always be informed
of how the information gathered through the instru-
ments will be used by the health care providers.
Two other family data-gathering instruments
that should be used in working with families are the
family genogram and the family ecomap. Both are
short, easy instruments and processes that supply
essential family data and engage the family in ther-
apeutic conversation.
Family Genogram and Family Ecomap
Genograms and ecomaps provide care providers
with visual diagrams of the current family story and
situation (Harrison & Neufeld, 2009; Kaakinen,
2010). The information gathered from both the
genogram and ecomap help guide the family plan
of action and the selection of intervention strate-
gies (Ray & Street, 2005). One of the major bene-
fits of working with families with these two
instruments is that family members can feel and vi-
sualize the amount of energy they are expending to
manage the situation, which in itself is therapeutic
for the family (Harrison & Neufeld, 2009; Holts-
lander, 2005; Rempel, Neufeld, & Kushner, 2007).
The use of genograms and ecomaps among nurses
and other disciplines is growing and these useful tools
are being applied in a number of practice and re-
search contexts. Genograms, used historically in the
context of genetic prediction and counseling, have
been applied alongside ecomaps as primary assess-
ment and decision-making tools in acute centers
(Leahey & Svavarsdottir, 2009; Svavarsdottir, 2008).
Examples of how other providers have applied the
use of these tools include enhancing health promo-
tion (Cascado-Kehoe & Kehoe, 2008); increasing
provider cultural competence and spiritual assess-
ment of families (Hodge & Limb, 2010); and assess-
ment of child social support systems (Baumgartner,
Burnett, DiCarlo, & Buchanan, 2012). It is clear that
generating and annotating visual data in these dia-
grammatic forms will be increasingly useful to nurses
caring for families in many settings and contexts.
Family Genogram
The family genogram is a format for drawing a fam-
ily tree that records information about family
members and their relationships over at least three
generations (McGoldrick, Gerson, & Petry, 2008).
This diagram offers a rich source of information
for planning intervention strategies because it dis-
plays the family visually and graphically in a way
that provides a quick overview of family complexi-
ties. Family genograms help both nurses and fam-
ilies to see and think systematically about families
and the impact of the health event on family struc-
ture, function, and processes.
The three-generational family genogram had its
origin in Family Systems Theory (Bowen, 1985;
Bowen & Kerr, 1988). According to family systems,
people are organized into family systems by gener-
ation, age, sex, or other similar features. How a
person fits into his or her family structure influ-
ences its functioning, relational patterns, and what
type of family he or she will carry forward into the
next generation. Bowen incorporated Toman’s
(1976) ideas about the importance of sex and birth
order in shaping sibling relationships and charac-
teristics. Furthermore, families repeat themselves
over generations in a phenomenon called the trans-
mission of family patterns (Bowen, 1985). What hap-
pens in one generation repeats itself in the next
generation; thus, many of the same strengths and
problems get played out from generation to gen-
eration. These include psychosocial and physical
and mental health issues.
Nurses establish therapeutic relationships with
families through the process of asking questions
while collecting family data. Families become more
engaged in their current situation during this inter-
action as their family story unfolds. Both the nurse
and the family can see the “big picture” historically
on the vertical axis of the genogram and horizontally
across the family (McGoldrick et al., 2008). This ap-
proach can help families see connectedness, and help
identify potential and missing support people.
The diagramming of family genograms must ad-
here to specific rules and symbols to ensure that all
parties involved have the same understanding and
interpretations. It is important not to confuse family
genograms with a family genetic pedigree. A family
pedigree is specific to genetic assessments (see
Chapter 7), whereas a genogram has broader uses
for family health care practitioners. Olsen, Dudley-
Brown, and McMullen (2004) have suggested, how-
ever, that given the advancement of genomics in
driving health care, nursing should consider blend-
ing pedigrees with genograms and ecomaps as a way
to offer a more comprehensive holistic nursing care
perspective. Creative blended models built upon
116 Foundations in Family Health Care Nursing
3921_Ch04_105-136 05/06/14 10:58 AM Page 116
these ideas are emerging in practice with innovative
applications such as the use of color coding for en-
hancing multimodal understanding of children and
families (Driessnack, 2009).
Figure 4-4 provides a basic genogram from
which a nurse can start diagramming family mem-
bers over the first, second, and third generations
(McGoldrick, Gerson, & Schellenberger, 1999).
Figure 4-5 depicts the genogram symbols used to
describe basic family membership and structure,
family interaction patterns, and other family infor-
mation of particular importance, such as health sta-
tus, substance abuse, obesity, smoking, and mental
health comorbidities (McGoldrick et al., 2008). The
health history of all family members (e.g., morbid-
ity, mortality, and onset of illness) is important in-
formation for family nurses and can be the focus of
analysis of the family genogram. An example of a
family genogram developed from one interview is
contained in the Bono family case study below.
The structure of the interview for gathering the
genogram information is based on the reasons why
the nurse is working with the family. For example,
if the context of creating a genogram is that of ob-
taining a health history aimed at uncovering family
patterns of illness, the nurse may wish to explore
more fully the health history of each generational
family member. If, on the other hand, the context
of the nursing care is determining the nature of so-
cial relationships and roles among family members
to craft an acute care plan of discharge, the nurse
may wish to focus the interview more closely on
determining who is directly in the home and how
their relationships function to aid in the recovery
of the ill family member. A suggested format for
conducting a concise, focused family genogram in-
terview is outlined in Box 4-4. Most families are co-
operative and interested in completing their
genogram, which becomes a part of their ongoing
health care record. The genogram does not have
to be completed at one sitting. As the same or a dif-
ferent nurse continues to work with a family, data
can be added to the genogram over time in a con-
tinuing process. Families should be given a copy of
their own genogram.
Family Ecomap
A family ecomap provides information about systems
outside of the immediate nuclear family that are
sources of social support or that are stressors to the
family (Olsen et al., 2004). The ecomap is a visual
representation of the family unit in relation to the
larger community in which it is embedded (Kaaki-
nen, 2010). It is a visual representation of the rela-
tionship between an individual family and the
world around it (McGoldrick et al., 2008). The
ecomap is thus an overview of the family in its cur-
rent context, picturing the important connections
among the nuclear family, the extended family, and
the community around it.
The blank ecomap form consists of a large circle
with smaller circles around it (Fig. 4-6). A simpli-
fied version of the family is placed in the center of
the larger circle to complete the ecomap. This cir-
cle marks the boundary between the family and its
extended external environment. The smaller outer
circles represent significant people, agencies, or
Family Nursing Assessment and Intervention 117
FIGURE 4-4 Basic genogram format.
3921_Ch04_105-136 05/06/14 10:58 AM Page 117
Sexual abuse
Female
Heterosexual
Gay Lesbian
Male Therapy or
Institutional
Connection
Household shown by circling members living together
(couple living with their dog after launching children)
Age
above
symbol
m 1970 LT 95
*When multiple deceased generators are included, use an X only for untimely death.
inside
symbol
Adopted at 5
use an
arrow to
show family
into which child moved
Birth Date
Marriage Secret Affair
Man to
woman
Woman
to man
82
23
60
62 63
27
Ed Judy
DogSam
Jolie
Transgender People
Pet
Sexual Relationship
Living Together
LT 95
Committed
Relationship
m 70, s 95
Marital Separation
Marital Reconciliation
After Separation
Adopted Child/Foster Child
Bisexual
94 A 99
10
lesbian couple’s
daughter
conceived
with egg of one
partner and
sperm donor
gay couple’s
daughter
conceived
with sperm of one
partner and
egg donor,
carried by
surrogate mother
Donor
Insemination
95
A 97LW 98–99
10
41
Immigration
94
1113
92
Location &
Annual
Income
X and age
at death in
symbol, death
date above*
above
birth date
identified patient (IP)
symbol has double line
and is written lower
than siblings
spouses
written
smaller &
lower
Death
72
Boston
$100,000
1941–2001
Has Lived in
2+ Cultures
Family
Secret
24
m 70, s 95, d 97
Divorce
s 95–96
Reconciliation After Divorce
d 98, remar 00
Divorce and Remarriage
d 98, remar 00m 95
Biological
child
Focused on HostileClose Fused
Close-hostile
Focused on
negatively
Distant Cutoff
Cutoff
repaired
Caretaker
Spiritual
connection
or affinity
Positive
relationship
Physical abuse Emotional abuse
Physical or
psychological illness
Physical or psychological
illness in remission
In recovery from
substance abuse
In recovery from mental
or physical problems and
from substance abuse
Language difficulty (person
does not speak dominant
language of the country)
Substance abuse
Suspected
substance abuse
Physical or
psychological illness
Smoker
S
Obesity
O
97
99 03 04 05
Stillbirth
Information
unknown
Miscarriage
01
AbortionFoster
child
Adopted
child
Twins Identical
twins
Pregnancy
m 80, s 85–86 d 90, remar 93, rediv 94
Children
Interactional Patterns Between People Addiction, Physical or Mental Illness or Other Problem
list in birth order beginning with the oldest on left
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.)
3921_Ch04_105-136 05/06/14 10:58 AM Page 118
institutions with which the family interacts. Lines
are drawn between the circles and the family mem-
bers to depict the nature and quality of the rela-
tionships, and to show what kinds of energy and
resources are moving in and out of the immediate
family. Straight lines show strong or close relation-
ships; the more pronounced the line or greater the
number of lines, the stronger the relationship is.
Straight lines with slashes denote stressful relation-
ships, and broken lines show tenuous or distant re-
lationships. Arrows reveal the direction of the flow
of energy and resources between individuals, and
between the family and the environment. Ecomaps
not only portray the present situation but also can
be used to set goals, for example, to increase con-
nections and exchanges with individuals and agen-
cies in the community. See the Bono family case
study later in this chapter for an example of a com-
pleted ecomap.
The value of using a genogram and ecomap in
family nursing practice is expansive. By creating
a visual picture of the system in which the family
Family Nursing Assessment and Intervention 119
FIGURE 4-6 Blank ecomap.
BOX 4-4
Family Genogram Interview Data Collection
1. Identify who is in the immediate family.
2. Identify the person who has the health problem.
3. Identify all the people who live with the immediate
family.
4. Determine how all the people are related.
5. Gather the following information on each family
member.
■ Age
■ Sex
■ Correct spelling of name
■ Health problems
■ Occupation
■ Dates of relationships: marriage, separation, divorce,
living together, living together/committed
■ Dates and age of death
6. Seek the same information for all family members
across each generation for consistency and to reveal
patterns of health and illness.
7. Add any information relative to the situation, such as
geographical location and interaction patterns.
Place basic genogram of
the immediate family in the
center of the ecomap circle
Child’s
school
Subsystem
Family
interacts
Extended
family or
family
Church
Work
Strong relationship
Weak relationship
Tense relationship
Direction of
energy flow
3921_Ch04_105-136 05/06/14 10:58 AM Page 119
exists, families are more able to envision alternative
solutions and possible social support networks (Ray
& Street, 2005; Yanicki, 2005). In addition, the
process of this data collection itself helps to expose
a clearer picture of the supportive or unsupportive
family relationships that are going on in a family
system (Neufeld, Harrison, Hughes, & Stewart,
2007). This information will enhance understand-
ing of the family’s social network with their care-
givers (Ray & Street, 2005).
Family Health Literacy
Health literacy is the ability to use health infor-
mation to make informed decisions through the
comprehension of reading material, documents,
and numbers. Functional health literacy incorpo-
rates all of these elements, but it also implies that
the client (family) has the ability to act on health
care decisions. Concepts of health literacy include
the comprehension of medical words, the ability
to follow medical instructions, and the under-
standing of the consequences when instructions
are not followed (Speros, 2005). Nurses who
understand the concept of health literacy will ac-
tively seek to collect ongoing assessment data
about the learning needs of family members in
their meetings, interviews, or conferences. This
data about the family members’ abilities and pref-
erences for learning will help guide the nurse to
provide education, materials, and other supports,
such as videos or Web sites, that are accessible to
the family.
Through interactions with the family and when
completing the genogram and ecomap, nurses have
the opportunity to determine whether there is an
issue of health literacy for any member of the fam-
ily. Health literacy is an important measure for
health care practitioners because lower health lit-
eracy is strongly associated with poor health out-
comes (Berkman, Sheridan, Donahue, Halpern, &
Crotty, 2011; Sentell & Halpin, 2006; Speros,
2005). Health literacy plays a primary role in peo-
ple’s ability to gain knowledge, make decisions, and
take actions that result in positive health outcomes
(Berkman et al., 2011; DeWalt, Boone, & Pignone,
2007; Speros, 2005), especially when managing a
chronic illness (Gazmararian, Williams, Peel, &
Baker, 2003). Assessment is particularly important
when low literacy or low language proficiency ex-
ists, because such individuals are more likely to at-
tempt to hide their inability to read or understand
because of shame or embarrassment (Bass, 2005;
Dreger & Tremback, 2002; Osborn et al., 2007).
When nurses design written material for the
family, the following common elements make it
easier to understand from a health literacy per-
spective (Bass, 2005; Peters, Dieckmann, Dixon,
Hibbard, & Mertz, 2007):
■ All written information should be in at least
14-point font using high-contrast Arial or
sans serif print with plenty of blank space on
glossy paper.
■ Uppercase and lowercase letters should be
used.
■ Information is most easily seen when using
black ink on white paper. Use short sen-
tences with bullets or lists no longer than
seven items (Peters et al., 2007).
Written information presented at the third-
grade reading level will reach the largest audience,
but it may be necessary to write at the fifth-grade
level to retain the meaning of the content (Mayer
& Rushton, 2002; Peters et al., 2007). Using mul-
tiple forms of communication, including visual
aids, will help families retain the information (Bass,
2005; Dreger & Tremback, 2002; Osborn et al.,
2007).
Nurses need to approach assessment of the fam-
ily health literacy with sensitivity and understand-
ing. It is a crucial element to take into consideration
during the analysis of the family story and in the de-
velopment of the family action plan.
ANALYSIS OF THE FAMILY STORY
One of the challenges of data collection is organ-
izing the individual pieces of information so that
the “big picture” or whole family story can be un-
derstood and analyzed. To understand the family
picture, the nurse must consolidate the data that
were collected into meaningful patterns or cate-
gories so as to visualize the relationships between
and among the patterns of how the family is man-
aging the situation. Diagramming the family and
the relationships between the data groups assists
identifying the most pressing issues or problems for
the family. If the family and nurse focus on solving
these major family problems, the outcome will have
a ripple effect by positively influencing the other
areas of family functioning.
120 Foundations in Family Health Care Nursing
3921_Ch04_105-136 05/06/14 10:58 AM Page 120
The Family Reasoning Web (Fig. 4-7) is an
organizational tool to help analyze the family
story, by clustering individual pieces of data into
meaningful family categories. The components of
the Family Reasoning Web have been pulled from
various theoretical concepts, such as Family
Structure and Function Theory, Family Develop-
mental Theory, Family Stress Theory, and family
health promotion models. This systematic ap-
proach to collecting and analyzing information
helps structure the information collection process
to ensure inclusion of important pieces of infor-
mation. The categories of the Family Reasoning
Web are as follows:
1. Family routines of daily living (i.e., sleep-
ing, meals, child care, exercise)
2. Family communication
3. Family supports and resources
4. Family roles
5. Family beliefs
6. Family developmental stage
7. Family health knowledge
8. Family environment
9. Family stress management
10. Family culture
11. Family spirituality
Once the data have been placed into the cate-
gories of the Family Reasoning Web template, the
nurse assigns a family nursing diagnosis to each cat-
egory. “A nursing diagnosis is defined as a clinical
judgment about individuals, families, or community
responses to actual or potential health problems/life
processes. Nursing diagnoses link information to
care planning. Nursing diagnoses provide the basis
for selecting nursing interventions to help achieve
outcomes for which nurses are accountable”
(Doenges et al., 2013, p. 11). The case study below
presents more information on nursing diagnoses.
The North American Nurses Diagnosis Associ-
ation (NANDA) (2007) is the most global nursing
classification system. NANDA nursing diagnoses
that are specific to families are listed in Box 4-5. If
the pattern of family data in the specific category
in the Family Reasoning Web does not match one
of the NANDA nursing diagnoses, nurses are en-
couraged to create a family nursing diagnosis that
captures the family problem. Nursing diagnosis
manuals are extremely important resources for
nurses because family nursing diagnoses are read-
ily linked with both the Nursing Intervention
Classification (NIC) (Bulechek, Butcher, Dochter-
man, & Wagner, 2013) and Nursing Outcomes
Classification (NOC) (Moorhead, Johnson, Maas,
Family Nursing Assessment and Intervention 121
FIGURE 4-7 Family Reasoning
Web template.
Family
environment
Family health
knowledge
Family
developmental
stage
Family diagnosis
Family
communication
Family social
supports and
resources Family
roles
Family
beliefs
Family
culture
Family stress
management
Family routines
of daily living,
(e.g., meals, sleep,
exercise, child)
Family
spirituality,
religion
3921_Ch04_105-136 05/06/14 10:58 AM Page 121
& Swanson, 2012) data sets. These resources pro-
vide many new ideas for family interventions and
suggest focused family outcomes that can be ex-
plored with families.
Other diagnostic classification systems that can
be used to identify problems include the Omaha
System–Community Health Classification System
(Martin, 2004), the Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-5; American
Psychiatric Association, 2013), and the International
Classification of Diseases: Clinical Modifications, Ninth
Edition (ICD-9-CM; American Medical Associa-
tion, 2012). See Tables 4-3 and 4-4, respectively,
for examples of selected family diagnoses from the
DSM and ICD-9-CM sources.
A rapidly growing system of diagnostic language
relevant to nursing in North America is that of the
World Health Organization ICD companions,
the International Classification of Functioning
(ICF) and its related child and youth version
(ICF-CY) (World Health Organization, 2013).
This broad schema of classification focuses on
making diagnostic statements of health impact in
four domains: body structure, body function, activ-
ity and participation, and environment (World
Health Organization, 2013). Family nursing practice
greatly involves the focus on the domains of activity
and participation and the environmental context of
family life. Given that nurses’ primary focus with
individuals and families is the functional aspect of
health in daily life, this system of categorizing and
coding functional outcomes of health is com-
pelling. The ICF and ICF-CY approaches are
being used with expanded focus in Europe and
Canada particularly (Florin, Björvell, Ehnfors, &
Ehrenberg, 2012; Raggi, Leonardi, Cabello, &
Bickenbach, 2010).
After the categories have been assigned and a
family nursing diagnosis determined, the next step
in analyzing the family story is for the nurse and
family to work together to determine the relation-
ships between the categories. Arrows are drawn
122 Foundations in Family Health Care Nursing
BOX 4-5
NANDA Nursing Diagnoses Relevant to
Family Nursing
■ Risk for impaired parent/infant/child attachment
■ Caregiver role strain
■ Risk for caregiver role strain
■ Parental role conflict
■ Compromised family coping
■ Disabled family coping
■ Readiness for enhanced family coping
■ Dysfunctional family processes: alcoholism
■ Readiness for enhanced family processes
■ Interrupted family processes
■ Readiness for enhanced parenting
■ Impaired parenting
■ Risk for impaired parenting
■ Relocation stress syndrome
■ Ineffective role performance
■ Ineffective family therapeutic regimen management
Source: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2013).
Nursing diagnosis manual: Planning, individualizing, and doc-
umenting client care (3rd ed.). Philadelphia, PA: F. A. Davis,
with permission.
Table 4-3 Selected Family-Centered Diagnoses
From Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition
V61.9 Relational problem related to a mental disorder
or general medical condition
V61.20 Parent-child relational problem
V61.10 Partner relational problem
V61.8 Sibling relational problem
V71.02 Child or adolescent antisocial behavior
V62.82 Bereavement
V62.3 Academic problem
V62.4 Acculturation problem
V62.89 Phase-of-life problem
Source: American Psychiatric Association. (2013). Diagnostic
and statistical manual of mental disorders (DSM-5)
(5th ed.). Washington, DC: Author.
Table 4-4 Selected Family-Centered Diagnoses
From ICD-9-CM
313.3 Relationship problems
313.8 Emotional disturbances of childhood or
adolescence
V61.0 Family disruption
V25.09 Family planning advice
V61.9 Family problem
94.41 Group therapy
94.42 Family therapy
Source: American Medical Association. (2013). International
classification of diseases: Clinical modifications (IDC-9-CM).
Dover, DE: Author.
3921_Ch04_105-136 05/06/14 10:58 AM Page 122
between the family categories showing the direc-
tion of influence if the data in one category influ-
ence the data in another category. The important
family problems or issues surface by systematically
working through all of the relationships because
they are the ones that have the most arrows indi-
cating the strongest relationships to all other areas
of family functioning. The step reveals the primary
family problems.
Another dimension of the family story that is of
importance to nurses is the dimension of beliefs.
Family and family member beliefs about health, ill-
ness, health care providers, and even their own
roles and processes are of great importance for
nurses to assess in planning to provide optimal care.
The Beliefs and Illness Model by Wright and Bell
(2009) suggests that nurses should assess families’
beliefs in a number of areas, specifically, family
structure, roles, communication, and decision-
making authority; beliefs about health and illness
(how they are defined, why they occur, how they
are managed); and beliefs about health care
providers (their intentions, motivations, and
knowledge and the meaning of their presence and
actions to the families and their health or illness ex-
perience). Individuals and families often behave
based upon their beliefs and thus any attempt for
nurses to engage families in health promotion,
health literacy, or health intervention in any setting
requires an exploration of these key areas. After
verifying all of these findings with the family, the
next step is to work with the family to understand
their preferences for decision making and design a
family plan of care accordingly.
Shared Decision Making
Family nurses should explore how involved the
family would like to be in the decision-making
processes. Universal needs of families include con-
sistency, clarity, comprehensive information, and
involvement in shared decision making with the
health care provider (Salmond, 2008; Schattner,
Bronstein, & Jellin, 2006; Whitmer, Hughes,
Hurst, & Young, 2005). Nurses, consciously and
otherwise, affect the family stress level by control-
ling how much (and how quickly) they involve the
family in the care of their family members (Corlett
& Twycross, 2006). Nurses control how much in-
formation they share with families, how much they
involve the family in the daily routine, visiting
hours, and even discussions with/among family
members. Families have expressed fears of alienat-
ing health care providers (Taylor, 2006), thus com-
promising their loved ones’ care. All of this may
interfere with nurses being able to be effective fam-
ily advocates (Leske, 2002).
Health care providers underestimate the extent
that families want to be involved in the care of and
decision making about loved ones (Bruera, Sweeny,
Calder, Palmer, & Benisch-Tolly, 2001; Pierce &
Hicks, 2001). Although most families prefer a shared
decision-making approach (de Haes, 2006; Schat-
tner et al., 2006; Whitmer et al., 2005), families vary
relative to the amount of information they want and
their role in the decision-making process (Sobo,
2004). The amount of information families seek or
need changes over the course of the health event, the
stage of the illness, and the likelihood of a cure
(Butow, Maclean, Dunn, Tattersall, & Boyer, 1997).
An option grid is one strategy for implementation
of shared decision making (Elwyn et al., 2012). An
option grid is developed by the family nurse keeping
health literacy principles at the fifth-grade level.
Elwyn et al. specifically developed the grid format as
a decision-making paper worksheet addressing com-
mon therapeutic approaches to specific health con-
ditions where patients and families could view the
benefits or drawbacks associated with different pos-
sible treatment decisions. On the worksheet, the
most relevant, frequently asked questions about a
specific condition make up the rows of the grid, and
the specific options available for the decision make
up the columns. Patients are given the paper grid and
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-
mine respite placement for their 12-year-old daugh-
ter who is medically fragile with severe cerebral palsy.
This specific tool shows promise for nurses working
with families because not only does it represent the
principles of family-centered care in practice, but also
because families often have difficulties understanding
their options and the potential benefits or conse-
quences associated with their choices.
Another approach to shared decision making is
to use the Patient/Parent Involvement Informa-
tion Assessment Tool (PINT) developed by Sobo
(2004). The PINT is a self-administered survey
that can be kept in the medical record to facilitate
and target information for communication be-
tween the health care team and the family. In the
Family Nursing Assessment and Intervention 123
3921_Ch04_105-136 05/06/14 10:58 AM Page 123
challenge to collaborate in the care and meet the
needs of individuals and family members, nurses
may ask the following two sample questions from
the PINT tool (Sobo, 2004, p. 258):
1. When possible, what level of information
would you prefer to receive?
■ The simplest information possible
■ More than the simplest, but want to keep
it on everyday terms
■ In-depth information that you can help me
understand
■ As much in-depth and detailed informa-
tion as can be provided
2. When possible, what decision-making role
do you want to assume?
■ Leave all decisions to the health care team
■ Have the care team make the decisions
about care with serious consideration of
our views
■ Share in the making of the decisions with
the health care team
■ Make all the decisions about care with se-
rious consideration of the health care team
advice
Supporting the hypothesis that not all families and
family members want full involvement in making
health care decisions, Makoul and Clayman (2006)
have outlined the following nine options for shared
decision making (p. 307):
■ Doctor alone
■ Doctor led and patient acknowledgment
sought or offered
■ Doctor led and patient agreement sought or
offered
■ Doctor led and patient views/option sought
or offered
■ Shared equally
■ Patient led and doctor views/opinions sought
or offered
■ Patient led and doctor agreement sought or
offered
■ Patient led and doctor acknowledgment
sought or offered
■ Patient alone
One of the problems with the implementation
of shared decision making is that every health
care provider has a different definition and un-
derstanding of the components of this concept,
as well as personal biases and beliefs about how
individuals and families may or may not wish
to participate (Elwyn et al., 2012; Makoul &
Clayman, 2006). Shared decision making is not
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
Child knows own home and is around
familiar surroundings.
Home is adapted to the child’s needs
and wheelchair.
Caregiver would be the skills trainer
who knows the child.
Parents are comfortable with the child
being with the skills worker during the
day, but do not have experience with
this person at night.
Cost: $250 a day for 7 days for a total
of $1,750. This would come out of the
parents’ pocket because insurance does
not cover this care.
Option 2: Grandmother’s home
Child has been to grandmother’s home
only a couple of times because it is in
a different city.
Home is not adapted to the physical
care needs of child, such as wheelchair
and bathing.
Caregiver is grandmother, who the
child knows well and has spent consid-
erable time with.
Parents are comfortable with the child
being with grandmother. Grandmother
has helped take care of child for short
times before, such as a weekend.
Cost: nothing.
Option 3: Nursing home
New setting for child.
Setting can accommodate the child’s
special needs and wheelchair.
No personal relationship with care-
givers in this setting. Grandmother
could visit during day.
Parents do not have a relationship with
the caregivers in this setting.
Cost: Covered by insurance.
3921_Ch04_105-136 05/06/14 10:58 AM Page 124
just informing the family of the decisions and
keeping the lines of communication open, nor is
it the health care providers determining what de-
cisions the family can make. Shared decision
making requires that health care providers tailor
their communication, accommodate their talk to
the level of the family, and present information
in a way that allows the family to make informed
choices. Shared decision making includes the fol-
lowing steps as outlined by Makoul and Clayman
(2006, pp. 305–306):
■ The family and health care provider must de-
fine and agree on the health problem that is
confronting the family member.
■ The health care provider presents and dis-
cusses options of care in a way that invites
family questions.
■ The family and health care provider discuss
pros and cons of options, including cost ben-
efits, convenience, and financial costs.
■ The family and health care provider discuss
values and preferences, including ideas, con-
cerns, and outcome expectations.
■ The family and health care provider discuss
ability and confidence to follow through with
steps or regimen for each option.
■ Both the health care provider and family
should check and clarify for understanding
the discussion and information shared.
■ Both the health care provider and family
should reach a decision or defer decisions
until an agreed-on, specified time.
■ The health care provider should follow up to
track the outcome of the decision.
FAMILY NURSING INTERVENTION
The family plan of action (or care) is designed by
the nurse and the family to focus on the concerns
that were identified in the Family Reasoning Web
as the most pressing or causing the family the
most stress. The plan should account for the fam-
ily preferences for decision making and should
meet their health literacy needs. The more spe-
cific the family plan of action and the interven-
tions, the more positive the outcomes. The role
of the nurse is to offer guidance to the family, pro-
vide information, and assist in the planning inter-
ventions. Working with families from an outcome
perspective helps to clarify what information and
resources are necessary to address the family need.
The following four points will help the family
break the plan into action steps:
1. We need the following type of help.
2. We need the following information.
3. We need the following supplies or resources.
4. We need to involve or tell the following
people about our family action plan.
For the purposes of clarity and evaluation, this
plan should be a written document. The action
steps or interventions should be clear and concise.
The plan should outline specifically who needs to
do what by when and also articulate the timeframe
in which the nurse will follow up. The last step of
any family action plan should entail evaluation that
involves the nurse and family reflecting and sharing
ideas about what worked well, what needs to con-
tinue to be addressed by the family, and avenues for
seeking help in the future.
Working with families to improve health and
adapt to illness is the primary goal of family health
care nursing. Nevertheless, there has been little direct
evidence of the potential outcomes and effects asso-
ciated with family nursing intervention because
nurses are not often leading such research and/or tend
to focus more on descriptive rather than interven-
tional research (Chesla, 2010). What has been dis-
tilled from the bodies of literature on family health
care intervention, however, is that family intervention
does seem to produce better effects than usual, indi-
vidual-focused medical care; greater effects have been
shown in improving child health than adult health in
some chronic conditions; and family-focused inter-
vention examples found in childhood obesity efforts
reveal the most compelling effects (Chesla, 2010).
Chesla (2010) also articulated that the means of
interventions varied and ranged from simple home
visits to coach families to much more complex edu-
cational and skill-developing strategies. Nurses
were involved in relationship-based interventions to
improve family communication, problem solving,
and skill building as they related to illness or health
management. The more tools nurses tended to use
to assist families (multimodal) as part of their care
plans, the better the outcomes seemed to be, par-
ticularly in managing complex health conditions
that required numerous lifestyle changes. Family
members were sometimes noted to be beneficiaries
of interventions, experiencing unique and improved
outcomes that were separate from the health of the
patient (Chesla, 2010). The field requires additional
intervention strategies and resulting evidence of
Family Nursing Assessment and Intervention 125
3921_Ch04_105-136 05/06/14 10:58 AM Page 125
outcomes, though more frequent examples are be-
ginning to emerge in practice (Svavarsdottir &
Jonsdottir, 2011).
Nurses help families in the following ways:
(1) providing direct care, (2) removing barriers to
needed services, and (3) improving the capacity of
the family to act on its own behalf and assume re-
sponsibility. Family nursing interventions can be di-
rected toward improving the health outcomes of the
member with the illness or condition, the family
members’ health-related outcomes of caregiving, or
a combination of both. One of the important as-
pects of working with the family is the nurse-family
relationship, which is an intervention in and of itself
as families can experience a sense of strength, com-
fort, and confidence that can be therapeutic and
useful (Friedman, Bowden, & Jones, 2003).
The nurse is responsible for helping the family
implement the plan of care. The nurse can assume
the role of teacher, role model, coach, counselor,
advocate, coordinator, consultant, and evaluator in
helping the family to implement the plan of the
care they jointly created. The types of interventions
are limitless because they are designed with the
family to meet its needs in the context of its family
story. Three examples below illustrate different
family nursing interventions in various contexts.
Brief Therapeutic Conversations
in Acute Care
Brief family conversations or interviews can be con-
sidered a family intervention. These brief interviews
could include nurses making introductions to family
members, collecting focused data to complete simple
genograms and ecomaps, and opening pathways of
knowing about families’ self-defined needs and pri-
orities (Wright & Leahey, 2013). Svavarsdottir,
Tryggvadottir, and Sigurdardottir (2012) conducted
a study measuring families’ perceptions of nurse sup-
port and their own reports of family functioning.
The study compared families who received brief
family intervention interviews with nurses and those
who did not. Predictably, families who received the
nursing intervention interview reported feeling
more supported than those who did not. Surpris-
ingly, this finding was true for families with a child
with an acute health crisis but was not true for those
coping with chronic conditions. Expressive family
functioning did not seem to change in the latter sit-
uation. Families of acutely ill children may experi-
ence significant benefits, however, when nurses take
small amounts of time to enact simple family health
care strategies (Svavarsdottir et al., 2012).
Home Visits and Telephone Support
Nursing visits to family homes are part of the early
historical tradition of nursing and are appropriate to
use today in family nursing. Northouse et al. (2007)
utilized a clinical trial design to provide three in-
home support visits along with two follow-up tele-
phone calls to partnered couples where men were
living through prostate cancer treatment. In the
study, both patients and partners who received the
in-home visits and phone calls reported that their
communication and relationship with one another
improved. Nurses offered these families coaching in
communication, facilitated discussions that identified
the beliefs and needs of both partners, and helped the
families make decisions about care tasks and life bal-
ance. The partners seemed to benefit by demonstrat-
ing improved quality of life, increased self-efficacy,
and less overall caregiving negativity than partners
who did not receive the intervention. Additionally,
some spouses continued to report these effects for up
to 8 months following the intervention, suggesting
that the act of providing access to nurses in the home
and via telephone helped spouses long after the con-
tact ended (Northouse et al., 2007).
Self-Care Talk for Family Caregivers
Nurses caring for families can intervene to pro-
mote health by helping families to identify poten-
tial health risks that stress the health of the family,
126 Foundations in Family Health Care Nursing
3921_Ch04_105-136 05/06/14 10:58 AM Page 126
such as when a 45-year-old father and husband
with metabolic syndrome refused to comply with
diet and exercise interventions. Parker, Teel, Leen-
erts, and Macan (2011) proposed a unique family
nursing intervention for developing self-care mo-
tivation and implementation in family caregivers of
people with high-acuity health needs; it is widely
known that intensive periods of caregiving can re-
sult in worsening health of caregivers. In this inter-
vention, family nurses made a series of six extended
telephone calls that helped the family caregivers
identify the barriers they faced in taking care
of themselves and then used a theory-based frame-
work to remove those barriers and implement
self-care strategies to improve their own health.
Clinical trial research is needed to demonstrate the
efficacy and effectiveness of this intervention, but
early evidence from similar approaches indicates
that the ideas have promise for improving caregiver
health. Moreover, the relational nature of the in-
tervention, supplied entirely by telephone, is cre-
ative and has implications for nurses serving
families in a variety of settings, including those in
rural locations.
FAMILY NURSING EVALUATION
In making clinical judgments, nurses engage in
critical thinking to determine whether and to what
extent they have met an outcome. The means of
measuring desired changes in outcomes varies with
the specific problem upon which the action plan is
focused. For example, if the family has identified
that a primary focus problem is disrupted sleep
routines for their young child with attention-
deficit/hyperactivity disorder, the nurse may pro-
pose that the family create a simple chart to
measure their new routine of sleep hygiene prac-
tices on a daily basis. The family determines that
at present, the child is not able to fall asleep with
ease on any given night and they set a goal to have
the child falling asleep with ease 3 nights a week
initially. Using the simple daily charting concept,
the nurse and family can easily look to the col-
lected data at a specified time to determine if the
goal has been met. The team makes the decision
about whether to proceed as originally planned, to
modify the family action plan, or to revisit the fam-
ily story in total. As indicated previously, the crit-
ical reasoning approach of thinking about families
and their needs is not linear. In practice, a constant
flow occurs between the components of the family
assessment and intervention strategy with plans
being continually evaluated and modified through
reflection.
There can be many reasons underlying a lack of
success in meeting desired outcomes when working
with families, some of which may be related to fam-
ily factors, others to nurse factors, and even others
to additional environmental factors. Apathy and
indecision are examples of potential family barriers.
Family apathy may occur because of value differ-
ences between the nurse and the family. The family
may be overcome with a sense of hopelessness, may
view the problems or bureaucracy as too over-
whelming, or may have a fear of failure. Nurses also
should consider whether they themselves imposed
barriers. Examples of nurse barriers to achieving
desired family outcomes could include discrepant
values or beliefs from the family, resulting in a lack
of follow-through on the part of the nurse; not lis-
tening to family concerns about the problems of
importance, leading to two separate, rather than
one unified, outcome goal; or even lack of time and
resources needed for the nurse to address the fam-
ily needs in a timely fashion. Examples of additional
environmental factors that act as barriers to desired
outcomes can be things such as a change in the pre-
scription formulary that limits access to the effec-
tive drug of choice on a family’s insurance plan,
lack of access to an appropriate specialty care
provider because of rural geography, or the loss of
a job by the primary wage earner in the family. A
more detailed list of possible barriers to family out-
comes can be found in Box 4-7.
Family Nursing Assessment and Intervention 127
BOX 4-7
Barriers to Family Outcomes
■ Family apathy
■ Family indecision about the outcome or actions
■ Nurse-imposed ideas
■ Negative labeling
■ Overlooking family strengths
■ Neglecting cultural or gender implications
■ Family perception of hopelessness
■ Fear of failure
■ Limited access to resources and support
■ Limited finances
■ Fear and distrust of health care system
3921_Ch04_105-136 05/06/14 10:58 AM Page 127
Aside from evaluating outcomes, another im-
portant part of the family evaluation is the decision
when to end the relationship with the family.
Sometimes care with a family ends suddenly. In
this case, it is important for nurses to determine
the forces that brought about the closure. The
family may seek to end the relationship prema-
turely, which may require a renegotiating process.
The insurance or agency requirements may place
a financial constraint on the amount of time nurses
can work with a family. Other times, the family-
nurse relationship comes to an end more naturally,
as when the nurse and family together determine
that the family has achieved the intended out-
comes. Whatever the reason for the end of the
nurse-family relationship, it is crucial that closure
be achieved between the parties.
Building closure into the family action plan will
benefit the family by providing for a smooth transi-
tion process. Strategies often used in this transition
include decreasing contact with the nurse, extending
invitations to the family for follow-up, and making
referrals when appropriate. If possible, this process
should include a summary evaluation meeting where
the nurse and family put formal closure to their
relationship. Following up with a therapeutic letter
can encourage families to continue positive adapta-
tion. The therapeutic letter should include recogni-
tion of the family achievement, a summary of the
actions, commendations to each family member, and
an insightful question for the family to think about
in the future that may provide the family a future
direction (Wright & Bell, 2009). An example of a
therapeutic family letter is found in Box 4-8.
128 Foundations in Family Health Care Nursing
BOX 4-8
Example of Therapeutic Family Letter
Dear W, H, and T,
First, I want to thank all of you for allowing me the op-
portunity to get acquainted with your family. I appreciated
your openness and willingness to talk with me.
During our time together, we discussed several issues
that were important to your family. One of these issues
was the ongoing possibility of H losing his job because of
the seasonal nature of his work. We explored the effects
of potential job loss on a personal and family level.
H, you expressed some concern about your ability to
provide adequately for your family. You indicated a per-
sonal constraining belief that a lack of steady employment
meant that you were letting your family down and not
providing for them. We discussed the idea that a paying
job is only one part of the entire family support system
that you provide. We explored some examples of noneco-
nomic means of support, such as specific tasks related to
farm chores, household management, and child care. If
your job situation changes again, I hope you will find
some of these suggestions helpful.
W, I was so impressed with your ability to juggle your
caregiving job with home, farm, kids, and spouse. I can’t
think of many women who could handle all of that with
such strength and grace. With all that you do, it’s not sur-
prising that there isn’t much time left over for your own
personal endeavors. We discussed your constraining belief
that you had to be responsible for everything. You envi-
sioned the possibility of letting go of certain tasks and
suggesting ways to share other tasks more equitably
among family members. If you and your family choose to
implement some task-sharing ideas, I sincerely hope this
will work for all of you.
T, you have mapped out a path to higher education
and a future career. You have every reason to expect suc-
cess. We briefly touched upon what “success” might
mean for you and whether success depends on the uni-
versity attended. I hope you will consider my thoughts in
this regard. Whatever the outcome, you have the love and
support of your parents.
Finally, I would like to commend all of you for your
deep devotion to each other and for putting family first.
You value family time, and you strive to communicate in a
way that sustains your close relationship with each other.
I would like to invite W and H to consider a suggestion
regarding making time for just the two of you. “Couple
time” is easy to overlook when you are focused on creat-
ing a loving, stable home for E and helping to launch T
into higher education. Please remember that you two are
the solid foundation of your family; the stronger your rela-
tionship is, the stronger your whole family can be.
As a result of our time spent together, I came away
with the feeling that your family is exceptionally strong,
deeply committed to one another, and fully capable of
adapting to any of life’s challenges. Thank you again for
your time.
Best wishes to you and your family,
Nursing student signature here
3921_Ch04_105-136 05/06/14 10:58 AM Page 128
NURSE AND FAMILY REFLECTION
The final step in critically thinking about family
nursing is for nurses and families to engage in vital,
creative, and concurrent reflection about their work
together. There are two purposes of engaging in
individual and collaborative reflection: to facilitate
evaluation of progress toward the desired family
outcomes and to increase expertise of the nurse.
The first purpose is for the nurse to reflect on
the success of the family outcome in collaboration
with the family as part of outcome evaluation. Re-
flection entails thinking about your thought
process relative to this family client. Nurses can
link ideas and consequences together in logical se-
quences by using an “if (describe a situation) … then
(explain the outcome)” exercise, which can help the
family member articulate concerns. A comparative
analysis approach of the family problem can be
used to analyze the strengths and weaknesses of
competing alternatives. The nurse may decide to
reframe the family problem or priority need by at-
tributing a different meaning to the content or con-
text of the family situation based on testing,
judgment, or changes in the context or content of
the family story (Pesut & Herman, 1999). While
this process of reflecting with the family results in
new co-created evaluation and knowledge related
to the collaborative work, the nurse can also engage
in this comparative reflective reasoning individually
in preparation for and follow-up to the discussions
with the family.
The second purpose of reflection is for nurses
to build on their expertise by reflecting on client
stories and their practice with each family. In
essence, nurses create a library of family stories so
that each time they come upon a similar family
story, they can pull ideas from previous experi-
ences. This aspect of reflection assists nurses with
pattern recognition.
Yet another, more individual purpose of reflection
is to engage in self-reflection and self-evaluation. By
using this critical thinking strategy, nurses learn from
mistakes and cement patterns of action that assist
them to advance in their nursing practice from
novice to expert family nurse.
A family case study follows that demonstrates crit-
ical reasoning about a family, assessment to identify
concerns, and interventions to meet family needs.
Family Nursing Assessment and Intervention 129
new member. (See Chapter 3 for details about this theo-
retical model.) Based on this approach, Vicki has many
questions in her mind as she prepares for her appointment
with the Bono family. The questions Vicki has about each
family member and the whole family are presented in bul-
leted lists after a brief description of each family member.
Libby Bono is a 35-year-old mother recovering from a
cesarean section delivery 7 days ago. She does not have
any existing health problems. Libby’s roles in the family are
primary child-rearer, events planner, disciplinarian, and
health expert. Libby is a hairdresser and is independently
contracted with a hair salon. She has planned to take off
3 months for maternity leave.
• How might Libby’s recovery from the cesarean section
be affecting her roles in the family, especially with an
active 2-year-old and a newborn?
(continued)
Family Case Study: Bono Family
In preparation for her appointment with the Bono family in
the mother-baby clinic, Vicki reviews the chart notes written by
the nurse midwife about the family. Vicki sees that the Bono
family is coming in for a 1-week well-baby checkup of new-
born infant Hannah and a follow-up for Libby, the mother,
after her cesarean section (C-section) delivery 7 days ago.
The note from the receptionist indicates that Libby expressed
some concerns with her effectiveness in breastfeeding Han-
nah. The appointment book notes that the whole Bono family
is coming for this visit. Vicki notes that the Bonos are a nuclear
family that consists of a married couple with two biological
children. Figure 4-8 shows the Bono family genogram.
Knowing that this is a nuclear family coming in for a
well-baby checkup, Vicki decides to use a Developmental
Family Life Cycle theoretical approach to this family with a
3921_Ch04_105-136 05/06/14 10:58 AM Page 129
• What are Libby’s thoughts or plans for returning to work
after her maternity leave?
• How is Libby adjusting to her expanded mother role?
Assess Libby for postpartum depression.
Matt Bono, 36 years old, works for Frito Lay Company
in sales and distribution. His primary roles in the family are
decision maker, maintenance person, pioneer, and infor-
mation provider. He reports feeling little attachment to his
occupation and welcomes this new birth as a change in
routine and an opportunity to consider a change in his
place of employment. His current medical problems in-
clude type 2 diabetes and mild hypertension; both are well
managed and controlled by oral diabetic and antihyperten-
sive medications. Currently, he is following the Weight
Watchers diet to reduce his weight and to control the
symptomatology experienced from his health conditions.
• How is Matt adjusting to the expanded role of father of
two daughters?
• What are Matt’s plans for employment, specifically about
financial support for the family if he leaves his job? How
would this affect health insurance for the family?
Sabrina Bono is a healthy 2-year-old girl who is devel-
opmentally appropriate. Psychologically, Sabrina is in the
autonomy versus shame-and-doubt developmental stage.
Her parents report that she often attempts to try new
things on her own, and they frequently praise her efforts to
promote independence. Her interest in potty training is de-
veloping, but still intermittent. Her immunizations are cur-
rent. She normally goes to a day-care center that is close to
her mother’s work.
• How is Sabrina adjusting to the new baby?
• Is Sabrina showing any regression in her skills and abilities?
• Are each of the parents finding time to spend with Sab-
rina alone?
• How are the parents talking with Sabrina about her role
as big sister?
Hannah Bono, 7 days old, was delivered after 42 weeks’
gestation and was proved to be adequate for gestational age
(AGA; 10th–90th percentile), 53.75 cm and 3,966 g, with
American Pediatric Gross Assessment Record (APGAR)
scores of 8 at 1 minute and 9 at 5 minutes.
• Is Hannah developing on target for her age and gesta-
tional age at birth?
• How often is Hannah eating, and is she gaining weight?
• How is Hannah nursing?
The Bono family is a nuclear family with the addition of
second child.
• What are the major concerns for the family at this time?
• Who in the family is having the most difficult adjustment
to the changes brought about by the addition of a new
family member?
130 Foundations in Family Health Care Nursing
3 yr
Matt
36 yr
M 2000
Libby
35 yr
Works in sales
Diabetes type 2
Hypertension
Family health
insurance
Healthy
Developmentally appropriate
Behavior regression with birth of Hannah
Day care all week
C-section 7 days ago
Hairdresser,
on leave 3 months
HealthyHannah
7 days
Sabrina
2 yr
Ava
30 yr
FIGURE 4-8 Bono family genogram.
3921_Ch04_105-136 05/06/14 10:58 AM Page 130
• How is the family adjusting to these changes?
• Who or what are the support systems for this new
family?
Bono Family Story:
During the appointment, Vicki confirms that family life for
the Bono family has changed. Hannah was found to be
healthy and developmentally appropriate. Libby is healing
well from the C-section, but reported occasional discomfort
when she “overdoes it.” Libby’s concerns about breastfeed-
ing were easily relieved as Vicki validated her breastfeeding
technique. An assessment for postpartum depression re-
vealed that Libby is not demonstrating any signs of depres-
sion at this time. Throughout the examination of Hannah,
the parents demonstrated overwhelming signs of bonding,
such as talking with the infant and bragging about her
beauty and temperament. During the appointment, Vicki
noted that Sabrina was throwing toys and attempting to
crawl onto her mother’s lap while Libby was nursing Han-
nah. Sabrina would say “baby back” when she was upset.
When Matt attempted to coddle or praise the baby, Sabrina
became extremely angry with her father. They were not ig-
noring Sabrina but were not focused on her during the ap-
pointment. The parents’ nonverbal actions showed
frustration with Sabrina’s behaviors. When asked, they re-
ported that Sabrina has been very temperamental and in-
consolable at day care. They reported that she had begun
to show progress with toilet training before Hannah’s birth
but had now lost all interest.
Analysis of Bono Family Story:
To help everyone see the larger family picture, Vicki uses
the Family Reasoning Web (see Fig. 4-7). Based on the re-
sponses from using the Family Reasoning Web, she uncov-
ered the following family information for analysis:
• Family routines of daily living: Matt and Libby are both
tired from Hannah’s every-3-hour breastfeeding sched-
ule. They share some of the responsibility for comforting
Hannah and seeing to her needs. Meals have been chal-
lenging as Matt has had to assume this responsibility be-
cause Libby has not recovered from her C-section. At this
time, they do not have extended family support. Sabrina
is still going to day care but is evidencing difficulty there.
• Family communication: Communication has been identi-
fied as a strength of the couple. They have a shared de-
cision-making style. They appear nurturing with their
children. Sabrina is emotionally up and down. She is
clingy with her dad and ignores her mother except when
she is breastfeeding Hannah. Sabrina was throwing toys
when upset or frustrated. She periodically pointed to
Hannah and said, “Take back.”
• Family supports and resources: This family is fully cov-
ered under Matt’s health insurance through his work.
They have some family they can call on to help them.
Ava, Libby’s sister, volunteered to come for a visit and
stay for 2 weeks. Matt’s brother, his wife, and their 3-
year-old child live in the same city. They have informally
talked about sharing some child care. Both parents need
to work to sustain their family lifestyle. Libby does not
have benefits in her contracted hairdresser job. When
she is off work, she does not make money. She does not
have paid maternity leave. The couple planned for Libby
to take 3 months off from work. The needs identified are
for some immediate family support with everyday living
and some financial concern at the end of the 3 months,
given that the family had not planned for a longer period
of reduced income than this.
• Family roles: All of the family members are experiencing
role ambiguity with their new roles. Matt and Libby are
now parents of two daughters. Sabrina is a big sister, and
Hannah is the new infant. Matt expressed some role
overload because he is assuming many of the typical
daily household chores of meals, laundry, food shopping,
and primary care provider for Sabrina.
• Family beliefs: They strongly state that “family comes
first.” This was a planned pregnancy. They see them-
selves as loving parents. They express some confusion
about disciplining Sabrina given her recent behaviors.
• Family developmental stage: This is a nuclear family in
the family-with-toddler stage. They also have a new in-
fant; therefore, they are in two developmental stages at
the same time.
• Family health knowledge: The family expressed that it
needed more help in knowing how to help Sabrina. The
parents do not know how to work with Sabrina to help
her adjust to being a big sister. They are confused with
Sabrina’s behavior of aggression, mood swings, clinging,
and pointing at the baby and saying “take back.” They
feel that she has lost some of her skills. Health literacy
does not appear to be an issue.
• Family environment: At this time, they have enough
room in their home for a family of four. They live in a safe
neighborhood, but they do not know their neighbors well.
• Family stress management: They express feeling stressed
about Sabrina’s behaviors. They are both tired. Sabrina is
stressed, as evidenced by her behaviors and changes in
behavior. They are dealing with the current situation on
their own but are open to asking for help from family for
the immediate assistance with daily living routines. They
are open to learning more about how to help Sabrina.
(continued)
Family Nursing Assessment and Intervention 131
3921_Ch04_105-136 05/06/14 10:58 AM Page 131
• Family culture: They are white with an Italian Catholic
background. They are of working lower-middle-class so-
cioeconomic status.
• Family spiritually: They were both raised Catholic but are
not practicing their religion. They do not belong to a
church. They describe themselves as spiritual.
The parents identified that both of them and Sabrina
are having difficulty adjusting to the expansion of their fam-
ily and the shift in their family roles. They state that they
are most concerned with Sabrina’s adjustment to the new
baby. They state that they just do not know the best way to
help her. They shared that they thought that since this was
the “second time around” they believed they could be
even better parents. They have been frustrated thinking
about how to cope with what to do with two young chil-
dren. The nursing diagnosis Readiness for Enhanced Par-
enting is related to the new role of parents of two children
and is evidenced by the parents’ subjective statements
about parenting, Sabrina’s reactions to the new baby, and
parents asking for information and help on sibling rivalry.
Bono Family Intervention:
Together, the nurse, along with Matt and Libby, review the
family genogram (see Fig. 4-8), which helps the couple vi-
sualize the family. The parents decide that Ava is the best
person to come to help at this time. They say they will talk
later with Matt’s brother and family about sharing some
childcare. They complete a family ecomap (Fig. 4-9) to
help assess what is creating stress and determine what
could help alleviate family stress.
Vicki provides Matt and Libby with several educational
packets about toddlers and new infants. She directs them
to several online Web sites after she confirms that they
have computer skills. They discuss ideas on how both par-
ents can make personal time to spend with each daughter.
They brainstorm ways to help Sabrina interact with Hannah
but to keep Hannah safe from aggressive toddler behavior
132 Foundations in Family Health Care Nursing
Strong relationship
Weak relationship
Tense relationship
Direction of
energy flow
Day-care
center
Matt’s brother
and wife
Family health
insurance
Computer
resources
parenting
Libby’s
work
Ava
Vicki, RN
Matt’s
work
FIGURE 4-9 Bono family ecomap.
3921_Ch04_105-136 05/06/14 10:58 AM Page 132
to a new sibling. They plan to talk with the day-care
providers so they can be effective with their help for
Sabrina. They will call Ava as soon as they get home to
plan for her visit. Vicki makes a follow-up appointment with
the Bono family for their next well-baby visit and to see
how they are progressing with both children.
Bono Family Evaluation:
Vicki plans a follow-up phone call to check in with Libby
and Matt. At the next visit, Vicki will revisit the family action
plan with Libby and Matt to see whether their priority fam-
ily concerns remain the same, or have decreased/in-
creased or disappeared. Vicki plans to observe Sabrina’s
behaviors to see how she is coping and whether she is
adapting in more positive ways. She will talk with the par-
ents to assess their anxiety level. She will observe the par-
ents and their interactions with both children.
Nurse Reflection:
Vicki reflects about her work with the Bono family. She de-
termines that her therapeutic communication skills were
excellent. She showed empathy and validated the family’s
concern for the added stresses that a newborn child cre-
ates for a family. The 7-day-old well-baby visit in the clinic
setting presented an ideal time to observe and address
parenting techniques and ease parental concerns. Learning
how to shift focus from the more medical concern of the
well-baby to family dynamics was the most challenging as-
pect, yet also the most rewarding. The interventions were
appropriate and truly empowered their overall ability to
cope and function as a family.
Family Nursing Assessment and Intervention 133
SUMMARY
■ Conducting a family assessment includes the
following components: assessment strategies,
including how to select assessment instru-
ments, determining the need for interpreters,
assessing for family health literacy, and dia-
gramming family genograms and ecomaps.
■ Family nurses must work in partnership with
families as they build from a strengths model
and not a deficit model.
■ Using the family assessment approach out-
lined in this chapter, nurses and families to-
gether identify the family priorities.
■ The Family Reasoning Web is a systematic
method used to ensure that families are
viewed in a holistic manner, which also helps
to keep the interventions oriented to family
strengths.
■ Family interventions need to be tailored to
each individual family, with consideration of
the family’s structure, function, and
processes.
■ By subscribing to and selecting a theory-
based approach to assessment, and formulat-
ing mutually derived intervention strategies,
families are more likely to be committed
and follow through with family plans and
interventions.
■ Family nurses serve as the catalyst for assess-
ment, intervention, and evaluation that are
specific to family identified needs.
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137
Family Social Policy
and Health Disparities
c h a p t e r 5
Isolde Daiski, RN, BScN, EdD
Casey R. Shillam, PhD, RN-BC
Lynne M. Casper, PhD
Sandra M. Florian, MA, PhD Candidate
C r i t i c a l C o n c e p t s
■ Health disparities arise from complex, deeply rooted social issues, and are directly related to the social and political
structure of a society.
■ Many factors contribute to (determine) health status, including educational level, socioeconomic status, and physical
surroundings.
■ It is critical for nurses to recognize the link between the determinants of health and health disparities.
■ The social and political structures of a society influence how health care is delivered to and restricted from those in
need. An upstream approach of health promotion and disease prevention is more effective than a downstream
approach of reactive treatment of disease.
■ For those who are sick, access to quality, affordable health care should be considered a basic human right from a
societal perspective. All aspects of health care should be designed to minimize disparities.
■ The policy decisions made by a society or government about families and how they are legally defined, what
constitutes a legal relationship, and how health care is delivered have a profound effect on families and their health.
Defining families from a legal perspective may contribute to health disparities by restricting access to social and
health care services. Ethical issues can arise if we restrict care to families by how they are defined legally.
■ In the past, the profession of nursing had a well-defined role in advocating for vulnerable populations. Recently,
nursing involvement in the development of health policy from either professional organization or individual
perspectives has declined, resulting in increased health disparities for families.
■ Nursing professionals can benefit from theoretical and practical education about social policy issues, resulting in
resounding effects on the health of a family.
■ Nurses can participate in advocacy related to family policies at all levels of health care systems in the context of society.
■ Illness of one member affects all members of the family, and in turn, family health affects all of society. Therefore, nurses
have to consider the whole family unit within the context of the changed health situation and larger social system.
3921_Ch05_137-164 05/06/14 10:58 AM Page 137
This chapter exposes the nurse to social issues, be-
havioral risks, and disparities that affect the health
of families. Threaded throughout the chapter is the
role of the nurse providing care within a framework
of family nursing. Specifically, this chapter presents
the key components that contribute to health
disparities between families in the health care sys-
tem. It explores health disparities in the context
of health determinants, social policy, and the
nurse’s role with respect to social policy. This
chapter also discusses the unique factors that affect
health policy and family health in both Canada and
the United States. At the completion of this chapter,
the nurse will have developed a broad understand-
ing of social policy and how it can contribute to or
mitigate health disparities. Armed with this knowl-
edge, nurses can assist families to adopt health pro-
motion and disease prevention strategies and can
advocate for families in their organizations, com-
munities, and nations for policies that minimize
disparities and maximize access to resources.
DEFINING SOCIAL POLICY
AND HEALTH DISPARITIES
It is critical first to create a common understanding
of and foundation for the concepts underlying the
substance of the chapter, such as health determi-
nants, health disparities, and family social policy.
This section also provides a brief overview of where
both the United States and Canada stand in terms
of health care coverage for all citizens.
Determinants of Health
The determinants of health are defined as factors
that directly influence the health of individuals,
families, and communities (World Health Organi-
zation [WHO], 2012a). WHO (2012a) defines social
determinants of health as “the conditions in which
people are born, grow, live, work and age, including
the health system. These circumstances are shaped
by the distribution of money, power and resources
at global, national and local levels” (paragraph 1).
More specifically, determinants include a person’s
demographic characteristics, such as gender, race,
and ethnicity, which cannot be changed, but to
which societal responses can be altered. They also
include characteristics that can be changed. These
changeable characteristics are considered behavioral
or social. Behavioral determinants include activities
such as eating habits, smoking, substance use, phys-
ical activity, and coping skills. Social determinants
include physical, social, and economic environ-
ments, which further break down into income,
housing, education, employment, access to health
care, public safety, transportation, and availability
of community-based resources (Hunter, Neiger, &
West, 2011; Mikkonen & Raphael, 2010; U.S.
Department of Health and Human Services
[USDHHS], 2010). Along with demographic and
behavioral ones, these social determinants have a
strong, indelible influence on the health of families
and will continue to contribute to health dispari-
ties within family systems. An uneven distribution
of the social determinants of health is often
reported as the root problem of health disparities.
Without the necessary financial resources for a
healthy lifestyle, for example, it is difficult or even
impossible to overcome such disparities.
Health Disparities
Health disparities are defined in the United States
and Canada as follows: (a) health differences for
particular populations that are (b) closely linked
to social or economic disadvantage and (c) result
in distinct differences in the presence of disease,
health outcomes, or access to care (Public Health
Agency of Canada, 2012; USDHHS, 2010). Health
and health status are complex concepts, and no
universal agreement has been reached on the def-
initions. WHO defines health as a “state of com-
plete physical, mental, and social well-being and
not merely the absence of disease or infirmity”
(WHO, 2012b). This basic definition has not
been changed since it was published in 1948.
Later, the WHO (1986) added the following:
“Health is seen as a resource for living, a positive
concept” that affects the extent an individual is
able to change and cope with the environmental
factors. These definitions, combined, will be used
for the purposes of this chapter.
Family Social Policy
An exploration of health determinants and health
disparities logically begins with a discussion of so-
cial policy and its impact on families. But what
constitutes social policy? Policy can be under-
stood broadly as a course of action. Social policies
138 Foundations in Family Health Care Nursing
3921_Ch05_137-164 05/06/14 10:58 AM Page 138
are those policies that include social concepts,
such as health, education, housing, and employ-
ment affecting people’s everyday lives. Multiple
social issues affect the health of families; in effect,
they both create and mitigate health disparities.
Nevertheless, social policies are developed for the
purpose of mitigating health disparities and pro-
moting equity and social justice. Social justice has
been defined as “full participation in society
and the balancing of benefits and burdens by all
citizens, resulting in equitable living and a just or-
dering of society” (Buettner-Schmidt & Lobo,
2012, p. 948). Some examples of social policies
adopted in the United States that have had re-
sounding effects on the health of families include
the State Child Health Insurance Program
(SCHIP), Medicare Part D, and the Welfare-
to-Work program. These programs, enacted dur-
ing the 2000s, were intended to improve access to
health care, manage costs, reduce taxpayer burden,
and thereby ultimately address health disparities.
Interestingly, however, the very policies created to
mitigate health disparities often result in the most
vulnerable of these populations experiencing even
further challenges. For example, Medicare Part D
was enacted in 2006 to increase prescription cov-
erage for older adults. Although mean annual out-
of-pocket medication expenditures have decreased
by 30% to 50%, older adults with persistent pain
experience additional disparities (Millett, Everett,
Matheson, Bindman, & Mainous, 2010). Multiple
factors contribute to these disparities: pain medica-
tions are often more expensive than many other
medications, Medicare part D reimburses a lower
percentage of pain medications than other medica-
tions, and Medicare does not cover complementary
or alternative therapies often used for pain man-
agement such as massage therapy, acupuncture, or
transcutaneous electrical nerve stimulation. Cur-
rently, tremendous social policy changes are under-
way in the United States with respect to health care
access, changes that will bear heavily on the health
of the population.
Briefing on the Current State of Health
Care Policy
The United States is in the midst of a transition to
a more affordable and accessible health care system.
The Affordable Care Act (ACA), passed in March
2010 (USDHHS, 2011b), seeks to enhance access
to health insurance. Despite much legislative and
legal wrangling, the ACA was upheld by the U.S.
Supreme Court in 2012 and implementation efforts
began in 2013 (USDHHS, 2011b). The immediate
benefit of the law will be to decrease disparities
in access to health care insurance (and hence in
health) by, for example, providing expanded cov-
erage to young adults, addressing inconsistencies
in Medicare drug benefits, and disallowing cover-
age denial for many pre-existing health conditions.
Additionally, beginning in 2013, the approximately
40 million uninsured U.S. citizens will be able
to access health coverage through the Health
Insurance Marketplace. The Marketplace, a set of
government-regulated and standardized health
care plans, will allow those without insurance to
submit one application to choose from multiple
private-sector policies. The selection is based on
their individual eligibility, but there is no possibil-
ity of being denied coverage or being charged a
higher premium due to pre-existing treatments or
conditions (USDHHS, 2011b).
Despite the progress sure to be wrought by these
recent changes to the health care system, the United
States will continue to face health disparity issues for
many years to come. The long-standing lack of a
universally available health care system has resulted
in the development of social systems that will con-
tinue to influence determinants of health (Mikkonen
& Raphael, 2010; Raphael, Curry-Stevens, & Bryant,
2008). In fact, on an annual basis, it is estimated that
nearly 50 million residents of the United States have
no health insurance (Kaiser Family Foundation,
2011). More than three-quarters of those uninsured
are from working families whose employers do not
offer such coverage. Young adults are further dis-
proportionately affected, as their low incomes make
it more difficult to afford coverage if it is not
provided by the employer (Kaiser Family Founda-
tion, 2011). Women and children are also dispro-
portionately affected because they are more likely
to be living below the poverty level. Without a
payment system for health coverage, many people
delay seeking health care services, which increases
the likelihood that illness or need for services will be
at a crisis level when they enter the system and re-
quire intensive downstream care. When this delay
occurs, costs for health care increase.
The Centers for Medicare and Medicaid Serv-
ices is a governmental agency in the United States
with responsibility for Medicare, Medicaid, SCHIP,
Family Social Policy and Health Disparities 139
3921_Ch05_137-164 05/06/14 10:58 AM Page 139
the Health Insurance Portability and Accountability
Act (HIPAA), and the Clinical Laboratories Im-
provement Amendment. Medicare is a health
insurance program for people older than 65 years,
certain disabled individuals younger than 65 years,
and those with end-stage renal disease. Medicare
covers nearly 50 million persons on an annual basis
(Kaiser Family Foundation, 2012). Medicaid is a
federal–state partnership health insurance pro-
gram for eligible low-income groups and is man-
aged by individual states. SCHIP was enacted in
1997 to address the lack of health insurance cov-
erage of children who did not qualify for Medicaid.
In 2009, President Obama signed the Children’s
Health Insurance Program Reauthorization Act
(CHIPRA) into law, providing new financial re-
sources and options to expand and improve health
coverage for children through both Medicaid and
SCHIP (USDHHS, 2011c). This restructuring of
the program has been successful in delivering cov-
erage to more than 40 million children compared
to only roughly 10 million in the earlier part of the
century (USDHHS, 2011c). Enrollment growth is
attributed both to the restructuring of the program
and the economic downturn that began in early
2008.
Also worth noting is the Prenatal Care Assis-
tance Program (PCAP), which targets pregnant
women who meet certain income requirements
and are eligible for part of the Medicaid system.
The PCAP program includes prenatal care; deliv-
ery services; postpartum care up to 2 months after
the birth of the baby; referral to the Women, In-
fants, and Children Program (WIC); and infant
care for 1 year.
Because in the United States the majority of
government health care programs are managed and
delivered by individual states with only partial sup-
port by the federal program, the burden to state
budgets is enormous. Some unique programs have
been implemented to help individual states bridge
this gap in costs of health care coverage. The state
of Massachusetts now mandates that residents have
some form of health insurance, similar to the com-
mon requirement that anyone with a car have
collision insurance. Residents who do not have cov-
erage are at risk for fines and tax penalties. A Mas-
sachusetts state-subsidized plan, Commonwealth
Care, was established to offer affordable health care
to residents. Still, the potential exists of posing an
additional burden on the poor, especially if they are
fined for not enrolling in something they can ill
afford.
Canada
By way of contrast, Canada has boasted universal,
federally funded health care access for physi-
cians’ services, hospital care, and diagnostics since
1966 (Medical Care Act, Canada, 1966). Canada’s
Medical Care Act (1966) has had a major influence
on social policy affecting health care. It ensures
that on a national level, hospital care, doctor’s vis-
its, and diagnostic services are accessible to every-
one, without charge. Many people also have
additional extended benefit plans through their
employers, for medication coverage, dental care,
and other therapies. Persons who are on social as-
sistance programs, such as welfare or disability
pensions, as well as those receiving old-age pen-
sions, have additional publicly funded coverage
for essential medications and basic dental care.
These additional benefits do not, however, extend
to those working for low wages with no additional
benefits, who often cannot afford their medica-
tions (Pilkington et al., 2010). Although some
provincially funded coverage is available for this
group, obtaining it is very difficult; it is only
meant for dire situations of need, and disqualifies
most of those working for low wages. As a result,
many prescriptions remain unfilled as choices
have to be made between paying the rent, feeding
the family, and buying medications (Pilkington et
al., 2010). Although universal health care exists, it
does not cover all aspects of health.
So the system is not perfect. There is a gap in
the health care delivery for those who lack private
insurance. Provinces and municipalities provide
long-term care for persons in need, but there are
never enough facilities. At various times, some
cash-strapped provinces have attempted to imple-
ment user fees for doctor and emergency depart-
ment visits. Due to immense public pressure, the
federal government so far has stepped in to pre-
vent this from happening. One policy, severely
curtailing federal health care funding for refugees,
was implemented in 2012 by the federal govern-
ment, leaving this vulnerable and often trauma-
tized group unprotected (Canadian Association of
Community Health Centres [CACHC], 2012;
Service Canada, 2012). This move was seen as a
major injustice by the public—physicians’ and
nurses’ associations, as well as hospitals and
140 Foundations in Family Health Care Nursing
3921_Ch05_137-164 05/06/14 10:58 AM Page 140
community health centers, have voiced a strong
unified opposition to this policy. In the meantime,
much of needed care for this group is provided
free by volunteer health providers, while individ-
ual hospitals and provinces are absorbing the costs
for emergency treatments within their general
budgets. Care is provided first and questions are
asked later (CACHC, 2012).
MODELS
There are several models that pertain to health
determinants and implementation of social policy
that are worth mentioning briefly here. The Social
Determinants of Health Model (Dahlgren &
Whitehead, 1991; Institute of Medicine [IOM],
2002, p. 404) conceptualizes an approach to assess-
ment and planning care using a foundation of
family nursing theory. This model, depicted in
Figure 5-1, can assist the nurse in understanding
how—aside from the behaviors of individuals—
physical, social, environmental, and psychological
components influence and affect the state of family
health. In this model the general social, economic,
cultural, and environmental conditions are the con-
text and give rise to the next layer, which consists
of the social determinants of health, the specific
social and physical factors representing healthy
or unhealthy living conditions. In turn, these fac-
tors influence social and community networks,
which then influence the lifestyles possible within
this context. The center of the model finds the
individual/family with their age and gender, enabled/
restricted by the contextual layers. Nurses must
take into consideration the family within context to
provide holistic care. Changing any of the deter-
minants depicted can bring about changes in family
health, as they impinge upon the primary underly-
ing conditions of health and illness (Canadian
Nurse Association, 2012). Using this model pro-
vides an overview of how all factors interrelate and
what possibilities for health promotion may emerge
at the institutional and community/societal levels.
The Care Model (Fig. 5-2), pertaining specifi-
cally to health care delivery, can be used to guide
nurses’ care for families/communities in the context
of implementing social policy. Initially developed
by the Robert Wood Johnson Foundation to deliver
quality care to those with chronic illness, the Care
Model has since been adapted to assist health care
teams change the wider health care delivery sys-
tems with a goal of eliminating health disparities
(Dahlgren & Whitehead, 1991). Components of
the Care Model include the health care organiza-
tion, community resources and policies, decision
support, delivery system support, clinical informa-
tion systems, and self-management support. Fur-
ther, the Care Model has the potential to frame the
work necessary to address complex self-management
problems with a social-policy approach, which in-
cludes forming community partnerships to support
self-management. Acknowledging the importance
of family and community is essential in order to
implement a successful program, as humans are re-
lational social beings depending on each other.
A proactive health care team employing the Care
Model, for example, might initiate an intervention
policy of a community garden and kitchen within
a poor neighborhood, where many clients have
Family Social Policy and Health Disparities 141
Agriculture
and food
production
Education
Water and
sanitation
Health care
services
Housing
Work
Environment Unemployment
Living and working
conditions
G
en
er
al
so
cio
eco
nom
ic, cultur
al, and environmental conditionsSoc
ial a
nd community networks
Ind
ividu
al lifestyle factorsAge, sex, and
constitutional factors
FIGURE 5-1 Social Determinants of
Health Model suggested by Dahlgren
and Whitehead (1991).
3921_Ch05_137-164 05/06/14 10:58 AM Page 141
type 2 diabetes and lack the resources to buy healthy
foods. Clients referred to this program can share
growing food and cooking meals together. This in-
novative policy adds new resources, while enhancing
client skills and self-management support. At the
same time, the program also strengthens commu-
nity ties and cohesion.
Similarly, Canadian scholars Doane and Varcoe
(2005) describe a socio-environmental approach
to nursing care focused on relationships within fam-
ilies, communities, and health care systems. Health
is seen by these authors as a socio-relational experi-
ence that is shaped by contextual factors. As in the
models discussed earlier, nurses need to take into
consideration not only the clients and their families
but also all of their physical and social surroundings.
Working closely with families and communities and
building on the concept of health as a resource for
living, the socio-environmental approach recognizes
that health is deeply rooted in human nature and
environmental structures (WHO, 1986). Knowing
their needs and situations, empowered communities
therefore are able to promote health with the
capacity “to define, analyse and act on concerns in
one’s life and living conditions” (Doane & Varcoe,
2005, p. 29). This approach, like the Care Model,
functions under the premise that a comprehensive
social-health-policy approach must be utilized for
optimal delivery of health care, as change is most
effectively brought about at the level of physical and
social environments.
SOCIAL DETERMINANTS AND
RESULTING HEALTH DISPARITIES
Health disparities are such an overwhelming prob-
lem in the United States that Congress charged the
Institute of Medicine (IOM) to investigate and de-
velop a report on the subject. The landmark IOM
report, Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care (2003), detailed
long-standing and deeply rooted inequalities in
health care directly related to race and ethnicity.
Despite the IOM providing a comprehensive re-
view of the contributing factors to health disparities
and recommendations to promote health equity, a
2012 evaluation on the progress toward reducing
health disparities reveals continued health dispari-
ties (IOM, 2012). For instance, African Americans
continue to experience higher rates of death from
heart disease and cancer than white Americans, and
children who live in urban areas are more likely to
have asthma than children living in less population
dense areas (IOM, 2012). These health disparities
continue to correlate with certain environments
142 Foundations in Family Health Care Nursing
Care Model
Functional and Clinical Outcomes
Productive interactionsProductive interactions
Health System
Health care organization
Community
Self-
management
support
Clinical
information
systemDelivery
system
design
Decision
support
Resource
and policies
Informed,
activated
patient
Prepared,
proactive
practice team
FIGURE 5-2 The Care Model. (From Texas
Association of Community Health Centers. (2008). The care
model. Retrieved April 29, 2009, from http://www.tachc.
org/HDC/Overview/Care Model.asp, with permission.)
3921_Ch05_137-164 05/06/14 10:58 AM Page 142
and lack of adequate resources in multiple areas,
such as limited access to health care, exposure to
environmental toxins in impoverished environ-
ments, personal behaviors related to substance
abuse, inadequate nutrition, lack of physical exer-
cise, and lack of treatment for mental illnesses
(IOM, 2012). This section will discuss key social
determinants of health, their direct outcomes and
effects, and the associated health disparities.
Poverty
Social determinants of health are interrelated and
mutually reinforcing. Poverty is likely the most
fundamental social determinant contributing to
health disparities. It influences the other social de-
terminants, such as housing, food and job security,
education, and lifestyle choices, and is related to
racism and chronic illness. So, it is impossible to
discuss one without delving into the others. For in-
stance, poor-quality housing or overcrowding—a
result of poverty—affects health by contributing to
stress and safety issues, while mildew and dampness
might trigger asthma or other respiratory condi-
tions. Unemployment/employment insecurity,
which can result in poverty, limits the choice of
affordable housing, and living in a low-resource
community further adds to unhealthy lifestyle
choices. For example, areas where affordable hous-
ing is located tend to lack public transportation and
grocery stores, and they have less access to fresh
fruits and vegetables, which makes shopping for,
and eating, healthy foods difficult. Often, the only
choice is to buy unhealthy processed foods from
the local variety stores, and frequently at high
prices (Hilmers, Hilmers, & Dave, 2012).
Poverty creates serious issues when it comes to
housing and can result in homelessness for many
families who live below the poverty level. Homeless
children are three times more likely to have been
born to a single mother than their nonhomeless
counterparts (National Center on Family Home-
lessness, 2008). Education is a strong predictor of
eventual stability, success, and health, yet education
is not (or cannot be) emphasized within homeless
communities (National Alliance to End Homeless-
ness, 2006). In the end, homeless children are less
healthy—they are more likely to have developmen-
tal delays, to have learning disabilities, and to re-
peat a grade in school (National Center on Family
Homelessness, 2008).
In the United States today, as well as in Canada,
concern exists over a widening income gap leaving
many families and individuals below the poverty
level. Interestingly, although the annual median
household income for 2011 experienced a contin-
ued decline by 1.5% to $50,054, the national
poverty rate only declined 0.1%, indicating that
the top-income-earning Americans continue to
increase in wealth and the middle- and lower-
middle-class Americans are experiencing signifi-
cant declines in income (Luhby, 2012). This widen-
ing income inequality between the wealthy and
the middle class poses a serious threat of more
Americans heading toward poverty. Today, more
than 4.9 million Americans, including 1.2 million
children, live in poverty in the United States. As
explored further below in the sections on race and
gender, African American families and those with
female heads of households disproportionately ac-
count for those living at or below the poverty level.
African Americans earn 61% ($31,969) of what
non-Hispanic white individuals earn ($52,423).
Women continue to earn approximately 77% of
what men earn overall (DeNavas-Walt, Proctor,
& Smith, 2007).
Canada fares only slightly better, as there is a
widening income disparity too. Whereas the top
10% of incomes represent more than a quarter of
total incomes, the bottom 10% only represents
1/40th of total incomes. The 80% in between earn
the remaining 75% (Canadian Centre for Policy
Alternatives [CCPA], 2013). The Canadian Index
of Wellbeing [CIW] (2012, p. 2), reported that
Canada, since 2008, is experiencing an economic
backslide. From 1994 to 2010, even though Canada’s
Gross Domestic Product (GDP) grew by an im-
pressive 28.9%, improvements in Canadians’ well-
being grew by a significantly smaller 5.7%. The
key message is that despite years of steady eco-
nomic growth in Canada, this prosperity has not
been fairly distributed among the Canadian popu-
lation (CIW, 2012), as income disparities continue
to rise. CIW further pointed out that income in-
equality, measured as the difference between the
richest 20% and the poorest 20% of Canadian fam-
ilies, is particularly problematic, as this gap has
grown by over 40% since 1994.
In the United States, availability of employment-
based health coverage has declined from 64.4%
in 1997 to 56.5% in 2010 (U.S. Census Bureau,
2010). This decline has left many more workers
Family Social Policy and Health Disparities 143
3921_Ch05_137-164 05/06/14 10:58 AM Page 143
and their dependents without health coverage.
The cost of health coverage is well beyond the
means of those living in or close to the poverty
level. Meanwhile, the public debate on an appro-
priate level of support for families who lack basic
housing, food, health services, or social stability
continues. Another important factor that affects
poor families is a lack of affordable day care. To
relieve stress on the families and to escape
poverty, families need reliable and quality day
care allowing both parents to work.
Multiple other factors worsen the influence of
poverty on health outcomes (Woolf, Johnson,
Phillips, & Philipsen, 2007), factors such as access
to resources, health literacy, gender, ethnicity,
and education. All of these factors are considered
major contributors to poor health, particularly
cardiovascular disease (Shikatani et al., 2012),
type 2 diabetes (Chaufan, Constantino, & Davis,
2011; Pilkington et al., 2011), and mental illness
(Mental Health Strategy of Canada, 2012; Mental
Health Commission of Canada, nd). It is impor-
tant that nurses and other health professionals
support policies that help to eradicate poverty
and the resulting health disparities (Kirkpatrick
& Tarasuk, 2009).
Gender
Gender is a social determinant everywhere, with
women and sexual minorities experiencing dispar-
ities in access to resources and well-paying jobs
(Mikkonen & Raphael, 2010). Women earn less
than men when performing the same job, approxi-
mately 77% of men’s wages (Devas-Walt, Proctor
& Smith, 2007), yet they are more likely than men
to be heads of single parent households. In fact,
gender is one of the factors that further exacerbates
poverty and, in turn, contributes to even greater
health disparities. Gender affects health care in
other ways as well. For example, women with car-
diovascular disease are more likely to receive a mis-
diagnosis, as their symptoms do not follow the
typical presentation men demonstrate, and most
tests for cardiovascular disease were developed
based on male physiology (Schiff, Kim, Abrams,
Cosby, & Lambert, 2005). Women are also less
likely to receive referrals for surgical procedures,
pain management, and other health conditions
even when displaying comparable symptoms as
male controls.
Race and Ethnicity
Racial and ethnic minorities, or those of First
Nation status, tend to have lower incomes and
lower-quality jobs (Mikkonen & Raphael, 2010),
factors that contribute directly to health disparities.
Recent Canadian data show that the health of non-
European immigrants of color deteriorates over
time whereas the health of European immigrants
is actually superior to that of Canadian-born resi-
dents. Hispanic/Latino men are three times as
likely to contract HIV as white men, and Latino
populations are disproportionately affected by
HIV, accounting for nearly 20% of new infections
in the United States (Centers for Disease Control
and Prevention [CDC], 2013a). Other examples of
disparities based on race and ethnicity are as fol-
lows: African American, American Indian, and
Puerto Rican infants have higher death rates
than white infants; African Americans, Hispanics,
American Indians, and Alaska Natives are twice as
likely to have diabetes than non-Hispanic whites;
and Hispanic and African American older adults are
less likely than non-Hispanic whites to receive in-
fluenza and pneumococcal vaccines (CDC, 2013a;
Rodriguez, Chen, & Rodriguez, 2010).
Additionally, members of these groups may ex-
perience overt or subtle differences in treatment
in the health care system, due to discrimination
against minority populations. Self-reported racial/
ethnic discrimination encountered by health care
providers is significantly associated with lower
quality of care indicators, such as development of
foot disorders and regulation of HbA1c (Peek,
Wagner, Tang, Baker, & Chin, 2011). Other re-
cent studies indicate that although minorities are
more likely to require health care, they are less
likely to receive health services. Further, even when
access is equal, minorities are far less likely to re-
ceive surgical or other therapies. Nurses have the
moral obligation to advocate for clients who are
faced with discrimination in the system and ensure
that they receive the same care and treatment as
everyone else.
Presence of Chronic Illness
The presence of chronic illness is a determinant
that leads to health disparities beyond the mere
presence of the chronic illness. It often results in
poor quality of life and increased financial strain,
especially for those who have no or limited access
144 Foundations in Family Health Care Nursing
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to health care and resources. In severe cases
chronic illness also leads to inability to work and
therefore forces those who are ill to rely on the
social safety net, which has been increasingly cut
back over the last 20 years (Mikkonen & Raphael,
2010). Despite improvements in treatment and
management strategies for chronic illness im-
proving both quantity and quality of life, social
determinants continue to place disadvantaged
populations at risk of poor outcomes from chronic
illness. Likewise, the presence of chronic illness
itself is a determinant that leads to health dispar-
ities for and between families. If one family mem-
ber is ill the whole family is affected and often has
to pick up the financial and care burden. This is
true for the United States but also in Canada
where medications and home care, for example,
are not covered by universal health care. Unless
a patient has private insurance benefits, these
costly treatments place a burden on families. The
following section explores several common chronic
illnesses and the ways that they contribute to health
disparities.
Type 2 Diabetes
Type 2 diabetes is on the rise and is four times
more likely in low-income communities than in
their higher-income counterparts. Lower-income
communities often also coincide with high pro-
portions of immigrant population and people on
social assistance (Mikkonen & Raphael, 2010).
Health promotion efforts involving diet and
exercise to ward off obesity have a significant in-
fluence on disease rates; however, they require
sufficient resources (Webster, Sullivan-Taylor &
Turner, 2011). Due to lack of resources, preven-
tive measures, such as keeping a healthy weight,
are much less likely in lower-income groups
(Chaufan et al., 2011; Dinca-Panaitescu et al.,
2012; Pilkington et al., 2011; Raphael, 2008; Raphael,
Daiski, Pilkington, Bryant, Dinca-Panaitescu &
Dinca-Panaitescu, 2011). Aboriginal peoples, for
example, only developed diabetes when they
started to eat Western foods, instead of their
traditional diets. Before the 1940s, this disease
was virtually unknown in that group (Health
Canada, 2011).
Dinca-Panaitescu et al. (2012), however, pres-
ent research showing that even with obesity levels
the same, diabetes rates were four times higher
among those persons who lived in lower-income
neighborhoods, confirming that the reasons for
this disparity are complex and multilayered. These
layers include lack of needed resources for a
healthy lifestyle, such as healthy diets; lack of ex-
ercise; inability to pay for prescription drugs; lower
incomes; unhealthy environments; racial and/or
ethnic discrimination; and stress. Researchers have
found evidence that worry and chronic stress,
which leads to high cortisol levels, plays a role in
chronic disease (Brunner & Marmot, 2006).
Chronic stress disproportionately affects most
minority ethnic groups who are often subject to
discrimination and the constant worries attached
to low incomes. When people have to cope with
the added expenses of the illness, it increases stress
further, creating a cycle and exacerbating chronic
illness. As stated earlier, the social determinants
that create health disparities are multilayered,
complex and mutually reinforcing.
Asthma and Other Lung Diseases
According to the American Lung Association
(2008), approximately 34.1 million Americans re-
port a diagnosis of asthma, and the incidence of
asthma is increasing, with similar reports from
Canada (Public Health Agency of Canada, 2012).
Direct health costs for treating asthma are esti-
mated to be $10 billion annually. Asthma is the
leading chronic illness among children and is the
third leading cause of hospitalization for children
younger than 15 (American Lung Association,
2008). It is associated with poor-quality physical
environments, such as increased air pollution and
substandard housing. Major asthma attack triggers
include secondhand tobacco smoke, dust, pollu-
tion, cockroaches, pets, and mold. Less common
triggers include exercise, extremes of weather,
food, and hyperventilation (National Center for
Environmental Health, 2013).
In adults we find chronic obstructive pulmonary
disease (COPD) and lung cancer to be serious
chronic diseases that shorten life and decrease its
quality. Lung diseases, like all other diseases, are
associated with social determinants such as poverty,
as well as with considerable health care costs.
HIV/AIDS
More than 1 million people live with HIV/AIDS
today in the United States. AIDS is now seen as a
chronic, treatable disease in America and other de-
veloped countries (AIDS in America, n.d.). With
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the introduction of antiretroviral drugs in the 1990s,
HIV has been treated as a chronic illness, and more
people are living longer with the infection. Unfor-
tunately, the treatability has contributed to an
“unsafe sex problem” leading to complacency, and
the infection rate, instead of declining, has remained
stable since 2006 (AIDS in America, n.d.).
Mental Illness
Mental illness is widespread and very debilitating,
particularly due to the stigma attached. It often
leads to homelessness and family breakup, two
other significant health determinants. It is esti-
mated that one in five persons in North America
will have a mental illness at some point in their lives
and it can strike at any age, including childhood.
Those with mental illness who are poor are more
likely to end up homeless and destitute (Canadian
Mental Health Association [CMHA], 2009).
of nurses to help clients with chronic diseases is
teaching health literacy.
Health Literacy
Health literacy, first noted in the Healthy People
2010 objectives, is defined as “the degree to
which individuals have the capacity to obtain,
process, and understand basic health information
and services needed to make appropriate health
decisions” (National Network of Libraries of
Medicine, n.d.). Health literacy is one of the so-
cial determinants that contributes to health dis-
parities; but though a relationship between health
disparities and health literacy has been estab-
lished, it is complex. The IOM found that ap-
proximately 9 out of 10 adults have difficulty
understanding health information (IOM, 2011),
and the Canadian Council on Learning (2007)
found 60% of Canadians are health illiterate. In-
dividuals with low health literacy do not under-
stand health information, so it affects their health
outcomes disproportionately because they seek
fewer health screenings, they use urgent or emer-
gency care, they experience errors in medication
dosing and scheduling, they lack alternatives in
treatment regimens, and they are unable to
access accurate health-related information.
Nurses, as educators and advocates, must con-
sider the health literacy of the patients and fami-
lies that they serve. Explaining health-related
concepts in plain language will help to ensure
that patients understand the information cor-
rectly. Nurses may also assist families by filling
out complicated forms when applying for social
support or filing insurance claims (Street Health
Report, 2007).
The Definition of Family
The definition of family, rarely challenged until
recent times in the United States, has major social
implications in terms of health disparities. Most
directly, the definition of family can influence who
is able to access health care and social support
resources and who is not. The typical definition
of family is “two or more people who are related
by blood, marriage/partnership or adoption, that
live together for a certain period of their lives”
(Statistics Canada, 2011). In Canada “the tradi-
tional family, a married couple with 2.5 children,
146 Foundations in Family Health Care Nursing
In North America it is estimated that 4 persons
out of 10 will develop cancer in their lifetime. In
recent years, with improved detection and treat-
ments, many cancers are now cured or, like AIDS,
can become chronic diseases that people live with
for some time. Similarly, cardiovascular disease is
becoming a chronic health condition (Hemingway,
2007; Shikatani et al., 2012), with those affected
needing support to manage their disease. As per-
sons with chronic illnesses live and work within
their communities, they need to learn how to self-
manage their conditions (Health Council of
Canada, 2012). Nurses as advocators and coaches
have a large role to play here, when they care for
individuals and families within the context of their
physical and social environments. One of the roles
3921_Ch05_137-164 05/06/14 10:58 AM Page 146
has been reconfigured to include cohabiting cou-
ples (with or without children), lone parent fami-
lies, blended or step-families, same-sex couples,
couples who remain childless by choice, and inter-
generational families” (Statistics Canada, 2011).
The definition is evolving as families evolve, but
perhaps not as quickly as necessary.
Members of a “family” can be given access to
or denied health insurance, housing, and access to
social and health programs. In the United States,
the Administration for Children and Families,
overseen by the USDHHS, “is responsible for
federal programs that promote the economic and
social well-being of families, children, individuals,
and communities in the U.S.” (USDHHS, 2013a).
Such programs include, for example, Temporary
Assistance to Needy Families (TANF), the Healthy
Marriage Initiative, and Head Start (USDHHS,
2008). But because of how families are legally de-
fined, many individuals who consider themselves
part of a family unit would be ineligible for these
programs. In fact, a limited legal definition of
family can have devastating results. Take, for ex-
ample, one instance in Black Jack City, Missouri,
where a family composed of two parents and three
children was denied an occupancy permit simply
because the parents were not legally married
and the male parent was not the biological father
of the oldest child residing in the household
(Coleman, 2006).
Canada is somewhat more liberal in this regard.
The provinces, with exception of the Province of
Quebec, legally recognize the common-law fam-
ily, meaning two people cohabitating without
being officially married (Statistics Canada, 2011).
In 1967, former Prime Minister Pierre Elliott
Trudeau, then Justice Minister, declared: “The
state has no business in the bedrooms of the
nation” (cited by Overall, 2004, p. 1). Today,
same-sex marriage is legally recognized in that
“a couple may be of the opposite or same sex”
(Statistics Canada, 2011). Canada’s recognition
of both same-sex and common-law families re-
sults in major implications for access to spousal
benefits and pensions, child custody, and other
traditionally family-oriented rites of inheritance.
Previously, only traditionally married couples of
the opposite sex were recognized as beneficiaries,
leaving many nontraditional spouses destitute
after their life partners died or divorced them.
Legal definitions of family in the United States
will continue to be blurred as families continue
to evolve through adoption, same-sex marriage,
cohabitation, and blended families.
Education
Education is another key social determinant of
health. Schools in affluent areas have better re-
sources for the most part. In poor areas, poor qual-
ity education and high drop-out rates contribute
further to poverty, preventing access to high-quality
jobs and incomes. School districts vary greatly, as
does the quality of education they provide. They
may be as small as a single grade school or as large
as the multimillion-pupil New York City system. In
the United States, the historical expectation is that
a locally elected or appointed school board will de-
termine the way in which the community’s children
will be educated. Federal funds, often for special
education or programs for impoverished students,
account for only about 7% of school expenditures
(Ramirez, 2002). The reporting about schools with-
out texts, without modern science laboratories or
computers, and cutting back on “frills” such as
music, art, and gym has stimulated an active search
for ways to make equitable funding available. Given
the high positive correlation between health status
and level of education, this determinant of health
and associated policies should be an area of concern
to every nurse. Education makes it possible to
obtain a better job and higher income and is the
best way out of poverty.
Health Resources
Despite the presence of the universal health insur-
ance program in Canada, some major inequities re-
main. For example, in rural areas, access to health
care is often very limited. This is of particular con-
cern in Canada’s far north, inhabited mainly by
First Nations people. Communities there are
served mostly by nurses. Although the nurses have
the opportunity to provide primary health care,
resources are limited. For major health problems
requiring surgical or other complex interventions,
or even to give birth, patients are routinely flown
out to larger centers, resulting in family separation
and lack of community support for the patient.
Using technology such as telemedicine provides
hope for improvements of health care in these un-
derserviced communities.
Family Social Policy and Health Disparities 147
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RISKS AND BEHAVIORS THAT
CONTRIBUTE TO DISPARITIES
This section focuses on the behavioral health de-
terminants that contribute to health disparities. In
popular discussions, and sometimes among profes-
sionals, health-related behaviors are treated as re-
sulting solely from conscious choice by individuals,
who are to blame if their risky behavior leads
to poor health outcomes. Many health activists, by
contrast, seek to place blame on commercial inter-
ests that profit from these behaviors or on govern-
ment policies that protect them. Research on the
causes of risky behaviors is much less developed
than is research on the consequences of such
behaviors. But even so, it is clear that these risky
behaviors are the result of multiple causes and can
be influenced by health policy in multiple ways
(Berkman & Mullen, 1997; Singer & Ryff, 2001).
This section explores obesity, alcohol use, smoking,
and other risk factors specifically pertinent to
adolescents.
Obesity
In North America, one of the most disturbing
trends in health over the past decade has been the
increase in the proportion of the population that is
overweight or obese. Obesity is defined as body
mass index (BMI) at or above the 95th percentile
of the sex-specific BMI, according to the CDC’s
BMI-for-age growth charts (CDC, 2010). BMI is
calculated as weight in kilograms divided by the
square of height in meters. Obese people are more
likely than are those of normal weight to suffer
from heart disease, stroke, diabetes, gallstones,
sleep apnea, and some types of cancer (USDHHS,
2009). Hypertension, musculoskeletal problems,
and arthritis tend to be more severe in obese
people. Obesity increased little in the U.S. popu-
lation between the early 1960s and 1980. Since
1980, however, obesity has increased dramatically
in the United States. Fifteen percent of American
adults were obese in the mid-to-late 1970s. The
prevalence of obesity doubled in the two subse-
quent decades to 31% by 2000, and by 2009–2010,
nearly 36% of adults were obese (CDC, 2012).
Women (36.2%) are more likely than men (32.6%)
to be obese (Shields, Carroll, & Ogden, 2011).
Obesity rates are lower in Canada than in
the United States, but Canadian rates have also
increased rapidly in recent years. Approximately
24% of Canadian adults were obese in 2007–2009
(Shields et al., 2011). In contrast to the United
States, in Canada men were more likely to be obese
than women; trends in the incidence of obesity are
now similar for both: in 2007–2009 24.3% of men
and 23.9% of women were obese in Canada
(Shields et al., 2011).
In 2009–2010, over one-third of adults age 65
and older in the United States were obese (CDC,
2012). Since 1999, the incidence of obesity among
older adults has increased, especially among men.
With projections for the number of older adults
to more than double from 44.2 to 88.5 million by
2050, obesity in this group will contribute signifi-
cantly to health care costs (Fakhouri, Ogden,
Carroll, Kit, & Flegal, 2012).
The percentage of children and teenagers who
are obese has been increasing dramatically since
the 1980s. In the mid-1980s in the United States,
only 5% of children were obese, yet by the early
2000s, obesity increased to 18% among children
and adolescents (Federal Interagency Forum on
Child and Family Statistics, 2012). A recent report
in August 2013 by the CDC (2013b) reveals for the
first time in decades that there is a slight improve-
ment in obesity rates in the United States among
preschool children who live in low poverty. From
2008 through 2011, data were collected in 43 states
and territories for preschool children who partic-
ipate in the Women, Infants, and Children (WIC)
federally funded program. There was a slight drop
in the obesity rates in 19 of these states, with the
largest drop of 1% in Florida, Georgia, Missouri,
New Jersey, and South Dakota. One factor that
could contribute to this new trend is changes
in the WIC program, which include eliminating
juice from food packets, less food with saturated
fats, and easier access to fruits and vegetables.
Along with these changes, the breastfeeding rates
in the United States continue to increase. Whereas
this is an excellent trend, childhood obesity
remains of deep concerns as one in eight children
are obese, with one in five African American chil-
dren and one in six Hispanic children still obese.
Boys and girls have been historically about equal in
their likelihood to be overweight, but in 2007–2008,
a higher percentage of boys (21.2%) were obese
than girls (17.3%). Mexican American and African
American teenagers are more likely to be over-
weight than are non-Hispanic white teenagers.
148 Foundations in Family Health Care Nursing
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By 2007–2008, the percentage of overweight
Mexican American teenagers was 24.2%, compared
with 22.4% for African Americans and 17.4% for
whites (Federal Interagency Forum on Child and
Family Statistics, 2012).
By comparison, in 2011, 24% of 12- to 17-year-old
Canadian boys were obese and about 17% of girls
(Human Resources and Social Development
Canada, 2013). Over the past quarter century, the
percentage of Canadian adolescents ages 12 to 17
who are overweight has more than doubled, and
the percentage of those who are obese has tripled.
North American children who eat fruits and veg-
etables frequently are less likely to be overweight.
By contrast, those who watch TV, play video
games, or spend time on the computer are more
likely to be overweight (USDHHS, 2010).
U.S. medical expenditures related to obesity are
estimated to be as high as $147 billion dollars annu-
ally (Finkelstein, Trogdon, Cohen & Dietz, 2009).
The most common recommendations for the treat-
ment of overweight and obesity include participating
in physical exercise and following dietary guidelines
for healthy eating. Although healthy diets and exer-
cise are part of the solution to the obesity epidemic,
nurses must consider constraining social and policy
factors determining health, including lack of access
to healthy foods, unsafe neighborhoods with limited
facilities for physical exercise, and cultural beliefs
and attitudes about weight and health. Overall, we
know that losing weight reduces and sometimes cor-
rects type 2 diabetes. Obesity plays a major role in
cardiovascular diseases and puts unnecessary stress
on joints, which causes them to become deteriorated
with painful arthritic symptoms. In general this con-
dition leads to debilitating health problems and may
also lead to self-esteem issues, particularly in
younger people.
Tobacco
Smoking and substance abuse are critical behav-
ioral health determinants that lead to multiple
health disparities among families in the United
States and Canada. Although smoking is still preva-
lent, it has declined steadily among adults in the
United States. In 1965, more than half of adult men
smoked, as did a third of adult women. Smoking
has declined more rapidly for men than for women,
and the gap between sexes has narrowed. By 2011,
approximately 21.5% of adult men and 17.3% of
adult women were current smokers. Prevalence of
cigarette smoking is highest among American In-
dians/Alaska Natives (31.4%), followed by whites
(21.0%), African Americans (20.6%), Hispanics
(12.5%), and Asians (excluding Native Hawaiians
and other Pacific Islanders) (9.2%) (USDHHS,
2011a). In Canada, the proportion of daily smokers
decreased from 24% to 15.1% between 1995 and
2011. In 2011, another 5% of Canadians reported
being occasional smokers. As in the United States,
more men (22.3%) were smokers than women
(17.5%) (Human Resources and Social Develop-
ment Canada, 2013).
Smoking is a significant behavioral health de-
terminant. It harms most body organs, reduces
circulation, and causes several diseases, including
coronary heart disease, chronic obstructive lung
diseases, lung cancer, leukemia, and other types
of cancer. Smoking also has adverse reproductive
effects and is associated with infertility problems,
low birth weight, and stillbirth. Smokers are
at higher risk than nonsmokers of developing
many other diseases and chronic health condi-
tions (USDHHS, 2011a). The myriad of health
implications from smoking are of critical impor-
tance for nurses to consider when planning care
for families with members who smoke. The im-
pact of the behavior on the entire family should
be included in all health teaching, with realistic
goals set by the nurse and family in collaboration
with one another.
Alcohol
Use of alcohol is a risk factor and determinant for
a wide range of poor physical and mental health
outcomes. Alcohol use is legal for adults, though
impaired driving (DUI) and, to a lesser extent, pub-
lic drunkenness are banned. Alcohol use is illegal
for minors, though widely tolerated in both the
United States and Canada. In 2011, 62.6% of
American adult men (age 21 or older) and 50.9%
of American adult women reported that they cur-
rently drank alcohol. Almost one-third of men and
16% of women reported “binge drinking” (defined
as the consumption of five or more drinks on one
occasion for men, and four or more drinks for
women) during the preceding month. In the
United States, non-Hispanic whites were more
likely than other race groups to be current drinkers,
whereas Native Americans were more likely than
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other race groups to be binge drinkers (USDHHS,
2011b). In Canada in 2011, 18.7% of those who
consumed alcohol engaged in chronic drinking, de-
fined as 10 or more drinks per week for women and
15 or more for men; and 13.1% engaged in acute
drinking, defined as three or more drinks during a
single occasion for women, and four or more drinks
for men (Health Canada, 2012).
The prevalence of illegal drug use, the particular
drugs used, and the methods in which they are
taken vary considerably over time, among racial
and ethnic groups, across social and economic
classes, and among regions of the country or even
neighborhoods. In 2011, 21.4% of Americans ages
18 to 25 reported that they were current users of
illicit drugs; this rate lessened to 6.3% among
adults age 26 or older (USDHHS, 2012). In 2011,
illicit drug use of one of five substances was re-
ported to have decreased from 11.3% in 2004
to 4.8% in 2011 among the Canadian population
age 15 or older (Health Canada, 2012). Alcohol
consumption can result in malnutrition, liver dis-
ease, and both short- and long-term cognitive im-
pairment (Antai-Otong, 2006).
Alcohol and substance abuse have serious conse-
quences for individual health. Individuals who en-
gage in excessive drinking are more likely to suffer
from high blood pressure and to develop chronic dis-
eases such as liver cirrhosis, pancreatitis, and different
types of cancers. Excessive drinking also affects
psychological health. Substance abuse also causes
unintentional injuries produced by car accidents,
drowning, falls, and other types of incidents.
Adolescence
Once children survive the first year of life, the risk
of death decreases dramatically (Federal Intera-
gency Forum on Child and Family Statistics, 2012).
The risk of death increases again in the teen years
as youths, especially male and minority youths, are
subject to heightened risk of fatal motor vehicle
accidents and homicides. In the United States,
African American teenage men are more often vic-
tims of homicide than teens in other racial and eth-
nic groups (Federal Interagency Forum on Child
and Family Statistics, 2012). For young Americans
ages 15 to 24, the most common causes of death in
2009 were unintentional injuries and homicide, ac-
counting for more than three-fourth of deaths to
young people. Additionally, the risk of dying for
those between 15 and 24 years of age was more
than twice as high for boys as for girls. Asian or
Pacific Islander teenage girls have the lowest mor-
tality rates, and African American teenage boys
have the highest. Automobile accidents account for
more deaths among American Indians or Alaskan
Natives, followed by white male and female ado-
lescents, than among other minority adolescents
(Federal Interagency Forum on Child and Family
Statistics, 2012). These distressing statistics can be
attributed to the fact that adolescents experiment
more with risky behaviors that result in health
consequences.
Still, in the United States, from 1991 to 2011,
adolescent smoking and alcohol consumption sig-
nificantly declined (Federal Interagency Forum on
Child and Family Statistics, 2012). And though the
use of illicit drugs increased substantially in the
mid-1990s, these rates likewise decreased during
the 2000s. Despite some historical fluctuations in
the rate of smoking over the last several decades,
by 2011 only 10% of high-school seniors reported
regular cigarette use (Federal Interagency Forum
on Child and Family Statistics, 2012). The risky
behaviors of smoking, alcohol use, and drug use are
all much more likely among white than among mi-
nority youths (Casper & Bianchi, 2002). African
Americans were the least likely to report engaging
in most of these behaviors. The rates of alcohol use
for Canadian adolescents remained relatively stable
during the 1990s, but decreased in the 2000s. Dur-
ing 2007–2008, the rates of alcohol use hovered
between 46% and 62% for both boys and girls ages
12 to 18, depending on the province (Drug &
Alcohol Use Statistics, 2012). Similar to the United
States, 12th-graders in Canada also exhibit the
highest rates of alcohol and drug use among ado-
lescents (Canadian Centre on Substance Abuse,
2011). Fewer Canadian adolescents smoke today
than was the case a decade ago. In 2011, slightly
more than 9% of adolescents ages 15 to 19 smoked
daily or occasionally compared with nearly 30% in
1994 (Human Resources and Social Development
Canada, 2013).
Researchers evaluating large data sets of repre-
sentative samples of young people over time, such
as the National Study of Adolescent Health, are be-
ginning to untangle the effects of peer influences,
family factors, school climate, and neighborhood
contexts on youth risk-taking behavior (Duncan,
Harris, & Boisjoly, 2001; National Center for
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Health Statistics, 2012). As this section reflects,
multiple, complex, and challenging factors con-
tribute to the nurse’s ability to evaluate risks and
behaviors that lead to health disparities. Families
comprised of members demonstrating one or more
of these risks or behaviors may present challenges
to the nurse developing a comprehensive plan of
care that meets all needs of all family members.
Nevertheless, it is critically important that each
family member be assessed and evaluated when cre-
ating a family plan of care.
SOCIAL POLICY
As discussed earlier, the U.S. Public Health Service
has set a target goal to eliminate health disparities
among the poor, minority groups, and genders.
The U.S. Department of Health and Human Serv-
ices Bureau of Primary Health Care has developed
the Health Disparities Collaborative as a mecha-
nism to change the delivery of care to populations
at risk and meet this goal (Gillis, 2004). The great-
est impact will be achieved through an upstream
approach of primary prevention and health promo-
tion (Falk-Rafael & Betker, 2012; Smith Battle,
2012). This section presents some current social
policy aimed at mitigating health disparities and
then explores several key areas in need of additional
social policy to minimize disparities.
Educational Policy
Education is a crucial social determinant of health
and illness disparities. Educated individuals are
more likely to follow health practice advice that
substantially reduces adult and children health risk
factors. Better-educated individuals are also more
likely to look for medical care when they get sick,
and thus they receive more health care (Cutler,
Deaton, & Lleras-Muney 2006). As a consequence,
a gradient in health disparities exists by educational
level. This section explores some of the educational
policies in place to minimize disparities and pro-
mote health.
Every child in the United States and Canada has
a right to an education, up through the completion
of high school. This social policy is one of the few
guarantees given to residents of the United States.
The majority of American and Canadian children
attend a school that is in the same community in
which they reside with their family. When a school
is community based, it can also serve as a commu-
nity center, providing after-school programs for
working parents and evening educational programs
to community members. Schools can support and
improve the lives of children and their families by
serving community needs. The school system also
functions as a social gatekeeper and may be held
accountable for enforcing many public health laws
and regulations, such as the requirement for vacci-
nation before children enter the system.
Nurses, social workers, and psychologists in
U.S. and Canadian schools are now well established
as integral providers of services for children and
families. Psychological testing and services, speech
and language therapy, occupational therapy, and
physical therapy are a legal right for all children as-
sessed as having special health care or learning
needs and are administered under such legislation
at Section 504 of the Americans with Disabilities
Act. In Canada, the provincial Ministry of Educa-
tion is responsible for administering the public
funds of children’s education (Canadian Encyclo-
pedia, 2012).
Nevertheless, educational equity is not always
easy to achieve, and educational inequity leads
ultimately to health disparities. For example, the
No Child Left Behind (NCLB) law was enacted in
2001 and was a reauthorization of the Elementary
and Secondary Education Act originally adopted in
1965. This educational plan has four pillars: ac-
countability, flexibility, proven methods, and
parental ability to transfer their children out of
low-performing schools after 2 years. On paper,
the NCLB does not appear to hinder the educa-
tional process, but there are many concerns about
this law. The title of the law is intentionally inclu-
sive and brings to mind equity in education, but
when put into practice, equity was elusive among
disabled students and students from ethnic and
racial minorities (Thompson & Barnes, 2007,
p. 12). The process of grading schools and requiring
continuous improvement in test scores as a condi-
tion of economic support may prove impossible to
manage. Some schools starting with high scores
may not be able to make substantial increases, and
other schools starting with very low scores may
make meaningful improvement without meeting
the stated standards. In Canada too, recent cutbacks
to education have resulted in curtailing some pro-
grams considered “frills,” such as sports and music.
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They have met with public outcries from parents,
often reversing the decision to cut back.
School Nursing
The National Association of School Nurses
(NASN) in the United States holds the position
that each school nurse plays an active role in assist-
ing children to optimize health, wellness, and
development as a foundation to achieve educational
success (NASN, 2003). This organization supports
the need for a nurse in every school and acknowl-
edges the role of the nurse that extends to family
nursing, often the only health care resource in a
community. As a resource, the school nurse should
function as a case manager with knowledge of avail-
able insurance programs, health care providers, and
community-based health-related services.
Traditionally, the school nurse has been respon-
sible for managing emergency situations, providing
mandatory screenings and immunization surveil-
lance, dispensing prescribed medications, and serv-
ing as a resource for health-related information
(American Academy of Pediatrics [AAP], 2001).
The role of the school nurse, as part of a compre-
hensive school-based health care team, has ex-
panded into many communities as a source of
health care for the uninsured. Many large cities
employ registered nurses and advanced practice
nurses who provide primary care services in school-
based clinics, not only because children lack a
source of care but because school-based care is
accessible and comfortable for young people.
The AAP (2001) describes the role of the school
nurse as one who provides care to children, includ-
ing acute, chronic, episodic, and emergency care.
The nurse is also responsible for the provision of
health education and health counseling, and serves
as the advocate for all students, including those
with disabilities. The school nurse should work in
collaboration with community-based doctors, or-
ganizations, and insurers to ensure that each child
has access to health care (AAP, 2001). This recom-
mendation is an exceptional expectation, especially
when many schools function without a full-time
nurse. Far too many schools have no nurse, only a
part-time nurse, or a nurse whose only role is to
ensure that children with special health care needs
receive their medications, catheter care, or other
prescribed services.
In Canada, where all permanent residents have
universal health coverage, most individuals and
families have a family physician and therefore better
access to health care. School nursing falls under the
purview of public health nurses who visit schools as
part of their roles determined by various provincial
government mandates. These nurses have an op-
portunity to connect with children and families and
mediate their needs and available resources and
practice health promotion. They play an important
role in primary health care with an emphasis on up-
stream approaches of health promotion and disease
prevention (Butterfield, 2002; Falk-Rafael &
Betker, 2012; Smith Battle, 2012). Recently, with a
push from governments to focus more strongly on
the “three Rs” (reading, writing, and arithmetic)
and increasing standardization and testing, time al-
lotted for public health nurses to service the indi-
vidual schools is being cut. School health today falls
under a consensus statement of many public agen-
cies, rather than nursing alone (Canadian Consen-
sus Statement on Comprehensive School Health,
2007). In Ontario, for example, if specific nursing
services are required today, the trend is to provide
services by nurses attached to a Community Care
Access Centre (CCAC), an agency that delivers
nursing care in the community in general. These
nurses are only looking after specific children with
specific health care needs, which range from phys-
ical problems to learning disabilities. Therefore, the
coordinated health promotion aspect of school
nursing is disappearing in Canada too.
The variability in the presence or expectations
of school nurses is a source of concern in the
United States. In some districts (and by law in some
states), every school has full-time nurses with both
knowledge and time to work with children and par-
ents to support or improve physical or mental
health. According to the NASN, schools that pro-
vide “adequate nursing coverage” have lower
dropout rates, higher test scores, and fewer ab-
sences, which translate into better health outcomes
for children and families. The U.S. government
recommends one nurse for every 750 students as
outlined in the Healthy People 2020 objectives, with
adjustment depending on community and student
needs (USDHHS, 2010). To date, only 45% of
public schools have a school nurse all day every day,
and an additional 30% have a nurse part-time in
one or multiple schools (NASN, 2010).
School nurses are in a unique position to pro-
vide many health-related services to school-age
children and their families. Unfortunately, in
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many communities in both the United States and
Canada, social policy and funding shortfalls are
constricting these resources. If given the appropri-
ate resources and backing, school nurses are well
positioned to promote and facilitate family health
and creatively bring needed services to schools
such as can be seen in the establishment of school-
based community health centers.
Housing and Poverty Reduction Policies
The Canadian Centre for Policy Alternatives
(CCPA, 2012) points to the lack of national policies
on housing and poverty reduction, creating an
urgent need for developing policies to mitigate in-
come disparities, by (a) increasing minimum wages
to a “living wage,” meaning a wage large enough
to live comfortably with a healthy lifestyle; (b) in-
creasing social support payments to allow for the
necessities of life; and (c) a fairer system of taxation
in which higher incomes are taxed progressively
more. The public good should come before the in-
dividual good in this vision based in principles of
social justice and dignity (CCPA, 2012). Nurses
should advocate for policies ensuring quality hous-
ing, including subsidized housing for low-income
families. Since Canada has no national housing
policy, creating one seems to be of utmost priority.
Policy Related to Chronic Illness
As discussed earlier in the chapter, chronic illness
is both a social determinant of health for families
and a creator of health disparities between families.
A number of chronic health-related policies have
been created that have the potential to reduce dis-
parities in this area. This section explores several
of these policies.
Asthma Policy
The objective of policy makers now is to create
“asthma-friendly communities.” These communi-
ties would offer better access to and quality of treat-
ment for all populations, but especially those in
poorer communities; increased awareness of asthma
and its risks; and environmentally safe schools and
homes (Lara et al., 2002). New York City, for ex-
ample, began an Asthma Initiative in 1999 that
includes an Asthma Institute, a comprehensive pro-
gram called Managing Asthma in Schools and
Daycare, a Community Integrated Pest Management
program, and an Asthma Care Coordinator pro-
gram that provides follow-up care and support to
children hospitalized for asthma. The Asthma In-
stitute provides free education to health care
providers, community educators, and homeless
shelter workers on asthma signs and symptoms,
asthma self-management, and other clinical topics
related to asthma. This initiative helped reduce hos-
pitalizations for asthma by 9% in 2005 (New York
City Department of Health and Mental Hygiene,
2008). No-smoking policies, legislation on emission
controls for industries and car exhausts, and cleaner
electricity generation initiatives also make a differ-
ence in terms of asthma health.
HIV/AIDS Policy
As discussed earlier, with the introduction of anti-
retroviral drugs in the 1990s, HIV has been treated
as a chronic illness, and people are living longer
with the infection. Therefore, an increased need for
nurses exists to offer prevention education and pro-
mote testing for all men and women. Moreover,
nurses should join the campaign to continue to
encourage the safer-sex practices that helped to re-
duce the rates of infection in the earlier days of the
illness. As stated earlier, with the successful intro-
duction of the antiretroviral drugs, safer-sex prac-
tices have been relaxed and rates of infection are no
longer decreasing. The CDC currently recom-
mends routine screening and testing for all adults,
adolescents, and pregnant women (CDC, 2006).
It is believed that when a person infected with
HIV is aware of his or her sero-status, he or she
can live a healthy and long life by adopting healthy
behaviors and using antiretroviral drugs. Knowing
HIV status also helps to reduce transmission
by practicing safer sex. Prevention education,
screening, and counseling are priorities for the
family nurse. Policies that prevent the spread of
AIDS would also include sex education in schools
and for the public at large.
Mental Illness Policy
As a first step, Canada is about to introduce its first
national mental health strategy (Mental Health
Strategy of Canada, 2012). The Housing First pro-
gram for individuals with mental illnesses who are
homeless, which gets them into supportive housing
without demanding that they first be treated, seems
to have made a big difference to this vulnerable
population, reducing the numbers of unhoused and
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sick individuals living on the street and in shelters
(Mental Health Strategy of Canada, 2012).
Aging Population Policy
Many chronic and debilitating illnesses in the
elderly are preventable or can be delayed. Early
adoption of a healthy lifestyle and prevention of
obesity decreases the prevalence of illnesses such as
diabetes, cardiovascular disease, pulmonary disease,
and physical disabilities. Hence, it is important to
create policies that promote health in an upstream
approach before illness sets in, making healthy
lifestyles affordable for all. This calls for policies to
mitigate the root causes, such as poverty, unhealthy
living conditions, food insecurity, lack of access to
early interventions when ill, and all other relevant
social determinants of health. For nurses it means,
once again, advocating for their clients and helping
them attain the necessary resources within the com-
plicated systems of health care and social support.
Health Promotion Policies
Health promotion generates health improvements
through multiple approaches of research, public ed-
ucation, changes in the physical and social environ-
ment, regulation of disease- and injury-promoting
activities or behaviors, and improved access to high-
quality health care through policies that mitigate dis-
parities and promote equity. For effective outcomes,
these policies must consider the social determinants
of health as the foundational concepts influencing
health (Marmot, 1993; Mikkonen & Raphael, 2010).
In 1990, at the urging of the Surgeon General of the
United States, the U.S. federal government pub-
lished a national agenda for health promotion, titled
Healthy People 2000, which identified 319 objectives
for health promotion and set measurable goals for
achieving them. Many of the objectives for the
decade dealt with health behaviors such as physical
activity and exercise; tobacco, alcohol, and drug use;
violent and abusive behaviors; safer sexual practices;
and behaviors designed to prevent or mitigate
injuries. These objectives were set as national goals
to be realized through a combination of public sec-
tor, private sector, community, and individual efforts
(see National Center for Health Statistics [2011]
for a complete list of objectives and an assessment
of progress toward their achievement). The out-
comes to date appear to be mixed, with considerable
success in some areas, including increases in moder-
ate physical activity; moderate improvements in
some others, including decreases in “binge drinking”
and increases in safer sexual practices; and little
progress in some other behavioral objectives, includ-
ing marijuana use and tobacco use during pregnancy
(National Center for Health Statistics, 2011). A
new set of objectives and measurable goals were
established in Healthy People 2010 and revised again
in Healthy People 2020. The relevant Healthy People
goals provide a standardized approach to assess
changes in behaviors that determine health out-
comes. Numerous tables in the statistical yearbooks
published by the National Center for Health Statis-
tics form a “scorecard” for this national health pro-
motion effort.
Ensuring access to health and illness care services
is one way to improve the health of individuals and
families. Using upstream approaches, children
should receive necessary immunizations and should
be evaluated on a regular basis for normal growth
and development. Likewise, it is important that
adults be adequately immunized and screened for
hypertension, diabetes, and cancer at appropriate
ages and intervals. The absence of a comprehensive
commitment to access or assurance of universal
health insurance coverage for all, until now, has
made achieving the desired level of interaction with
health professionals extremely difficult in the United
States (Bernstein, Gould, & Mishel, 2007). Commu-
nity health centers (CHCs), offering a wide range of
services, could hold possibilities for more coordi-
nated care in the United States, as well as in Canada.
Although much emphasis has been on the roles
parents have in ensuring that their children receive
needed services, many adults also have responsibil-
ities for the health care of aging parents. Adults
with both children and aging parents dependent for
support struggle with access to health care and
management of illnesses, and therefore experience
a particularly difficult burden in today’s world.
They are referred to as the sandwich generation
and are in danger of caregiver burnout (Drew,
2012). Adequate supports for families are needed
so they do not have to shoulder the burden of care
alone. Suggestions for promising approaches are
health coaches, particularly registered nurses
(RNs), who develop a trusting relationship with
their clients and act as advisors and resources for
the clients. The RN–Health Coach was recently
introduced in the United States with good results
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and is currently piloted in Canada as well (Change
Foundation, 2013).
Areas in Need of Additional Social
Policy to Avoid Growing Disparities
There are a number of areas in particular need
of additional social policy to help stem growing
disparities.
Elder Care
The Administration on Aging (USDHHS, 2012)
predicts that by 2020, 19.2% of the 15.2 million
persons older than 65 living alone will need help
with daily living. The provision of care to the eld-
erly is growing both as a family responsibility and
as a profession. More women are caregivers than
men. Policies such as the Family and Medical
Leave Act are written as gender neutral, but
women experience a general expectation that they
will be the caregivers regardless of the burden
that places on them. Lay caregivers are unpaid,
which benefits social programs, especially
Medicare and Medicaid. Home care in Canada is
also poorly funded and benefits enormously from
free labor by family members. Women who pro-
vide lay home health care experience much
greater levels of stress than their other family
members, as well as more alienation from those
outside of the home (Armstrong, 1996). Respite
care and increased home health nursing and other
supports are needed here to ease the burden
(Bookman, Harrington, Pass, & Reisner, 2007;
Change Foundation, 2013). Recently, some parts
of Canada introduced compassionate care bene-
fits, which apply when the death of a family mem-
ber is expected within the next 6 months. A
family caregiver can be granted up to 6 weeks
leave from work, during which time she receives
Employment Insurance benefits (Employment
Insurance Compassionate Care Benefits, 2013).
Day care for elders and increasing funding for
community-based care in the home would make
it easier for older people to stay out of costly in-
stitutional care and increase their quality of life.
This type of care needs to include house calls by
doctors, nurses, physical therapists, and other
health care professionals if clients are unable to
go to appointments. It also needs to focus on
home safety (Change Foundation, 2013). It could
go a long way toward reducing health disparities
imposed by chronic illness by providing access to
optimal care for vulnerable older persons.
Women’s Reproduction
Women’s reproduction is another area where social
policy could help stem health disparities. In 2006, for
example, the state of South Dakota banned access to
abortion services. This ban was seen as a direct chal-
lenge to federal precedent set in Roe v. Wade. In
South Dakota, it is now a felony for a health care
provider to perform an abortion unless there is proof
that the mother’s life is at risk. At the time of the ban,
only one provider of abortion services, Planned Par-
enthood, operated in the state. The clinic was reliant
on physicians who would fly in from other states be-
cause no local physician was willing to provide abor-
tions to women. As a result of this law, women do
not have access to abortions unless they have the re-
sources to leave the state for care. In Canada, in the
small province of Prince Edward Island, many doc-
tors have refused to perform abortions, which forces
women to seek them outside of the province, even
though it is a legalized procedure there.
On a similar note, some pharmacists across both
countries have refused to fill prescriptions for con-
traceptives, including emergency contraception,
stating that doing so is in direct conflict with their
moral and personal beliefs (Stein, 2005). Women,
who are often unaware of these reproductive health
issues until they are directly affected, are outraged
when pharmacists’ beliefs override their right to
services. Women have a legal right to access pre-
scription medications. The question is, whose rights
prevail? In Canada, religious-based health care in-
stitutions, as well as individuals, can also refuse
abortions and birth control counseling, although
women have the right to these services under the
Canadian Charter of Rights and Freedoms. Those
who are refusing to provide the services are legally
required to refer the women to another practitioner
who is willing to perform the service. In underser-
viced areas, this might mean traveling long dis-
tances, which not all women can afford.
In the United States, according to the
Guttmacher Institute (2005), 47 states have a
policy that allows health care providers, including
nurses and pharmacists, to refuse to participate in
the delivery of reproductive health services, which
could leave many women with no choice regard-
ing their reproductive health. Once again, gender,
socioeconomic position, and geography seem to
Family Social Policy and Health Disparities 155
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be determinants of health that disproportionately
disadvantage women by denying them access to
care. Both countries are in need of social policy to
help mitigate these disparities.
LGBT Health Disparities
Arguably one of the most significant areas of cur-
rent relevance to family health in North America
relates to families with nonheterosexual or gender-
conforming identities. Lesbian, gay, bisexual, and
transgendered (LGBT) families characterize a
growing number of households in the United States
(U.S. Census Bureau, 2011). Some estimates from
these data suggest that there has been as much as a
51.8% increase in the number of formal same-sex
households from the previous decade, though the
prevalence in the overall population is still quite
small at approximately 1% of U.S. households. The
majority of these households, approximately 81%,
do house children (U.S. Census Bureau, 2011).
This prevalence is significant because with the defi-
nition of family currently in flux, these couples
and parents face a number of challenges with
insurance access, financial benefits and death plan-
ning, decision-making abilities, and other key social
policy related family health challenges. In Canada,
where same-sex marriages are legalized, same-sex
marriages have all the rights, duties, and privileges
that come with being a married couple. Neverthe-
less, the stigma associated with homosexuality re-
mains in varying degrees, so the issues cited below
in both countries are similar.
According to data presented by the Healthy
People 2020 initiative, LGBT individuals face a
number of specific health disparities, such as stigma
and discrimination-related mental health disorders,
and increased rates of suicide and substance abuse
(USDHHS, 2013b). As a result of systemic and
policy-related stigma and barriers, these individuals
experience significant differences in health-seeking
and health-promoting behaviors: they are far more
likely to delay accessing health care; they are less
likely to receive preventive screens such as mam-
mograms; and they experience greater alcohol and
tobacco use, as well as physical violence, than their
heterosexual counterparts (Krehely, 2009). Fami-
lies with LGBT youth are particularly vulnerable
and experience significant family life challenges re-
lated to stigma and acceptance. As such, LGBT
adolescents experience much higher rates of home-
lessness, prostitution, and substance use, and they
are at increased risk of infectious diseases such as
HIV, hepatitis, and a host of sexually transmitted
infections (Ryan, Huebner, Diaz, & Sanchez, 2009).
Both the United States and Canada need additional
social policies to decrease these disparities.
To combat these individual and family health
problems, San Francisco State University com-
pleted a significant family-based intervention
project to assist families to develop skills and at-
tributes of acceptance, particularly among fami-
lies with high degrees of religiosity (Ryan, Russell,
Huebner, Diaz, & Sanchez, 2010). Their Family
Acceptance Project provides an entire evidence-
based family intervention plan and resources
available to the general public, along with links
to peer-reviewed research aimed to assist families,
that can be accessed at http://familyproject.sfsu.
edu. Efforts such as these, aimed at assisting fam-
ilies at the individual and community level, in
combination with systems of health research,
provide an important link between social policy
development and LGBT individual and family
health issues.
THE NURSE’S ROLE IN ADVOCACY
FOR SOCIAL POLICY
This section will look at the role of the nurse his-
torically and today in advocating for social policies
to promote the health of clients and families, par-
ticularly those who are disadvantaged. As holistic
care providers, nurses are in an excellent position
to inform the public, including politicians, about
what policies are needed and why, and to negotiate
for, and help clients and families obtain, the best
possible resources.
Historical Involvement in Social Policy
Historically, nurses have worked closely with vul-
nerable populations and developed unique solu-
tions to challenging health care problems. Many of
these interventions took place in the community
setting and focused on the family, not just the in-
dividual. The profession of nursing historically has
been involved in social issues and has worked tire-
lessly to advocate and provide a voice to many
vulnerable populations, starting with the Grey nuns
in the 18th century in Canada. The Grey nuns
were Catholic, religious sisters who established
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themselves in the city of Montreal. Their mission
was to care for the poor and destitute (Hardill,
2006). In England, in the mid-19th century, Flo-
rence Nightingale began to reform the Poor
Houses of London and stressed the importance of
the environment in health care (Hardill, 2006;
Monteiro, 1985). The Henry Street Settlement
(HSS) in New York City, founded by Lillian Wald,
likewise demonstrated nursing’s role as an advocate
for vulnerable populations. Founded in the late
19th century, the mission of the HSS was to pro-
vide “health teaching and hygiene to immigrant
women” (Henry Street Settlement, 2004). Today,
the HSS continues to function as a community cen-
ter for families in New York through its midwifery
and nurse practitioner program. Mary Breckin-
ridge established the Frontier Nursing Service
(FNS) in Hyden, Kentucky, in 1925. The FNS in-
troduced community-based midwifery care to the
women of Appalachia, a vulnerable population with
distinct health care needs. These nurses were serv-
ing the needs of women and vulnerable minority
populations who, at the time, had no human rights,
such as voting or owning property.
In the early 20th century, as nursing care moved
into the hospital setting, the role of the nurse
changed. Nurses lost their autonomous practice as
healers and became subordinated to physicians
(Ashley & Wolf, 1997). Care became increasingly
centered on the medical model and focused on cur-
ing the sick individual as opposed to caring for the
human response to illness in the context of the
physical and social environments. Assessing the in-
fluence of the determinants of health and evaluat-
ing their effects on the overall health of the
individual and family lost much of its importance,
as care delivery became focused on the individual’s
medical diagnosis.
Nursing Today
Today most front-line nurses in the United States
and Canada function primarily in the acute care
setting, a practice that breeds an inadequate per-
spective on the role of the social determinants of
health and an associated limitation in advocacy.
This limited involvement, however, will be forced
to change with the looming transformation of
health care through the Affordable Care Act in the
United States and talk on both sides of the border
to move care from institutions into the community.
In 2011, the IOM released a report outlining key
recommendations for preparing the nursing work-
force to meet the needs of the population: The
Future of Nursing: Leading Change, Advancing
Health. This landmark report describes the need
to harness the power of nurses to realize the ob-
jectives set forth in the Affordable Care Act by
transforming the health care system from one that
focuses on the provision of acute care services to
one that delivers health care where and when it is
needed, ensuring access to high-quality preventive
care in the community. The IOM committee ex-
plains that nurses will need to be full partners in
redesigning efforts, to be accountable for their
own contributions to delivering high-quality care,
and to work collaboratively with leaders from
other health professions by taking responsibility
for identifying problems, devising and implement-
ing solutions to those problems, and tracking im-
provements over time to ensure the health of the
population (IOM, 2011).
Numbering over 3 million in the United States
and just over 250,000 in Canada, RNs comprise
the largest segment of the U.S. and Canadian
health care workforce and must be active leaders
in improving the access to and quality of health
care. Advancing health care will require a cultural
shift in the expectations of the nursing profession
regarding education, practice, and advocacy for
vulnerable populations. In Canada, Pilkington,
et al. (2011) found that, even in community-based
health care centers, many nurses failed to take
into account the clients’ social and housing con-
ditions, as these concepts were not included in
the standard nursing assessment forms. The
allotted time spent with clients was mostly focused
on traditional health teaching about lifestyle
changes, despite the fact that these same nurses
indicated that assessment of access to necessary
resources was a critically important component
for success in meeting clients’ needs promoting
their health (Ministry of Community and Social
Services, 2012).
Although nurses today may have difficulty mak-
ing the link between clinical practice and social
policy, nursing leaders are pressing for greater
involvement in such efforts. On a professional
level, many nursing organizations advocate for vul-
nerable populations and attempt to solve health
disparity issues. In fact, in 1992 the American
Nurses Association moved the national office to
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Washington, DC, to increase visibility of the pro-
fession of nursing among U.S. legislators (Milstead,
1999). Similarly, the Canadian Nurses Association
(CNA) and provincial professional associations,
such as the Registered Nurses Association of On-
tario (RNAO) (2012), play an increasingly stronger
advisory role, advocating with the federal and
provincial governments regarding health policies.
Most nurses currently may not possess the
knowledge and skills to interact with policy makers,
an activity that must be learned if the needs of the
population are to be met. Although few studies
exist to describe this complex topic, undergraduate
students report limited knowledge of how to en-
gage in a dialogue with legislators or how the role
of the nurse relates to such activity (Schofield,
2007). Hewison (2007) acknowledges the lack of
policy involvement among nurses and concludes
that this may be related to the complexity of the
policy process. In Canada too there is very little
focus on policy in nursing education. This lack of
preparation in policy development is due in part to
the traditional focus of curriculum to be foremost
on the competencies necessary to obtain licensure.
Another reason contributing to this omission in
nursing education is the biomedical institutional
focus associated with nursing, even in community
settings. Advocacy work is mostly not recognized
as part of the nursing job description or scope of
responsibility (Pilkington et al., 2011).
Brewah (2009) recommends integrating advo-
cacy into nursing curricula and staff education.
Primomo (2007) studied the influence of an edu-
cational intervention on political awareness in a
group of graduate nursing students and found that
perceived competence among the students in-
creased after the intervention. Hewison (2007) de-
scribes an organized method for policy analysis to
be used by nurse managers. This method involves
a process by which a summary of the policy is de-
veloped, including its origin and status, a history
and link to other policy initiatives, and, finally,
themes and elements of nursing practice affected
by the policy. Once the analysis is concluded, the
nurse can take a position on whether this policy will
meet the needs of the constituency. Nurses with
strong policy analysis skills are critical to improving
health for all citizens and to closing the health
disparities gap.
Professional nurses with an interest in learning
more about their role in the policy arena can find
resources through professional associations or can
enroll in a health care policy course. One example
is the Washington Health Policy Institute con-
ducted by George Mason University in Arlington,
Virginia. Nurses and other health care professionals
spend 1 week learning about health and social pol-
icy, strategies to advocate for at-risk populations,
and how to influence policy makers. Similarly, in
Canada, the CNA and provincial associations such
as the RNAO also offer information, workshops,
and training for nurses to gain skill in health care
policy development. Social policies are a major
contributing factor to the mitigation of health dis-
parities. Nurses have the ability to influence policy
on many levels, but not all policies are focused on
interactions with governments.
Nursing Policy, Research,
and Education
Many important policies are at the institutional
level, where nurses work; nursing practice, research,
and education should reflect this orientation.
Nurses Influencing Social Policy
The implications of becoming involved in the in-
fluence of social policy as a context for nursing
care of families are limitless, especially in commu-
nity and institutional settings. Nurse involvement
in policy development can constitute a wide range
of activities, from a micro level, where nurses can
inform institutional policies in the workplace, to
a macro level, where nurses may petition govern-
ment representatives regarding development of
needed or modification of harmful policies.
Nurses can influence policy in small ways. Be-
ginning by using open-ended questions that do not
assume marital status, gender of partner, relation-
ships with children, and sources of financial sup-
port will yield a much more complete assessment.
Discharge planning for return to the community
should begin with an open exploration of potential
support and resources, without assuming that any
are automatically available. Here are some ways in
which nurses can get involved in influencing policy
from micro to macro levels:
■ Join committees in your institution to change
relevant policies (e.g., include questions
regarding available resources in assessment
forms; make sure needed resources are
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available before discharge; ensure follow-up
after discharge/referrals)
■ Join professional association and advocate for
needed social policies
■ Write to or phone elected representatives
regarding needed policies or changes to
those that are harmful
■ Join community advocacy groups, such as
those requesting affordable day care
■ Join boards of directors for agencies, such
as social housing, CHCs
Nursing Research
Nursing research has already developed useful tools
and frameworks for providing nursing care across
cultural barriers and under difficult circumstances.
The recent development of community-based par-
ticipatory research models (Minkler & Wallerstein,
2008) provides a methodology for studies more re-
spectful of the potentially diverse views of family in
a community. This approach requires the nurse
researcher to establish a relationship with the com-
munity in which the study is to occur before the de-
velopment of the research question. Sharing all
stages of the research process with the members of
the community, nurse scientists using this collabo-
rative approach to examining health disparities can
directly affect community improvement based on
the results of the study. Adopting this level of respect
for reshaping nursing studies of “family” helps
nurses gain a more complete understanding of
health care for all types of families. This approach is
particularly important as trends in care move away
from acute care institutions toward community-
based care delivery provided by CHCs and home
care delivery in both the United States and Canada.
Nurses will be particularly well positioned to partic-
ipate in policy changes and program development in
collaboration with an interdisciplinary team, includ-
ing their clients and families, providing comprehen-
sive health care where and when the community
needs it (Hankivsky & Christoffersen, 2008).
Nursing Education
As discussed earlier, there is currently very little
inclusion of policy development and advocacy work
in nursing curricula. Opportunities for learning
experiences in settings that have established serv-
ices for vulnerable populations provide the nursing
student with clinical situations in which to practice
assumption-free assessment skills and learn about
diverse life situations and needs. Homeless shelters,
services for gay and lesbian adolescents, shelters for
victims of intimate partner abuse, outreach centers
for sex workers, and street syringe and needle ex-
change programs all reach a disproportionate share
of individuals whose family experiences are not the
idealized norm (Hunt, 2007). Working in coalition
with clients and other health care providers, nurses
can ensure the maximum beneficial influence of
such policies on the needs of families, communities,
and society (Bergan & While, 2012; Brewah, 2009).
The inclusion of health policy in nursing educa-
tion has the potential to increase the sensitivity of
nurses to social and health policy issues. Policy in-
volvement is about empowering others through
leadership, not exerting power over others (Brewah,
2009). Nurses must understand that it is not suffi-
cient to provide care in isolation from the forces that
increase risk for disease or limit access to medical
services. Electives in history, economics, and politi-
cal science inform nurses’ understanding of policy.
The IOM recommends that nurses engage in life-
long learning, thereby speaking to the need for
nurses to engage in professional practice that strives
to stay current on the state of the science in health
care and the influences of public policy on the de-
livery of that health care (IOM, 2011). Nurses, at all
levels, must be able to understand current affairs,
join nursing and other advocacy organizations, and
participate in local, state/provincial, or national po-
litical processes. Nurses should be educated to take
on responsibility of advocating for equity and social
justice to help develop family-friendly policies.
SUMMARY
This chapter has focused on health disparities and
how they can be mitigated by social policies. As
nursing care shifts from institutions into the com-
munity, nurses wanting to deliver the most effective
care need to return to historical role models in nurs-
ing. They need to become knowledgeable about the
influence of the political social structures that are
facilitating or hindering health promotion and par-
ticularly affect those families who are vulnerable.
Promoting health and mitigating disparities, nurses
have to be aware of and keep in mind the following:
■ Health disparities arise from complex, deeply
rooted social issues.
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■ Health disparities are directly related to
the social and political structure of a society,
which gives rise to the determinants of
health.
■ The social determinants of health include
poverty, housing, education, employment
and food security, accessibility to health
care, presence of chronic illness, gender,
and being of an ethnic, racial, or sexual
minority.
■ All these social determinants of health
intersect and mutually reinforce each other.
■ The social determinants are the root causes
of illness and health, as they affect lifestyle
possibilities and limitations and access to
health care resources.
■ The policy decisions made by a society or
government about families and what consti-
tutes a legal relationship, and how health
care is delivered, have a profound effect on
families and their health.
■ In the past, the profession of nursing had a
well-defined role in advocating for vulnera-
ble populations. In the last century, nursing
involvement in the development of health
policy has declined, due to a focus on medical
diagnosis rather than whole individuals and
families in their environmental and social
contexts.
■ Nurses today need again to get involved
in policy development at institutional and
societal levels to promote health and
well-being for families.
■ Nursing professionals can benefit from theo-
retical and practical education about social
policy issues that are broad and complex, but
result in resounding effects on the health of a
family.
■ Family nursing practice has the potential to
improve the health of all families, regardless
of definition and composition, by closely col-
laborating with clients and interdisciplinary
health care teams.
■ Nursing education needs to include teaching
policy development and advocacy.
■ Nursing research should include collabora-
tive, community-based participatory research
with families for best meeting their needs, as
they are the experts of their own lives.
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U N I T
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Relational Nursing and Family
Nursing in Canada
c h a p t e r 6
Colleen Varcoe, PhD, RN
Gweneth Hartrick Doane, PhD, RN
C r i t i c a l C o n c e p t s
■ Relational inquiry rests in a socio-environmental understanding of health and health promotion (World Health Organi-
zation, 1986). A socio-environmental understanding of health incorporates sociological and environmental aspects, as
well as medical and lifestyle choices. Thus, a person’s/family’s capacity to define, analyze, and act on concerns in
one’s life and living conditions joins treatment and prevention as an essential goal of family nursing practice.
■ Families, health, and family nursing are understood to be shaped by the historical, geographical, economic, political,
and social diversity of the particular person’s/family’s context. By purposefully working with this diversity when provid-
ing care, nurses are prepared to take into account the contextual nature of people’s/families’ health and illness expe-
riences, and how their lives are shaped by their intrapersonal, interpersonal, and contextual circumstances to provide
more appropriate care.
■ “Context” is not something outside or separate from people; rather, contextual elements (e.g., socioeconomic
circumstances, family and cultural histories) are literally embodied in people and within their actions and responses
to particular situations.
■ Similar to other Western countries, Canada is prosperous, but has a significant and growing gap between rich and
poor, along with a biomedical- and corporate-oriented health care system. These influences shape Canadians’ health,
experiences of family, and experiences of health care and nursing care. By understanding how these economic and
political influences shape family experiences and nursing situations, nurses can promote health more effectively.
■ Dominant expectations and discourses about families in Canada are similar to other Western countries. These expec-
tations and discourses shape Canadians’ health, their experiences of family, and their experiences of health care and
nursing care. By examining how families and nurses themselves draw on these expectations and discourses, nurses
can improve their responsiveness to families.
■ Multiculturalism is part of Canada’s national identity and is enshrined in Canadian state policy. Multiculturalism is
understood in Canada to promote equality and tolerance for diversity, especially as it relates to linguistic, ethnic, and
religious diversity. Tensions exist between this understanding and the lived experiences of families, however, particu-
larly those who are racialized, do not have French or English as their first language, and are from nondominant
religions. Racialization refers to the social process by which people are labeled according to particular physical
(continued)
3921_Ch06_165-186 05/06/14 10:59 AM Page 167
Relational inquiry, the process of understanding
and assessing the importance of relationships in
order to support optimal health, is a valuable ap-
proach to family nursing. This approach rests in a
socio-environmental understanding of health and
health promotion (World Health Organization,
1986). This understanding of health incorporates
sociological and environmental aspects, as well as
medical and lifestyle (behavioral) ones. From this
perspective, health is considered to be “a resource
for living . . . a positive concept . . . the extent to
which an individual or group is able to realize as-
pirations, to satisfy needs, and to change or cope
with the environment” (World Health Organiza-
tion, 1986, p. 1). Subsequently, promoting health
and the capacity of people/families to define, ana-
lyze, and act on their concerns is the central goal
of family nursing practice.
Relational inquiry family nursing practice is
oriented toward enhancing the capacity and
power of people/families to live a meaningful life
(meaningful from their own perspective). Although
this may involve treating and preventing disease
or modifying lifestyle factors, the primary focus
is to enhance peoples’ well-being, as well as their
capacity and resources for meaningful life expe-
riences. Thus, relational inquiry focuses very
specifically on how health is a socio-relational expe-
rience that is strongly shaped by contextual
factors.
Understanding and working directly with context
provides a key resource and strategy for responsive,
health-promoting family nursing practice. Having
an appreciation for the range of diverse experiences
and how the dynamics of geography, history, poli-
tics, and economics shape those experiences allows
nurses to provide more effective care to particular
families, better understand the stresses and chal-
lenges families face, and better support families to
draw on their own capacities. Developing such an
appreciation requires that nurses consider how the
varied circumstances of their own lives shape their
understanding.
Grounded in a relational inquiry approach, this
chapter focuses on the significance of context in
family nursing practice. Specifically, we highlight
the interface of socio-political, historical, geo-
graphical, and economic elements in shaping the
health and illness experiences of families in
Canada and the implications for family nursing
practice. This chapter begins by discussing why
consideration of context is integral to family nurs-
ing. The chapter then covers some of the key
characteristics of Canadian society, and how those
characteristics shape health, families, health care,
and family nursing. Finally, informed by a rela-
tional inquiry approach to family nursing, the
chapter turns to the ways nurses might practice
more responsively and effectively based on this
understanding.
168 Families Across the Health Continuum
C r i t i c a l C o n c e p t s ( c o n t . )
characteristics or arbitrary ethnic or racial categories, and then dealt with in accordance with beliefs related to those
labels (Henry, Tator, & Mattis, 2009). Nurses who understand these tensions and how they shape families and
experiences are better prepared to provide responsive nursing care.
■ As a colonial country, Canada has an evolving history of oppressive and genocidal practices against Canada’s indige-
nous people, and an evolving history of varied immigration practices. Understanding how migration and colonization
affect both indigenous and newcomer families, and the health and lives of people within those families, is funda-
mental to providing effective family nursing care.
■ Competent, safe, and ethical family nursing involves taking the intrapersonal, interpersonal, and contextual aspects
of families’ lives into account. Nurses also need to consider how their own contexts shape their understandings and
responses to particular families and situations. Together, these actions enable nurses to tailor their understanding
and care to the specific circumstances of families’ lives and mitigate the possibility of making erroneous assumptions
about the families they serve.
■ Without a careful consideration of context and its influence on families’ health and illness experiences, nurses typically
draw uncritically on stereotypes in ways that limit possibilities for families they serve. By inquiring into the context of
families’ and nurses’ own lives, nurses are able to provide responsive, ethical, and appropriate care.
3921_Ch06_165-186 05/06/14 10:59 AM Page 168
CONTEXT IS INTEGRAL TO FAMILY
NURSING
Whereas “context” is often conceptualized as a
sort of container of people, something that sur-
rounds people but is somewhat distinct and sepa-
rate from people, this chapter encourages readers
to think of context as something that is integral to
the lives of people, as something that shapes not
only people’s external circumstances and opportu-
nities but their physiology at the cellular level. In
other words, context is embodied. For example, if
a person is born into a middle-class, English-
speaking, Euro-Canadian family, the very way that
person speaks—accent, intonation, vocabulary—is
shaped by that context. The way that person’s
body grows is influenced by the nutritional value
of the food and quality of water available, the level
of stress in the family, the quality of housing the
family has, the opportunities for rest and physical
activity. Similarly, the person’s sense of self and
expectations for her life are shaped by the circum-
stances into which the person is born. The indi-
vidual’s success in education will depend not only
on what educational opportunities are available,
but on how the person comes to that education—
for example, how well fed or hungry, well rested
or tired, or confident and content he is—and the
economic resources available that shape which
school the person attends. It will also be affected
by how education is valued within the person’s
family or community. Thus, a person’s/family’s
multiple contexts cannot be “left” or understood
as being outside or separate from one’s self or
necessarily under one’s control. Rather, people/
families embody their circumstances, and their cir-
cumstances embody them. Although they have
some influence over their circumstances, such in-
fluence generally is more limited than we would
like to imagine. Moreover, the contextual ele-
ments, and the experiences to which those ele-
ments give rise, live on in people. That is, past
contexts go forward within people, shaping how
they experience present and future situations.
People are both influenced by their context and
live within contexts. Throughout nursing careers,
nurses provide care in specific contexts, and fami-
lies will live in their own diverse contexts. Con-
sciously considering the interface of these differing
contexts and how they are shaping families’ health
and illness experiences is vital to providing respon-
sive, health-promoting care. Also foundational to
this process is the need to inquire into how “con-
text” is shaping your own life and practice as a
nurse. This enables you to choose more intention-
ally how to draw on those influences to enhance
your responsiveness to families. For example, many
nurses practice in health care settings, surrounded
by well-educated and financially stable profession-
als. This context contrasts with many clients, who
may lack education and live in low-income and un-
stable housing due to financial instability. When a
nurse recognizes this difference, care includes sen-
sitivity to the disparity between these two contexts.
CANADA IN CONTEXT
Canada is diverse in multiple ways. This section
considers five key areas of diversity that are signifi-
cant to families and family nursing: geographical,
economic, ethnocultural, linguistic, and religious
diversity. These contextual elements overlap and
intersect, shaping health, experiences of family, and
experiences of health care and nursing.
Geographical Diversity
Canada’s varied geography, encompassing differ-
ing terrains and climates, and ranging from dense
urban settings to sparsely populated remote rural
areas, shapes Canadian life. Across the prairies,
the various coastal regions, the remote areas of the
north, and the different mountain ranges are var-
ied resources and climatic conditions that shape
the lives of Canadians in differing ways. The pop-
ulation of Canada is concentrated primarily in
urban centers in the south. In 2011, Statistics
Canada reported that less than 20% of Canadians
(about 6.5 million people) were living in rural
areas (areas located outside urban centers and that
have a population of 10,000 or more people). A
continuing trend exists toward urbanization as
more people move from less to more urban set-
tings. In 2011, more than 27 million Canadians
(81%) lived in urban areas, a reversal from over a
century ago. The three largest urban areas in
Canada—Toronto, Vancouver, and Montréal—
made up just over one-third (35%) of Canada’s
entire population in 2011 (Human Resources and
Social Development Canada, 2012).
Relational Nursing and Family Nursing in Canada 169
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Geographical differences influence other as-
pects of life. For example, incomes in rural settings
are lower than in urban settings (Canadian Popu-
lation Health Initiative, 2006), and health indica-
tors are generally poorer in rural settings. In 2001,
a lower proportion of Canadians living in small
towns, rural regions, and northern regions rated
their health as “excellent” compared with the
national average and had a greater prevalence of
being overweight and smoking (Mitura & Bollman,
2003; Williams & Kulig, 2012). People living in
northern regions had greater unmet health care
needs compared with the national average,
whereas people in major urban regions had lower
unmet health care needs. Life expectancy is lower
and mortality rates are greater, particularly from
diabetes, injuries, suicide, and respiratory disease,
in rural settings compared with urban settings
(Canadian Population Health Initiative, 2006;
Williams & Kulig, 2012).
Geographical diversity shapes health through
multiple pathways, including different access to
food, housing, and other health resources; the
kinds of employment available; environmental con-
ditions and hazards; and social patterns. The health
disparities across geographical areas continue to be
a challenge to the quality of nursing care. Rural
areas of Canada, in particular, lack sufficient num-
bers of nurses to meet the complex needs of rural
and poor clients (Williams & Kulig, 2012). Family
nursing is challenged by the distance between
clients, the difficulty clients have in reaching health
care centers, and the lack of resources needed to
provide quality care. Nurses are often faced with
having to provide care in a shortened amount of
time with fewer resources. Yet, if nurses recognize
these challenges, they can work on a micro level to
incorporate relational inquiry into even the briefest
contact, asking family members how they support
healthy living patterns, and at a macro level by
being advocates for improved rural health.
Economic Diversity
Although Canada is a wealthy, developed nation, a
large and steadily widening income gap exists be-
tween rich and poor (Conference Board of Canada,
2012; Statistics Canada, 2006), with many Canadi-
ans living in poverty. Statistics Canada estimated
that in 2009, nearly 3.2 million Canadians, or 9.6%
of the population, lived in low-income families
(Statistics Canada, 2011b). About 634,000 children
age 17 or under, or 9.5%, lived in low-income fam-
ilies in 2009. About 196,000 of these children, or
31%, lived in a lone-parent family headed by a
woman. Roughly 22% of children living with a sin-
gle mother were in low-income households in
2009. Among 29 of the “richest countries” in the
world, Canada’s child poverty rate is about midway
between those with the lowest child poverty rates
(less than 5% in the Netherlands) and those with
the highest, with over 15% in Greece, the United
States, Lithuania, Latvia, and Romania (UNICEF
Office of Research, 2013).
The economic prosperity of Canada is dispro-
portionately distributed, and the inequities be-
tween those who are wealthy and those who are
poor, and between those who are healthy and those
who are not, continue to grow (Coburn, 2010). For
example, a study analyzing the Canadian Commu-
nity Health Survey found that, compared with
white people, minorities were more likely to earn
less than $30,000 Canadian per year (Quan et al.,
2006). A study of Aboriginal people in urban set-
tings found that approximately 30% of Aboriginal
households are headed by a lone parent compared
with 13.4% for non-Aboriginal households in the
same communities (Canada Mortgage and Hous-
ing Corporation, 2006). More than 50% of urban
Aboriginal children in the Prairie and Territories
Regions live in single-parent households versus
17% to 19% for non-Aboriginal children. Of those
Aboriginal single-headed households, 43% lived
in poverty compared with 28% of non-Aboriginal
single-headed households (Collin & Jensen, 2009).
This information is critical because income is a key
determinant of health, affecting multiple dimen-
sions of well-being. People who are racialized, are
new immigrants, live in rural settings, and have dis-
abilities are more likely to be poor, and are there-
fore more affected by the health consequences of
poverty. For example, the 2011 Child Poverty Report
Card (First Call, 2011) reports that despite an over-
all national “child poverty” rate of about 9.5%, par-
ticular groups are at greater risk for poor health
outcomes, including children of recent immigrants
(42%), Aboriginal children (36%), children of lone
female parents (33%), and children with disabilities
(27%). The reported measured poor outcomes, in-
cluding health, education, and long-term employ-
ment achievement. A review of these outcomes
from the Canadian Child Welfare Research Portal
170 Families Across the Health Continuum
3921_Ch06_165-186 05/06/14 10:59 AM Page 170
(Boer, Rothwell, & Lee, 2013) indicated that those
individuals in poverty, especially during the first
3 years of life, had lower developmental skills, had
poorer reading skills during school age, and were
more likely to be unemployed or underemployed
as adults.
Ethnocultural Diversity
Canada is one of the most ethnically diverse coun-
tries in the world, and the ethnic diversity of the
Canadian population is increasing (Statistics
Canada, 2009). More than 200 different ethnic
origins were reported in the 2006 Canadian Cen-
sus (Human Resource and Development Canada,
2012). In 2006, nearly 2 million people, or 6.3%
of the total population, were immigrants who had
arrived during the previous 10 years. In 2006,
there were 1,172,785 Aboriginal people in
Canada, comprising 3.8% of the Canadian popu-
lation. Of the three Aboriginal groups, First Na-
tions people (698,025) had the largest population,
followed by Métis (389,780), and Inuit people
(50,480).
(58.3%), whereas only 16.1% of immigrants came
from European countries (Human Resource and
Development Canada, 2012).
Although Canada has official state policy that
advocates equality and promotes tolerance
through multiculturalism, many argue that the
rhetoric of multiculturalism masks inequities and
discrimination based on ethnicity and racism
(Thobani, 2007). The Ethnicity Diversity Survey
(Statistics Canada, 2003a) found that 2.2 million
people, or 10%, reported that they felt uncom-
fortable or out of place sometimes, most of the
time, or all of the time because of their ethnocul-
tural characteristics. Those people who were
identified as “visible minorities” were most likely
to feel out of place. Recently a large study found
that many newcomer children and youth feel mis-
treated and isolated by both peers and teachers
(Oxman-Martinez et al., 2012). Henry et al.
(2009) argue that in Canada a form of racism is
practiced wherein policies and rhetoric simulta-
neously promote equity and justice and tolerate
widespread discrimination.
Racism has significant health effects (Harris et al.,
2006). Discrimination based on race has been
linked with health outcomes such as hypertension
and other chronic diseases (Krieger, Chen, Coull,
& Selby, 2005), mental health problems such as
depression and suicide (Borrell, Kiefe, Williams,
Diez-Roux, & Gordon-Larsen, 2006; McGill,
2008), and low birth weight (Mustillo et al., 2004).
For example, Veenstra’s (2009) analysis of the
Canadian Community Health Survey found signif-
icant relative risks for poor health for people iden-
tifying as Aboriginal, Aboriginal/White, Black,
Chinese, or South Asian that were not explained
by socioeconomic status, gender, age, immigrant
status, or location, suggesting that experiences with
institutional and everyday racism and discrimina-
tion play an important role.
Changing immigration patterns and increasing
ethnic diversity coupled with discriminatory poli-
cies and attitudes influence families’ experiences
and health. Migration processes are stressful, and
this stress is intensified when combined with lan-
guage barriers and downward economic mobility
(Papademetriou, Somerville, & Sumption, 2009).
These factors, combined with a gap between health
care providers’ lack of understanding of cultural
differences and clients’ lack of understanding of
cultural health practices in Canada, add to the risks
Relational Nursing and Family Nursing in Canada 171
Approximately 250,000 people immigrate to
Canada annually. Of the more than 13.4 million
immigrants who came to Canada during the 20th
century, the largest number arrived during the
1990s. The 2006 census showed that one in five
(19.8% of the total population) Canadians were
foreign born, the highest proportion since the
1930s (Statistics Canada, 2009). The origins of im-
migrants to Canada have changed in recent
decades, with increasing numbers coming from
non-European countries. Between 2001 and 2006,
the majority of immigrants arrived from Asia
3921_Ch06_165-186 05/06/14 10:59 AM Page 171
for poor health care. Nurses are key in minimizing
these risks by continually striving to assess and un-
derstand cultural differences and assisting families in
understanding Canadian health care practices.
Nurses can also be advocates for families by assisting
family members in protecting important cultural
practices in an unfamiliar health care setting.
Linguistic Diversity
Consistent with its history as a colonial nation and
destination for immigrants from around the globe,
Canada is linguistically diverse. The 2011 Census
recorded more than 60 Aboriginal languages,
grouped into 12 distinct language families, and
more than 213,000 people reported an Aboriginal
mother tongue. Most Canadians speak one or both
of the official languages: French and English. Yet,
in 2011, about one of every five people reported
having a mother tongue other than English or
French (Statistics Canada, 2012). Of these, one-
third reported that the only language they spoke at
home was a language other than English or French,
that is, a nonofficial language. Over the past few
decades, language groups from Asia and the Middle
East increased in number, and Chinese is now the
third largest language group after English and
French.
Language affects health in many ways. First, be-
cause language is connected to identity, language
loss is related to the loss of cultural identity expe-
rienced in an ongoing manner by Aboriginal peo-
ples and immigrants to Canada. When individuals
and families lose their cultural identity, they are at
risk of increased isolation and depression. This out-
come threatens not only their desire and ability to
seek health care, but also increases their risk for
secondary poor mental health outcomes. Second,
language barriers profoundly affect access to re-
sources, including employment, social, and health
resources. Finally, language barriers can be direct
barriers when receiving health care and communi-
cating with health care providers.
Some people who speak the dominant languages
of Canada presume that everyone should learn
French or English, without considering the re-
sources it requires to do so and the barriers (such
as poverty, transportation, discrimination, ability)
to doing so. Very limited supports are available for
language acquisition, and in the case of immigrant
families, the priority for who accesses language
classes is often the person who is most likely to be
able to obtain employment. This pattern leads to
higher health risks for those unemployed and with-
out the ability to speak the dominant languages,
including single parents, disabled adults, and chil-
dren. Nurses can be advocates for these family
members by assisting families with the use of inter-
preters, connecting families to community re-
sources that teach languages, and using visual
pictures and icons to explain health care procedures
rather than just verbal instructions.
Religious Diversity
Canada is also a country of considerable religious
diversity. Although Canada is predominantly
Christian, with 7 of every 10 Canadians identifying
themselves as either Roman Catholic or Protestant
in 2003 (Statistics Canada, 2003b), this pattern is
changing. Over the past decades, fewer people have
identified as Protestant and more have identified
with religions such as Islam, Hinduism, Sikhism,
and Buddhism, and more have reported no reli-
gion, with 35% in 2010 saying they do not affiliate
with any religion (Statistics Canada, 2011d). These
shifts are the result of changing sources of immi-
grants, and the decline in major Protestant denom-
inations since the 1930s, as their members age and
fewer young people identify with these denomina-
tions. Despite this changing profile, Christianity
continues to dominate many Canadian public in-
stitutions, including health care.
Religious affiliation affects health and nursing
practice in multiple ways, including fostering so-
cial inclusion and community support, and, de-
pending on the religion, serving as a basis for
discrimination and negative effects on health
practices, access to care, and acceptance of care.
Despite Canada’s professed tolerance for diver-
sity, acts of anti-Semitism and discrimination
against other non-Christian religious groups are
not uncommon, including escalating discrimina-
tion against Muslims and presumed Muslims
since 2001 (Mojab & El-Kassem, 2008). This
discrimination is brought on in part by the dra-
matic increase in immigration to Canada from a
variety of individuals from diverse religious back-
grounds. Canada now leads the world in accept-
ing immigrants, with 20.6% of Canadians now
foreign born, with the next country accepting
immigrants being Germany, at 13% of the
172 Families Across the Health Continuum
3921_Ch06_165-186 05/06/14 10:59 AM Page 172
population being foreign born. This acceptance
of immigration brings religious diversity and a
weakening of the majority culture, including re-
ligious affiliation. The largest share of immi-
grants to Canada (57%) came from Asia and the
Middle East, and these immigrants are predomi-
nately Buddhist, Muslim, and Hindu in religious
affiliation. At the same time, many Canadians are
claiming no religious affiliation, with as many as
24% of Canadians claiming no connection to
religious groups, up from 15% a decade earlier.
Still, 64% of Canadians affiliate with Christian
religious groups, with the largest group (39%)
being Catholics (Welcome/Bienvenue, 2011).
This increase in religious diversity means that in
order to offer culturally appropriate nursing care,
family nurses need to be familiar with major values
and beliefs of each religious group. For example,
families within certain religious groups participate
regularly in individual and group prayer as part of
the healing process (e.g., Catholics), whereas fam-
ilies without a religious affiliation do not generally
participate in religious prayer. Family nurses can
provide appropriate care by asking about religious
affiliations and how the families’ religious beliefs
affect their values and beliefs about healing. Nurses
should also seek families’ expectations of how
health care professionals can incorporate religious
beliefs into their treatment plan when appropriate
and possible. Nurses must also be knowledgeable
about not insulting religious beliefs unknowingly.
For example, males in the Muslim religion gener-
ally do not tolerate being naked in front of females.
It may be necessary to ask a male nurse to provide
care to a male patient. Likewise, females of the
Muslim religion are not allowed to be cared for
by male nurses. This religious value should be re-
spected whenever possible. If it is not possible, then
for females, the husband should be present. Having
a Muslim provider is ideal and should be sought
when possible to provide optimal and ethical care.
This holds true for all major religious groups
(Chicago Healthcare Council, 1999).
HOW FAMILY IS UNDERSTOOD
IN CANADA
Given this incredible geographical, economic, eth-
nocultural, and religious diversity, what constitutes
“family” in Canada, and how family is lived and
experienced, varies greatly. Despite this diversity,
age-old assumptions about family continue to dom-
inate. These ideas shape our expectations about fam-
ilies, such that families are “normally” nuclear and
comprise a mother, father, and two children. They
shape policies, such as the idea that people receiving
social assistance should turn to extended family and
“exhaust” family resources before accepting social
assistance. And they also shape health care providers’
expectations and practices, such as in the belief that
families should provide care to elderly members. Ex-
ploring and critically scrutinizing these dominant
ideas in light of the diverse contextual elements that
shape any particular family assists nurses to under-
stand their own and families’ expectations, the dif-
ferences between those expectations, and tensions
that might arise among different stakeholders.
Three general assumptions/expectations about
family are especially useful for nurses to explore in
order to understand families in Canada and similar
industrialized Western countries. First, families are
generally assumed to be “nuclear,” that is, to con-
sist of two generations, including parents (generally
assumed to be heterosexual) and children. Second,
women generally are expected to do the majority
of parenting and caregiving. Third, family is gen-
erally held to be a safe and nurturing experience.
In reality, however, people’s experiences vary
greatly and differ from these assumptions.
Heterosexual Nuclear Family
as the Norm
The idea that the heterosexual nuclear family is the
norm is belied by statistics; for example, in 2006,
16.5% of families with children in Canada’s met-
ropolitan areas and 13.3% of families in rural areas
and small towns were lone-parent families. The
rate of lone-parent families increased by 8% by
2011, with 1,527,000 children being raised by lone
parents (Statistics Canada, 2011a). Statistics Canada
notes that throughout the 20th century and into
the 21st century, the proportion of large house-
holds has decreased with each successive census,
and there has been a steadily increasing trend to-
ward smaller households. The 2006 census found
that there were more than three times as many one-
person households as households with five or more
persons. Of the 12,437,500 private households,
26.8% were one-person households, whereas 8.7%
were households of five or more persons. In 2006,
Relational Nursing and Family Nursing in Canada 173
3921_Ch06_165-186 05/06/14 10:59 AM Page 173
women living in a same-sex union represented
0.6% of all women in couples in Canada (or
41,200), and the 49,500 men living in a same-sex
union accounted for 0.7% of all men in couples. In
2006, 16% of women in same-sex couples had chil-
dren age 24 and under present in the home, repre-
senting a smaller share than for women in
opposite-sex unions (49%) but a much higher per-
centage than for men in same-sex couples (2.9%)
(Statistics Canada, 2011a).
Although some people construe living in house-
holds with larger numbers of people as a “cultural”
preference, doing so often increases financial strain.
For example, the Longitudinal Survey of Immi-
grants to Canada (LSIC) (Statistics Canada, 2005)
notes that, although the average size of a Canadian
household was 2.6 persons, the average household
size for LSIC immigrants was 3.4 persons, ranging
from 3.1 for skilled worker immigrants to 4.0 per-
sons for refugees. Most LSIC immigrants reported
living in two- (21%), three- (24%), or four-person
(22%) households, and were more likely to report
living in a household of six or more people (12%)
as compared with the Canadian average (3%). Abo-
riginal households were somewhat more crowded
than the general population, with an average of
2.9 occupants and 2.6 bedrooms, compared with
2.5 and 2.8, respectively, for non-Aboriginal house-
holds.
It is important for nurses to understand the eco-
nomic and social influences that shape housing for
families. For example, the number of lone mothers
heading families is, in part, a reflection of the
prevalence of violence against women and the so-
cial expectation for women to “leave” abusive part-
ners. The largest population-based survey focused
on violence in Canada revealed that 50.7% of
women reported physical assault from a former
partner, and that violence is a significant factor in
many separations and divorces (Varcoe et al.,
2011). If society could decrease violence in the
homes, the number of lone-parent families, partic-
ularly those run by women and at higher risk for
poverty, would in turn decrease.
Canada continued to study other family struc-
tures in the 2011 census, including same-sex par-
ents, common-law parents, stepfamilies, children
living with grandparents, children living in foster
homes, and young adults (ages 20 to 29 years) still
living in a parental home. Although traditional
nuclear families with opposite-sex parents remain
the majority, at two-thirds of all family structures,
other structures are growing. Common-law par-
ents account for 16.3% of families, and 10% of
children under 14 years of age live in stepfamilies.
A growing number of children are living with
their grandparent(s), with 4.8% of children under
14 years of age living with one or more grandpar-
ents, and 0.5% of those children do not have a
biological parent in the home. Foster children
make up another 0.5% of the children living in
families, and 0.8% of children are living with
same-sex parents. Finally, the age for independ-
ence is increasing, similar to other Westernized
countries. Forty-two percent of young adults
20 to 29 years of age are still living or have re-
turned to living in a parental home. This trend is
more true for males than females.
These trends have important implications for
nursing care. For example, family nurses can no
longer expect children to have two opposite-sex
parents in their home. Family nurses need to assess
the current family structure and avoid assumptions
or biases regarding expected norms. Each family
structure has benefits and risks, and family nurses
need to both assess these within individual families,
and educate families about changing structures and
how those changes influence child development.
Nurses also need to be familiar with, and connect
families to, appropriate support services to help
families do the best they can for their children re-
gardless of the family structure. For example,
although grandparents raising grandchildren poses
risks to the grandparents’ economic stability and
connection with peers, the grandchildren have an
opportunity to learn more about their family’s his-
tory and family tradition than those children not
raised by grandparents, and grandparents receive
more support from their grandchildren compared
with those grandchildren not raised by their grand-
parents (Rosenthal & Gladstone, 2000). Although
grandparents often struggle with the isolation and
economic hardship, most provinces in Canada pro-
vide financial support, health care, and legal sup-
port for grandparents raising their grandchildren.
Ideals of Motherhood and Women
In Canada, prevalent ideas about mothering and
women shape families’ experiences, their health,
and health care provider expectations. These ideas
include mothers living with their husbands and
174 Families Across the Health Continuum
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being the primary caretaker for their children. De-
spite the diversity of family structures and roles, the
“gold standard” continues to be mothering within
a two-parent family (Ford-Gilboe, 2000), with the
ideal being exclusive mothering, or mothering
without work outside the home. Another social ex-
pectation for women is primary responsibility for
family caregiving for dependent elders or those
who are ill or have disabilities, especially in the
wake of changes to the health care and social serv-
ices systems that include deinstitutionalization
of care.
These expectations are at odds with other social
forces, however, including financial forces and
changes to views about women’s interests and ca-
pabilities. Women, including mothers, increasingly
are expected and desire to work outside the home
(Statistics Canada, 2012). In 2009, 72.9% of
women with children under 16 living at home were
part of the employed workforce; 64.4% of women
with children less than age 3 were employed, more
than double the figure in 1976, when only 27.6%
of these women were employed. Similarly, 69.7%
of women whose youngest child was from 3 to 5
years of age were working in 2009, up from 36.8%
in 1976. Social policy, such as “workfare” social as-
sistance policies, increasingly only provides finan-
cial assistance to women with dependent children
if they seek employment, making many of these
women feel that they are forced into waged labor,
even when the work available is not adequate to
cover the costs of safe child care. At the same time,
policies such as cuts to minimum wage levels have
deepened women’s poverty even as they attempt to
participate in the waged labor force (Pulkingham,
Fuller, & Kershaw, 2010). Women are also seeking
higher education and more professional careers. A
study by Caponi and Plesca (2009), looking at
trends in education, wages, and work hours, found
that 50% of women were graduating from college
and universities compared with only 44% of men.
This trend has also contributed to women shifting
away from the more traditional role of full-time
caregiving to the more common role of shared re-
sponsibilities between work and career and home.
As described earlier, the “ideal” of the nuclear
family is often just that, an ideal. Women are in-
creasingly lone parents, often living below the
poverty line and often on social assistance (Statis-
tics Canada, 201a). At the same time, changing ex-
pectations of men as fathers mean that fathers are
somewhat more actively engaged in child care and
somewhat more likely to be the head of lone-par-
ent families than in previous decades. In 2006,
there were about four times as many female lone-
parent families (1.1 million) as male lone-parent
families (281,800) (Statistics Canada, 2011a). This
ratio has been fairly consistent over the past several
decades, but from 2001 to 2006, male lone-parent
families grew more rapidly (15%) than did female
lone-parent families (6.3%). At least partly because
of gender economics, many children are not being
raised by their mothers. For example, the 2006
Canadian census reported that over 28,000 grand-
children younger than 18 years were living with
their grandparents without parents in the home,
with implications for the health of older men
and women. Based on federal and provincial and
territorial reports from 2000, Farris-Manning and
Zandstra (2004) estimated that approximately
76,000 children in Canada were under the protec-
tion of Child and Family Services across the coun-
try. These trends, juxtaposed against ideals of good
mothering, have contributed to phrases such as
“working mother” and “welfare mom” that convey
negative judgments.
In fact, when families are judged against the
ideal of “exclusive” mothering, or against the ideals
of family caregiving, they are often found wanting.
That is, when women do not devote themselves to
mothering exclusively or take up caregiving for a
parent, spouse, or other dependent person and
forego labor force participation, they are often
judged as providing inadequate mothering. Still,
the economic and social conditions do not exist for
most women to care for children and other de-
pendents without also participating in waged work.
In Canada, as in most Western countries, the “typ-
ical” mother is working outside the home and is
often the lone head of a household and may also be
living under or near the poverty line, while at the
same time being responsible for mothering and/or
caregiving of other family members.
Family as Safe and Nurturing
In Canada, as in many Western countries, family is
portrayed generally as positive, supportive, and
safe. But statistics belie this ideal as well. Canada is
similar to other Western countries in the levels of
violence perpetrated within families and levels of
substance use. According to the most conservative
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estimates, 7% of female individuals and 6% of male
individuals in current or previous spousal relation-
ships reported having experienced some form
of spousal violence during the previous 5 years
(Statistics Canada, 2006). Violence against women
tends to be much more severe than against men.
Between 1995 and 2004, male individuals perpe-
trated 86% of one-time incidents, 94% of repeat
(two to four) incidents, and 97% of chronic inci-
dents (Statistics Canada, 2006). In that same time
frame, the rate of spousal homicide against female
individuals was three to five times greater than the
rate of male spousal homicide, a ratio that remains
consistent up to 2009 (Zhang, Hoddenbagh,
McDonald, & Scrim, 2012). In 2009, 46,918
spousal violence incidents were brought to the at-
tention of police, 81% involving female victims and
19% involving male victims (Zhang et al., 2012).
Using population surveys, lifetime rates of physical
assault by an intimate partner have been estimated
at 25% to 30% in Canada and the United States
(Johnson & Sacco, 1995; Jones et al., 1999). Phys-
ical assault is often accompanied by sexual violence
or emotional abuse, and many women experience
intimate partner violence in more than one rela-
tionship over their lifetime (Johnson, 1996).
Estimates of child abuse rely primarily on cases
reported to child welfare authorities and are thus
gross underestimates. Based on data from child
welfare authorities, the Canadian Incidence Study
(CIS) of Reported Child Abuse and Neglect esti-
mated a rate of 21.52 investigations of child mal-
treatment per 1,000 children (Public Health
Agency of Canada, 2001). Importantly, the greatest
proportion of reported and substantiated child
abuse cases involved neglect, which often overlaps
with the social conditions created by poverty. So-
cioeconomic status has been shown consistently to
be related to parenting effectiveness (Wekerle,
Wall, Leung, & Trocmé, 2007). Despite the preva-
lence of neglect, less attention is paid to neglect in
research, policy, and practice than to severe physi-
cal abuse and child sexual abuse, possibly in part
because those forms of abuse are more sensational
(McLean, 2001) and more visible. Child welfare
authorities tend to focus on risk assessment and ur-
gent intervention for severe cases of child physical
abuse, rather than on the more frequent situations
of neglect. Trocmé, MacMillan, Fallon, and De
Marco (2003) argue that because the CIS found
severe physical harm (severe enough to warrant
medical attention) in about 4% of substantiated
cases, assessment and investigation priorities need
to be revised and include consideration of long-
term needs for housing, income, child care, and so
on. Health care providers should focus on helping
families to access longer-term and broader social
support.
Although it is difficult to estimate the extent
of elder abuse in Canada, it is purported to be a
significant problem (Walsh & Yon, 2012). Almost
2% of older Canadians indicate that they had ex-
perienced more than one type of abuse (Canadian
Centre for Justice Statistics, 2011). Elder abuse
and neglect encompasses intimate partner violence
that continues into older adulthood, and forms
of abuse and neglect that arise as persons become
more vulnerable with age. As with any form of
intimate partner violence, in older adults it is gen-
dered—that is, older women are at greater risk than
men. Statistics Canada (2011c) reported that in
2009 although the overall rate of violent victimiza-
tion was higher for senior men than senior women,
family-related violent victimization was higher
among senior women. Spouses and grown children
were the most common perpetrators of family vio-
lence against senior women, and grown children
were most often the perpetrators of family violence
against senior men.
Substance abuse within families is another fac-
tor that may make the experience of family less
than safe and nurturing. Most problematic use in
Canada involves alcohol. The Canadian Addiction
Survey found that, although most Canadians
drink in moderation, 6.2% of past-year drinkers
engaged in heavy drinking (five drinks or more in
a single sitting for male individuals and four or
more drinks for female individuals) at least once a
week and 25.5% at least once a month (Collin,
2006). Using the Alcohol Use Disorder Identifi-
cation Test, which identifies hazardous patterns
of alcohol use and indications of alcohol depend-
ency, Collin (2006) identified 17% of current
drinkers as high-risk drinkers. Although most
heavy and hazardous drinkers were male individ-
uals younger than 25, this pattern suggests that
harmful alcohol use is fairly common. According
to the 2002 Canadian Community Health Survey,
2.6% of Canadians age 15 and older (3.8% male
and 1.3% female) reported symptoms consistent
with alcohol dependence at some time during the
12 months before the survey. Rehm et al. (2006)
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estimate that 9% of disease and disability in
Canada is caused by alcohol use. A range of prob-
lems are associated with problematic alcohol use,
including violence and neglect. In 2004, 14% of
Canadians reported using cannabis in the past
year and 1% or less reported using other illegal
drugs other than cannabis. For those who do use
drugs, the effects on families can be profound. For
example, one of the most common reasons stated
for grandparents raising grandchildren is paternal
drug abuse and addiction (Rosenthal & Glad-
stone, 2000). For those children raised in a family
with active addiction, the risk for all types of abuse
increases. Further, several studies in both Canada
and the United States document long-term nega-
tive outcomes for children being raised by parents
addicted to alcohol and other drugs, including
mental health risks, higher rates of unemploy-
ment, and poor relationship success. For example,
a study of 8,472 families in Canada by Walsh,
MacMillan, and Jamieson (2003) found that chil-
dren exposed to drug-addicted parents were twice
as likely to be abused than those without drug
addiction in their family.
Given the statistics on violence, neglect, and
substance use, although many families are safe
and nurturing, nurses cannot safely make this
assumption. Indeed, in light of the levels of
violence against women, children, and older per-
sons, and the levels of substance use, nurses can
anticipate that many families they meet are expe-
riencing some form of violence, neglectful par-
enting, or problematic substance use. In Canada,
it is mandatory to report child abuse, but it is not
recommended to screen for child abuse. Because
of the high rate of false-positive results in screen-
ing tests for child maltreatment and the potential
for incorrectly labeling people as child abusers,
the possible harms outweigh the benefits
(MacMillan, 2000). Similarly, insufficient evi-
dence of benefit has been reported to warrant
screening for other forms of violence (Coker,
2006; MacMillan et al., 2009; Ramsey, Richard-
son, Carter, Davidson, & Feder, 2002) and there
are no reporting requirements for other forms of
abuse outside of child abuse. Nevertheless, nurses
need to be aware that family is not always a safe
and nurturing experience for people, and to be
responsive to indications of harm. Alternatives to
screening include “case finding” in which nurses
have a clear understanding of the dynamics of
violence and abuse, and develop their practice
based on that understanding, using such knowl-
edge to attend to each family’s presentation
(Ford-Gilboe, Varcoe, Wuest, & Merritt-Gray,
2010). Case finding does not stop at identifying
families at risk and in need of further evaluation
and intervention, but rather begins the assess-
ment phase to identify and explore the incidence
of family violence.
CANADIAN HEALTH CARE CONTEXT
The funding and structure of the Canadian health
care system influences families, health, and family
nursing. Although Canada has “universal” health
care and all Canadian citizens have access to what
are termed medically necessary services, considerable
inequities are present in access to health care, and
these inequities are deepening as the health care
system is increasingly privatized. The privatized
portion of health care primarily includes funding
for services and products not covered by the public
services and not considered medically necessary,
such as vision and dental care, cosmetic surgery,
most home health services, and pharmaceuticals.
The amount covered and uncovered by the public
health care system varies from province to
province. Currently, the health care system in
Canada is approximately 70% publicly funded and
30% privately funded. This means that many im-
portant elements of health care are paid for by in-
dividuals or by private insurance. Therefore, in
most provinces, medications outside of hospital,
many types of treatments such as physiotherapy,
and services such as home care are paid for pri-
vately in whole or in part. In contrast, the govern-
ment discourages physicians from providing private
care through disincentives such as requiring physi-
cians to choose either private or public clients,
charging patients the same fee whether paid by
public or private insurance, and in some provinces,
banning privatized medical care for any essential
medical services.
Thus, despite commitment to universal access,
access to health care in Canada is inequitable along
many dimensions (Asada & Kephart, 2007; Barr,
Pedersen, Pennock, & Rootman, 2008). Families
in rural settings have access to fewer services and
must pay for their own transportation, accommo-
dation, and loss of income to access services.
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3921_Ch06_165-186 05/06/14 10:59 AM Page 177
Families without private insurance and those with
lower incomes face more financial hardship associ-
ated with illness. Because some groups of people
are more likely to have lower incomes, such as
those who are elderly, those with disabilities, and
women, families from such groups are more likely
to face greater barriers.
Although the Canadian health care system has
been dominated by hospital care, over the past sev-
eral decades fiscal concerns have stimulated shifts
to decrease hospital care and increase the care pro-
vided at home. From mental illness, to surgery, to
maternity care, to elder care, to end-of-life care,
the trend has been to deinstitutionalize care,
shorten length of stay, and shift to care “in the
community.” Such care mostly means care by fam-
ily members, primarily women (Statistics Canada,
2011a), which affects family well-being and health,
and, in turn, affects patterns of family nursing
(Funk et al., 2010; Williams, Forbes, Mitchell, &
Corbett, 2003). Family nurses need to provide
added support to all family members in teaching
home health care to avoid women in the family
suffering from role overload and caregiver
burnout. Family nurses can also help advocate for
families needing hospitalized care longer when
family members are unable to care for the individ-
ual at home.
Family nursing is not funded or identified as a
separate area of practice in Canada, with most
nurses still practicing in hospital settings. Because
government health care funding only covers what
is deemed to be medically necessary, only a very
small proportion of nursing care in homes and
communities is funded, leaving families to pay di-
rectly. Increasingly, in some areas, the shortage of
primary care physicians has made room for family
nurse practitioners to provide primary care and
enhance health care access. These trends shape
families’ experiences of health and affect their
health care.
FAMILY NURSING PRACTICE:
ATTENDING TO CONTEXT
To this point, this chapter has spoken to the sig-
nificance of context and offered details on the
specific context in which nurses operate in
Canada. As the discussion earlier has highlighted,
families in Canada live diverse lives that are
shaped by the interface of geography, economics,
culture, language, and religion. Similarly, their
lives and their health and illness experiences are
shaped by differing understandings and forms of
“family” and by the imperfect health care system
in place in Canada. This health care system, in-
cluding policies and norms that dominate health
care practices, has been built on limited under-
standings of family and health. For example, un-
derstandings of family most often reflect
Eurocentric, post–World War II notions of the
nuclear two-parent, heterosexual family. It is the
discrepancy between the reality of families’ lives
and the normative expectations and understand-
ings of family that often dominate health care set-
tings and practices that make attending to context
not only important but ethically essential in fam-
ily nursing practice.
Overall, attending to context requires taking a
relational inquiry stance as a family nurse. It in-
volves listening carefully to families; inquiring
into their health/illness situations; paying atten-
tion to, observing, and critically considering the
ways in which contextual elements are embodied
in people/families and shape their experiences;
and reflecting on how current contextual aspects
might be addressed to promote health. An essen-
tial feature of this inquiry process is reflexive con-
sideration of your own contextual location,
including the values, norms, and assumptions of
family, health, and nursing that you act both from
and within.
The following story illustrates the significance
of context to families’ health experiences and how
attending to context enhances family nursing
practice. As you read Sharon’s story, stay mindful
of the contextual elements that seem to be shap-
ing the experiences of the two families she meets.
Focus on how the elements discussed earlier (e.g.,
geography, economics, culture, language, reli-
gion, understandings of family, health care poli-
cies, and normative practices) are shaping the
experience and responses of the different family
members and of Sharon as a nurse. Also note how
Sharon is or is not attending to those elements as
she engages with the families. Ask yourself how
your own context is similar to or different from
Sharon’s, and from the two families’. Further-
more, reflect on how those similarities and dif-
ferences might affect how you would respond as
a nurse.
178 Families Across the Health Continuum
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Relational Nursing and Family Nursing in Canada 179
and how important supportive family is. Mr. Stanek be-
comes annoyed and insists that they cannot come to clinic
again. As Greg’s father becomes more frustrated, Sharon
finds it more difficult to understand what he is saying be-
cause of his heavy accent and rapid talking. Sharon tries to
engage Greg by asking him how he is feeling and how it is
going at school, but Greg answers Sharon’s questions by
shrugging his shoulders and saying “OK.” Greg’s father
attempts to return the conversation back to his own con-
cerns. Eventually, Sharon says that she will “see what she
can do.” The half-hour clinic visit ends with little of the in-
take form completed, all parties feeling frustrated, and no
follow-up appointment scheduled. As Sharon walks out of
the room, the clinic receptionist lets her know that Justin
and a woman, who turns out to be his grandmother, have
been waiting to see her for their appointment.
Sharon reviews what she knows about Justin from read-
ing his intake information. She remembers that the Stony
Life Reserve is located several hours from the hospital in
which her clinic is located, and that Jackson is a small town
near the reserve. Sharon wonders how Justin and his
grandmother got to the clinic today. As she walks in the
room, Sharon apologizes for keeping them waiting and
asks if they drove to the appointment. Justin’s grandmother
says one of her brothers drove them because the appoint-
ment was too early to be able to come by bus. She also
shares that she had to borrow money to pay her brother
for gas. Sharon does a brief physical assessment on Justin.
Justin, like Greg, barely looks at Sharon, even when she is
addressing him directly. Justin appears somewhat over-
weight, as does his grandmother, and on assessment
Sharon notes that he is 4 feet 5 inches tall and weighs
55 kg (121 lb). With Justin and his grandmother, who in-
troduces herself as Rose Tarlier, the intake assessment
goes more smoothly for Sharon. Mrs. Tarlier tells her that
she has had custody of Justin and his two younger sisters
since he was 4 years old and the sisters were infants. She
shares with Sharon that Justin’s mother, her daughter, has
had problems with alcohol for many years, is now living in
Montreal, and has not seen her children for several years.
Mrs. Tarlier makes it a point to tell Sharon that she herself
has been “clean and sober” for more than 20 years. As
Sharon continues with the intake assessment, she finds out
that Justin’s grandmother gives Justin his insulin and helps
him check his blood sugar. Sharon listens as the grand-
mother describes what she has been doing, and Sharon
provides positive feedback and encouragement. Although
Sharon tries to bring Justin into the conversation, he does
not look at her and does not answer her questions. Sharon
reviews what subsequent appointments will cover, and
Family Case Study: Sharon’s
Story
After several years of experience on a pediatric medical
unit, Sharon has begun to work in a pediatric diabetic
teaching clinic. She just completed her 1-week orientation,
and this morning is about to do an “intake” on two families
new to the clinic. It is clinic policy to have a half-hour ap-
pointment for “intake” and 15 minutes for subsequent ap-
pointments. Families usually attend the clinic for about
three or four sessions, biweekly, depending on their needs.
The referral information Sharon has on the two families is
as follows:
• Family 1: Justin Henderson, 11 years old, is from Stony
Life Reserve (designated land for Native Americans).
Justin has been newly diagnosed with diabetes. He
began an insulin regimen on Tuesday (3 days ago) that
was ordered by the general practitioner in a walk-in clinic
close to where he lives; Justin was referred to the clinic
for diabetic teaching and counseling. This is his first visit
to the clinic.
• Family 2: Greg Stanek, 12 years old, is from Belcarra.
Greg has been newly diagnosed with diabetes. His in-
sulin regimen was started yesterday by the family’s
general practitioner, who referred Greg to the clinic for
diabetic teaching and counseling. This is his first visit.
Justin’s appointment was scheduled for 9:00, but he
does not arrive on time. At 9:15, Sharon decides to see
her other new client, Greg Stanek, because he and his fa-
ther arrived early. Greg seems small for his age; he is thin
and looks quite pale. He is very quiet and barely looks at
Sharon. Greg’s father speaks with heavily accented Eng-
lish that Sharon recognizes as Czech, in part because she
associates Belcarra with the large community of people
who emigrated from the Czech Republic. Sharon does a
brief physical assessment, noting that Greg is 4 feet 8
inches tall, but weighs only 41 kg (about 90 lb). Sharon
attempts to take the family history as outlined on her in-
take form, but Greg’s father wants to address the fact that
he cannot bring his son to clinic. Greg’s father tells Sharon
that he was just laid off from his job as a carpet layer and
is required by unemployment insurance policies to be
searching for work. Mr. Stanek says bitterly that when he
came to Canada he had been promised he could find
work in his field as a mining engineer. Greg’s mother
works in a local meat processing plant, and she cannot
take time off to bring Greg to the clinic without risking the
loss of her job.
Sharon reinforces with the father how important it is for
Greg to learn about his diabetes and how to manage it, (continued)
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180 Families Across the Health Continuum
thinking about the distance and gas money, asks if they
need one longer appointment next week rather than the
usual two short ones a week apart. She schedules the next
appointment.
Taking a Relational Inquiry Stance:
Attending to context begins by taking a relational inquiry
stance to understand what is meaningful and significant to
a particular family, and inquiring into the family’s current ex-
perience and the contextual intricacies shaping the family’s
life. In taking this stance with the two families in the earlier
story, what becomes immediately apparent is the way that
contextual forces have contributed to and are shaping each
of the family’s situations. For example, although Justin’s
family may want to live in the Aboriginal community for
cultural and social reasons, it may have little choice for eco-
nomic reasons. Justin’s grandmother may well be one of
many Aboriginal women living on low income or in
poverty. At the time of the 2001 census, based on before-
tax incomes, more than 36% of Aboriginal women, com-
pared with 17% of non-Aboriginal women, were living in
poverty (Townson, 2005). High rates of poverty among
Aboriginal people have overwhelming effects on health,
with the life expectancy of Aboriginal people being 7 years
less than the overall Canadian population. Also, as Town-
son notes, there are almost twice as many infant deaths
among Aboriginal peoples compared to the national norm.
As noted, Aboriginal children are much more likely to live
in poverty than other Canadian children.
The fact that Justin lives on a reserve may negatively
influence his health care access and ability to adhere to
recommendations. The matrix of policies related to Abo-
riginal people in Canada has ensured that many reserve
communities have been denied access to traditional
foods (fish, game, naturally growing plants) and have
substandard housing, poor water supplies, and insuffi-
cient income opportunities. Justin’s grandmother’s atten-
dance at residential school, both his mother’s and
grandmother’s experiences with alcohol, and the current
situation with Justin’s grandmother being his primary
caregiver present a clear example of the impact coloniza-
tion has on family well-being. Historical colonizing poli-
cies and practices in Canada included the creation of the
Indian Act; removal of entire communities onto reserves,
often with insufficient resources to sustain the commu-
nity; government appropriation of Aboriginal lands;
forced removal of children into residential schools; out-
lawing of cultural and spiritual practices; and widespread
discriminatory attitudes toward Aboriginal peoples. The
effects of colonization continue to shape people’s health,
social, and economic status today (Kubik, Bourassa, &
Hampton, 2009). Colonizing practices continue as
Aboriginal people are racialized by wider society and
governed by race-based policies, including those related
to land ownership, banking, and health care.
Although Justin and his grandmother’s situation may
not reflect all of these contextual challenges, this historical
and current contextual backdrop shapes their situation and
responses to health care providers, including their willing-
ness and ability to attend clinic. Moreover, the challenges
they face accessing the clinic (e.g., appointment times that
are out of sync with bus schedules, having younger chil-
dren to care for, the cost of travel) may make coming to
clinic seem less than positive in terms of the effect on
Justin’s and the family’s overall health.
Similarly, Greg’s family experience has been shaped by
multiple factors. Both parents are facing significant job
insecurity. The family has experienced immigration laws
and policies that limit employment opportunities and con-
tribute to the “downward mobility” experienced by many
well-educated immigrants. As described, children in recent
immigrant families and racialized families are most likely to
live in poverty because of overrepresentation of racialized
groups in low-paying jobs, market failure to recognize
international work experience and credentials, and racial
discrimination in employment (2011 Child Poverty Report
Card, First Call, 2011).
Canada is a country of considerable ethnic diversity,
but despite national commitment to tolerance and multi-
culturalism, racialized groups experience considerable
discrimination both in policies and institutions, and in the
attitudes expressed toward them at an interpersonal level.
Was this playing out during the clinic visit? Although it
may not have been Sharon’s intent to be discriminatory,
the way in which she disregarded the contextual reality of
Mr. Stanek’s employment and its implications for future
clinic visits and the frustration she felt toward him was a
form of intolerance. Taking a stance of inquiry to attend
to context would have enabled Sharon to be aware of the
likelihood of discriminatory experiences and of the poten-
tial health effects.
Listening and Paying Attention to Experience
and Context:
Attending to context involves listening carefully to families,
and to what is meaningful and significant within the cur-
rent context of their lives. For Justin and his grandmother,
who live in a rural setting, and for Greg’s family, where
both parents need to work, it becomes apparent that ge-
ography, economics, and health are intricately intertwined.
For example, although for Sharon what is most significant
is getting Greg’s family to attend clinic so Greg’s diabetes
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Relational Nursing and Family Nursing in Canada 181
can be monitored and addressed, for Greg’s father, find-
ing and maintaining employment is of greatest concern.
Moreover, the experience of being told that he would be
able to work in his profession and then finding that this
was not the case may well be influencing his response
and willingness to engage with yet another authority and
institution that does not seem to be recognizing the im-
portance of his employment or interested in what is most
pressing for him. Although Sharon cannot address the
employment concern directly within her current role (i.e.,
she cannot help find him a job), it is obvious that those
concerns will ultimately affect Greg’s experience and
management of diabetes. Thus, listening to and recogniz-
ing the interrelationship of those concerns regarding how
the family will be able and willing to care for Greg and his
diabetes is crucial.
In fact, the well-intended clinic may be heightening
health challenges for families by not considering these con-
textual elements. Even how clinic appointments have been
structured as short, frequent sessions affects both families’
ability to attend clinic and ignores the socio-environmental
elements affecting families’ health on a day-to-day basis.
Thus, attending to family context involves also attending to
the health care context. Depending on the setting of care,
the nurse would have to work within that context to sup-
port more responsive care. For example, is it possible to
have fewer, longer appointments? Is a longer intake visit
possible—not just for Greg’s family, but for others as well?
Even within the prescribed time frame, the nurse should
acknowledge what is of meaning and significance to the
family.
Attending to context involves acknowledging Greg’s fa-
ther’s distress about his employment and inviting him to
talk about what it has been like for different family mem-
bers as they have sought employment and attempted to
build a life with limited resources, support, or both. As part
of this process, it would be important to communicate re-
spect and genuine interest and concern, asking what might
be helpful from their perspective, how the clinic could as-
sist them in caring for Greg’s diabetes in light of the other
challenges they are experiencing. On the surface, focusing
on the father’s concerns might not seem to be the top
nursing priority (or even relevant to diabetic care), but
doing so might reduce frustration for both Sharon and
Greg’s father, make better use of time, and allow them to
attend to Greg’s diabetes more effectively. If the family
concerns are not addressed, Greg’s care is jeopardized,
because he may not come back to the clinic.
Listening and paying attention to experience and con-
text with Justin’s family brings attention to the geographical
distance between the family’s home and the clinic, and
raises questions about other possibilities for supporting the
family in diabetes care. For example, knowing the eco-
nomic statistics for Aboriginal women, the cost of travel to
the clinic might have an impact on the family. If the family
is on a limited income, frequent travel may be impossible
and may take money from other essential needs. In re-
sponse, Sharon might look into resources at the local level,
such as a community health representative or local com-
munity health nurse, who might be able to provide face-
to-face care to the family while liaising with the clinic so
that the family does not need to travel such a great
distance so frequently.
Overall, attending to context sets one up to be curious,
to be interested, and to inquire, rather than make judg-
ments and assumptions based on surface characteristics
and behaviors. For example, both Greg and Justin were
quiet, did not make eye contact, and did not respond very
much to Sharon. Rather than making assumptions about
the children based on her own location and context,
Sharon might intentionally reflect on the contexts in which
they have been living recently. As a result, their responses
might be viewed through a range of possibilities, including
everything from wondering about the physiological effect
of diabetes, to the immediate effect of the diagnosis of dia-
betes, to the experience of coming to the clinic for the first
time, to the multiple contextual experiences and challenges
they and their families have been living. Part of assessing
the context includes the awareness of cultural differences,
which affect eye contact, reaction to health professionals,
reaction to genders, and behavior toward adults and elders.
Attending to context can cue nurses to stay open to possi-
bilities, gently and thoughtfully reaching out to connect with
people and families as they are in the moment. Rather
than focusing on behavior or lack of response as a prob-
lem or frustration, any response is viewed contextually.
People and families are not measured against any norms;
rather, the goal is to understand their reactions contextually
and to respond in a meaningful and relevant manner using
inquiry rather than judgment.
Attending to context also moves us beyond the imme-
diate situation of particular patients to question how larger
policies and structures governing our practice and agency
are affecting families. That is, the contextual particularities
of these families reveal limitations of the policies and struc-
tures of the clinic more generally. Clinic policies and struc-
tures might need to be changed to be more responsive to
families. For example, offering home visits, evening ap-
pointments, or both for families who have both parents
working and are unable to make daytime appointments
might enhance the clinic’s responsiveness. Similarly, seeing
(continued)
3921_Ch06_165-186 05/06/14 10:59 AM Page 181
182 Families Across the Health Continuum
the family in context draws attention to the importance of
working with the contexts within which the families live.
This could include everything from intentionally establishing
relationships with government departments and commu-
nity agencies that are part of the family’s context that might
liaise with the clinic in providing services and resources, to
lobbying for increased access and resources for particular
groups or particular services and supplies.
In regard to these particular families, first, the nurse
would want to optimize her ability to provide optimal care
given the restrictions within the current system. She must
prioritize her care to both acknowledge the families’ cir-
cumstances and begin to support Greg and Justin within
their families and those circumstances. Beyond a more
flexible pattern of appointments, are there other providers
who might be involved? A social worker, child and youth
care worker, or other resources may be available. Ways to
enhance access to health care, such as resources for
transportation, may be available. The nurse would want to
draw on broader social resources, such as those related
to immigration and employment, resources for working
parents (i.e., evening hours, weekend hours, online care,
etc.), and resources for parents (i.e., counseling, support
groups, other forms of diabetic care education such as
local classes, online classes, books, home health serv-
ices). Acknowledging Greg’s father’s concerns and sup-
porting him through referrals will allow the nurse to
integrate attention to the family while focusing on Greg
and his diabetes. In so doing, Sharon will develop ap-
proaches and knowledge of resources for a range of other
families as well.
Reflexivity:
Reflexivity, meaning intentional and critical reflection on
one’s own understanding and actions in context, is cen-
tral to using contextual knowledge. Reflexivity draws
attention to a nurse’s own contextual background, includ-
ing taken-for-granted assumptions, stereotypes, and
knowledge one draws on when engaging with families.
Examining how a nurse’s own context and social location
shape and structure her nursing is a first step to attend-
ing to families’ contexts. For example, if Sharon had
grown up in a rural setting or in poverty, it would be
important for her to consider reflexively how those expe-
riences influence her when working with families who
share that context and social location. Her background
might lead her to see herself as successful despite those
constraints, and to overlook how the challenges she
faced and privileges she enjoyed might differ from the
experiences of the families with whom she is working.
Or, if she had grown up in a middle-class urban setting,
she may find that she is somewhat oblivious to or does
not think to consider the challenges that poverty and
geography raise in accessing health care. Similarly, as a
nurse working within a diverse milieu, it is important for
Sharon to consider how her own family history might be
shaping her attitudes toward immigrants, people whose
first language is not English, racialized groups, Aboriginal
people, and other groups. Perhaps she herself is an im-
migrant, perhaps she is a member of a racialized group,
or perhaps she is a member of dominant groups—English
speaking, Euro-Canadian, middle class. It is important
that she ask herself how her religious affiliations (or lack
thereof) shape how she thinks religion is relevant to
health and to her nursing practice.
Although each aspect of Sharon’s social location may
shape her thinking, as Applebaum (2001) notes, one’s
social location “does not imply that we are inevitably
locked within a particular perspective. White feminists can
be anti-racist, men can be feminists, and heterosexuals can
be ‘straight but not narrow’” (p. 416). By reflexively scruti-
nizing our own social locations, we can examine our
understandings and make explicit decisions about how
to draw on (or not) various views and assumptions.
Examining our own contexts and social locations to
see how we are limiting our views of families can be
challenging. We can see more easily our own disadvan-
tages than our privileges. For example, Sharon might
have to work harder to see how her privilege as a se-
curely employed, fluent English-speaking health care
provider gives her an advantage that Greg’s father does
not have. If she has experienced employment disadvan-
tages based on her gender, she might see him as a
privileged man and have difficulty recognizing the
challenges he faces.
Overall, reflexivity in family nursing involves developing
a critical awareness of our own context and social loca-
tion, scrutinizing how that context/location is shaping our
view of a particular family, and intentionally looking be-
yond that location to consider the family within its own
context. In Sharon’s situation, this would involve her
examining how the rural context, economics, language,
ethnicity, and religion, and her understandings of these,
shape how she is engaging with the families. She might
ask how her own experiences of family are shaping her
ability to see and accept the differing forms of family—for
example, a family in which the parents are separated,
such as Greg’s, and a grandmother-led family such as
Justin’s. How does her own location enable or limit her
ability to understand how difficult it might be for Greg’s
father and mother to get him to the clinic appointments
given their current family situation?
3921_Ch06_165-186 05/06/14 10:59 AM Page 182
Relational Nursing and Family Nursing in Canada 183
Engaging in such reflexive examination also enables consid-
eration of the wider sociopolitical elements shaping families’
experiences, such as contextual factors (e.g., the stress of
immigration), that may have contributed to Greg’s parents
separating from one another. At the same time, approaching
her work in this reflexive manner highlights areas where she
may need to learn more. For example, how well does
Sharon understand the history of the Aboriginal people with
whom she is working? How well does she understand the
relationship between historical trauma and diabetes? How is
diabetes cared for in Czechoslovakia versus the Aboriginal
culture versus the broader Canadian culture? What are the
roles of children in understanding and participating in their
care across these multiple overlapping cultures?
present standardized action steps. The same action may in
one case be responsive and health promoting and in an-
other case not be. Thus, the question of how to intervene
is one that needs to be asked in and tailored to each and
every situation: How might I best relate to this family in a
way that is meaningful and significant and promotes their
health and healing capacity?
Consider how you might respond as a family nurse in
the situation above. Where would you begin? What would
you focus on? For example, it is evident from their facial
expressions and the question they pose that the daughters
are very worried about their mother. That might be an ef-
fective place to start because the question points to their
immediate concern, to what is of meaning and significance
to them. “Following their lead” (their worried expressions)
is a form of both assessment and intervention in a rela-
tional inquiry approach. Acknowledging Sandra and
Simone’s worry could be a way of joining them in their
experience and furthering your understanding of both the
immediate family situation and the context of their lives.
As you follow their lead and inquire into their living
experience and what is of meaning and significance to
them, focus too on picking up contextual cues. For exam-
ple, you might respond by sharing your observations in a
tentative manner by stating, “You look pretty worried,” or,
“It’s hard not knowing what is wrong with your mom,” to
invite them to confirm, expand, or modify your under-
standing. Making inclusive observations, asking open-
ended questions, and being interested to “know more”
invites people/families to lead the way. By working in this
collaborative manner, you work with the family to make
connections between experiences and context and dis-
cern the “so what” for action. This involves recognizing
the patterns of capacity and of adversity that are simulta-
neously part of the person’s/family’s illness experience. It
also enables you to understand how contextual elements
are shaping the situation and what their immediate
needs might be. For example, as you look contextually
you might be concerned about the caregiving load that
Simone is carrying (looking after her mother, brother, and
grandfather). If you were working from a relational in-
quiry approach that nursing concern is not something
you know, you inquire into its relevance in terms of ca-
pacity/adversity; keep in mind that what might be con-
sidered to be adversity to one person/family, may not be
adversity to another. Asking “How has it been for you to
be caring for your mom, brother, and grandfather while
your mom is ill?” enables you to learn how contextual
elements are meaningfully experienced by the
person/family. By inquiring, you might find that nothing
Family Case Study: Attending
to Context
Mrs. Dickson, a 40-year-old woman admitted with a diagno-
sis of bowel cancer, is a single mother of four children who
is experiencing postoperative complications. Discharged
home 3 days prior, Mrs. Dickson has been readmitted via
ambulance with undiagnosed pain and extreme nausea.
Her eldest daughter Sandra (age 21 years and married)
and her third daughter Simone (age 17 years), who are
present in the room, describe how their mother collapsed
at home after screaming out in pain. Throughout Mrs.
Dickson’s illness, Simone, who is the eldest child at home
(their middle sister lives in another city), has taken the role
of primary caregiver for her mother, her 13-year-old brother,
and her 86-year-old grandfather, who lives with them. As
you enter the room, they are sitting beside their sedated
mother. They look up with strained expressions and ask
whether the doctors have figured out what is wrong with
their mom.
What Intervention Strategies Might
You Employ?
A relational inquiry approach to family nursing rests on the
assumption that what constitutes high-quality nursing care
can only be determined in the relational situation. Because
the experiences of people/families vary so greatly, as do
the realities within which health care occurs, there is no
linearly laid out sequence or prescribed method. There are
no prescriptions for assessment or action because it all
depends on the situation. What constitutes contextually
responsive care depends on the particularities of specific
nursing situations. Because we work with particular
people/families in particular situations, it is impossible to (continued)
3921_Ch06_165-186 05/06/14 10:59 AM Page 183
SUMMARY
■ One of the few predictable characteristics of
families is diversity. By understanding and
intentionally attending to diversity when
providing care, family nurses in Canada are
prepared to take into account the contextual
nature of families’ health and illness experi-
ences, and how their lives are shaped by their
circumstances.
■ Contexts are literally embodied in people;
both nurses and families live their contexts
and circumstances.
■ For family nurses in Canada to work respon-
sively with a range of different families, it re-
quires understanding the particular families.
■ Understanding the families entails taking a
stance of inquiry, listening and paying at-
tention to the specific experiences of partic-
ular families, reflexively attending to one’s
own understandings, and continuously
developing new knowledge and cultural
awareness. This process embraces the com-
plexity of family nursing care and provides
more relational, and thereby more appro-
priate and successful, care for families.
■ Family nurses in Canada must also be aware
of the risks facing families, including chang-
ing family structures, risks for health dispari-
ties, risks for family violence, and risks for
families living in poverty, especially in rural
communities.
■ Family nurses in Canada must optimize fam-
ily care within a structure that limits out-
of-hospital care and limits access to care in
rural communities. Family nurses need to
collaborate with other providers and re-
sources to help families optimize their
health and long-term health outcomes.
184 Families Across the Health Continuum
has changed—that since her mother works long hours Si-
mone is used to assuming a lot of the domestic chores
or that she has a lot of support from friends or relatives.
Or, you may find that the added responsibility of caring
for her mother while her mother is ill is more than she
can handle, and she may open up and ask for more as-
sistance in problem solving.
As you “listen to and for context” you might learn
of other socio-contextual structures and processes
(economics, health care policies, values, norms, tradi-
tions, history) that are shaping the family’s experience.
Knowing the population you serve (e.g., income levels,
employment opportunities, social financial assistance)
you are attuned to listen for a range of possibilities
without assuming how this particular family “fits” with
population norms. So, this family might be fine in terms
of managing household and caregiving needs, but they
might not have access to money or transportation to
get to the hospital. Or, the worry for her mother may be
affecting Simone’s ability to do schoolwork or hold down
her part-time job that contributes to the family’s income.
Thus, as you listen contextually you are listening and
inquiring into resources—the resources they have,
need, and/or can access. You also listen for what has
enabled them to live in adversity—that is, what capacities
they have within them and/or have accessed or enlisted.
Similarly, you check your own view and your own capaci-
ties. Are your immediate nursing concerns obscuring
your understanding of broader contextual issues and/or
longer-term concerns? For example, given that you
are located in an acute care setting, is Mrs. Dickson’s
physical well-being your primary concern? Are you able
to extend your view to consider the longer-term health
impact of this illness situation? How do you balance
your need to care for Mrs. Dickson’s acute health
needs, while simultaneously consider her family
contextual needs?
Evaluating Family Nursing Action:
Specifically, relational inquiry involves asking the
person/family for their version of the story and purpose-
fully opening the space for their decision making. Thus,
evaluation of your nursing intervention involves an ongo-
ing reflexive process where you “check in” with both fami-
lies and yourself. Evaluation is centered in continually
asking the following questions: How might I be as respon-
sive as possible? How are my actions expanding (or con-
straining) the choice and capacity of this family? How
might I support this family in ways that are meaningful
to them and in ways that enable them to address their
concerns and realize their aspirations? Relational inquiry
helps you to evaluate nursing effectiveness in the longer
as well as the shorter term. For example, a quick dis-
charge may result in a readmission for Mrs. Dickson if the
context of the family situation is not taken into account. It
also helps you to provide family nursing care, beyond the
immediate individual patient and beyond the immediate
acute health care needs.
3921_Ch06_165-186 05/06/14 10:59 AM Page 184
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187
Genomics and Family Nursing
Across the Life Span
c h a p t e r 7
Dale Halsey Lea, MPH, RN, CGC, FAAN
C r i t i c a l C o n c e p t s
■ Genomics refers to the study of all genes in the human genome and their interactions with each other and
the environment.
■ Genetics refers to the study of individual genes and their effect on clinical disorders.
■ Biological members of a family may share the risk for disease because of genetic factors.
■ Families are unique and respond to genetic discoveries differently based on personal coping styles, family values,
beliefs, and patterns of communication. Even within the same family, members react differently.
■ In every case, it is the nurse’s role to support families to make decisions that are most appropriate for their particular
circumstances, cultures, and beliefs.
■ The two major nursing responsibilities when a genetic risk is identified are to help families understand that the risk is
present and to help families make decisions about management and surveillance.
■ Results of genetic tests are private and cannot be disclosed to other family members without the tested individual’s
consent.
■ Nurses identify accurate information and access resources for families with concerns regarding genetic and genomic
health risks.
■ All nurses, regardless of their areas of practice, apply an understanding of the effects of genetic risk factors when
conducting assessments, planning, and evaluating nursing interventions.
Some illnesses “run in families” and people com-
monly wonder if they, or their children, will de-
velop a disease that is present in their parents or
grandparents. The ability to apply an understand-
ing of genetics in the care of families is a priority
for nurses and for all health care providers. As a re-
sult of genomic research and the resultant rapidly
changing body of knowledge regarding genetic in-
fluences on health and illness, more emphasis has
been placed on involving all health care providers
in this field. This integration of genetic knowledge,
attitudes, and skills is especially important for
nurses, and is reflected in the Essential Nursing
Competencies and Curricula Guidelines for Genetics and
Genomics (Consensus Panel, 2008), hereafter re-
ferred to in this chapter as “essential nursing com-
petencies.” Essential nursing competencies include
both the ability to apply genetic and genomic
3921_Ch07_187-204 05/06/14 11:00 AM Page 187
knowledge in conducting nursing assessments and
the ability to assess responses to genetic and genomic
information (Consensus Panel, 2008). These com-
petencies are also identified in documents for general
practitioners in the United Kingdom (National
Genetics Education and Development Centre, 2008).
It is important for family nurses to be aware of
the effect of genetics on families because biologi-
cal family members share genetic risk factors. In
addition, families function as systems with shared
health risks that affect the whole family, and fam-
ily processes mediate coping and adaptation of
both individual family members and the family
unit as a whole (Walsh, 2003). Family members
inevitably have an effect on each other’s lives, and
in many cases, they support each other in seeking
and maintaining healthy growth and develop-
ment, regardless of their biological kinship. Much
of what is known about the health care needs of
persons with genetic conditions has focused on
the individual, with less attention directed toward
the person’s biological and socially defined family.
All nurses, regardless of their areas of practice,
apply an understanding of the effects of genetic
risk factors when conducting assessments, plan-
ning, and evaluating nursing interventions.
This chapter describes nursing responsibilities
for families of persons who have, or are at risk for
having, genetic conditions. These responsibilities
are described for families before conception, with
neonates, teens in families, and families with mem-
bers in the middle to elder years. The goal of the
chapter is to describe the relevance of genetic in-
formation within families when there is a question
about genetic aspects of health or disease for mem-
bers of the family. Family nursing knowledge is in-
complete without attention to the effects of genetic
factors on health and functioning of individuals, as
well as on family units.
GENETICS AND GENOMICS
The term genomics is commonly used to reflect the
study of all genes in the human genome, as well as
interactions among genes and with environmental
and other psychosocial or cultural factors (Feetham
& Thomson, 2006). The human genome consists
of approximately 3.1 billion bases of DNA se-
quence, some of which are unique to each person
(National Human Genome Research Institute,
2012). Individuals inherit genetic material from
their parents and pass it on to their children. Some
conditions result from a change or mutation in a
DNA sequence of a gene. A gene is defined as the
basic physical unit of inheritance (National Human
Genome Research Institute, 2013). For example,
Huntington’s disease results from a specific change
within the DNA sequence in a particular gene.
This is an example of a condition traditionally re-
ferred to as a “Mendelian” or “single-gene disor-
der” and is one that follows an identified pattern of
traditional inheritance in families, in this case, au-
tosomal dominant inheritance. Persons who are bi-
ologically related may have inherited many of the
same DNA sequences in addition to having shared
common environments with other family mem-
bers; this combination ultimately increases risks for
having similar specific illnesses.
Researchers also identify common genetic vari-
ations known as single-nucleotide polymorphisms.
These variations may not cause an actual disruption
in the DNA coding but can often be used as tools
that help scientists and clinicians recognize DNA
variations that may be associated with disease.
These conditions include common disorders, such
as diabetes, that are observed to occur more fre-
quently in families but do not follow a traditional
pattern of inheritance.
A core competency for nurses is to maintain
knowledge of the relationships of genetic and ge-
nomic factors to the health of individuals and their
families. Cancer provides an example of the rela-
tionships between genes, environment, and health.
The development of a malignant tumor is the result
of a complex series of changes at the cellular level.
A number of genes protect against cancer by regu-
lating cell division (during mitosis), and mutations
in those genes can occur over the course of a per-
son’s lifetime, affecting one’s predisposition to can-
cer. A person may be at increased risk of developing
cancer if an inherited mutation occurs in one of
those genes or if exposed to environmental factors
that influence genetic mutations. For example,
tumor suppressor genes help protect against the de-
velopment of breast cancer. If a woman inherits a
mutation in a tumor suppressor gene (such as the
BRCA1 gene), she has lost some of her protection
against breast cancer from birth, but she will not
necessarily develop cancer unless other cellular
changes (some of which are influenced by factors
such as her reproductive history) occur during her
188 Families Across the Health Continuum
3921_Ch07_187-204 05/06/14 11:00 AM Page 188
lifetime (Bougie & Weberpals, 2011). Others in her
family also may have inherited the same mutation
and are similarly at risk. If she subsequently be-
comes a smoker, she has an additional increased risk
for lung cancer because of the environmental influ-
ence of smoking on cell division in her lungs. In
families where smoking is the norm, there may be
a perceived “familial” condition because of the
shared environmental and genetic influences on a
number of members of the family. Box 7-1 lists in-
herited and multifactor inherited genetic conditions.
GENETIC TESTING
Genetic testing can be performed for several pur-
poses, including prenatal diagnosis, detection of
carrier status, predictive testing for familial disor-
ders, and presymptomatic testing. See Table 7-1
for types of genetic tests. Prenatal testing is avail-
able to pregnant women during a pregnancy, such
as prenatal testing for Down syndrome. Carrier
testing can tell people if they have (carry) a gene
alteration for a particular kind of inherited disorder
called an autosomal recessive genetic disorder, such
as cystic fibrosis or sickle cell anemia. Predictive
testing can identify individuals who have a higher
chance of getting a disease before the symptoms
appear. Predictive testing is available for inherited
genetic risk factors that make it more likely for
someone to develop certain cancers, such as colon
or breast cancer. Presymptomatic genetic testing
can indicate which family members are at risk for a
certain genetic condition that is already known to
be present in their family. This type of testing is
performed for people who have not yet shown symp-
toms of a disease, such as Huntington’s disease
(National Human Genome Research Institute, 2011).
The National Comprehensive Cancer Network
(2008) continually updates guidelines that specify
what kind of screening is indicated for a person who
has a gene mutation that increases the chances of can-
cer developing. For example, family members may
seek testing if they are at greater risk for familial colon
cancer (Madlensky, Esplen, Gallinger, McLauglin, &
Goel, 2003). In some cases, clinical practice guideline
criteria recommend that genetic testing be done to
determine whether a person is at risk.
A new type of genetic testing, called pharmaco-
genetic testing, is performed to examine an indi-
vidual’s genes to determine how medications are
absorbed, move through the body, and are metab-
olized by the body. The purpose of pharmacoge-
netic testing is so that health professionals can
create tailored drug treatments that are individu-
alized and specific to each person. For example,
there is a test that is used in patients who have
chronic myelogenous leukemia. The test indicates
which patients will benefit from the medication
Gleevec (National Human Genome Research
Institute, 2011). In addition, gene changes can af-
fect how an individual’s body metabolizes some
medications. For instance, patients can be tested
to see if they are poor metabolizers, intermediate
metabolizers, or ultrarapid metabolizers. Based on
the pharmacogenetic test results, patients would
be prescribed the right amount of the medication
for their body. For instance, pharmacogenetic test-
ing can help determine the best dose of the blood-
thinning medication warfarin. A patient who is a
Genomics and Family Nursing Across the Life Span 189
BOX 7-1
Genetic Conditions: Inherited and
Multifactor Inherited Genetic Conditions
■ Huntington’s disease
■ Cystic fibrosis
■ Sickle cell anemia
■ Familial hypercholesterolemia
Multifactor Conditions—Combination of Genetics
and Environment
■ Heart disease
■ Diabetes
■ Most cancers
■ Alzheimer’s disease
3921_Ch07_187-204 05/06/14 11:00 AM Page 189
poor metabolizer will be prescribed a lower dose
of warfarin, and a person who is an ultrarapid
metabolizer will be prescribed a higher dose of
warfarin (National Human Genome Research
Institute, 2011).
Another new type of genetic test, called direct-
to-consumer (DTC) genetic testing, is now avail-
able to the general public. DTC genetic tests are
offered over the Internet. They usually involve re-
ceiving a packet in the mail for DTC genetic test-
ing, which includes instructions and materials for
individuals to scrape a few cells from the inside of
their cheek and mail the sample to a particular lab-
oratory to perform the genetic tests (National
Human Genome Research Institute, 2012). Several
companies offer DTC genetic testing, including
the company 23andMe, which claims that its test-
ing can “help you manage risk and make informed
decisions” (23andMe, 2012).
The market for DTC genetic tests may increase
individuals’ awareness of genetic diseases and allow
them to take a more proactive role in their health
care (Genetics Home Reference, 2012). The types
of DTC tests that are offered include those that
evaluate parts of a person’s genome for variants
that may have an influence on that person’s risk for
developing particular diseases such as Alzheimer’s
disease. The DTC genetic tests offered by compa-
nies also claim they can test for particular genetic
markers that may indicate a person’s ancestry, per-
sonality, or physical traits, some of which may have
implications for the person’s health.
It is important that nurses are aware of DTC so
that they can advise patients interested in DTC to
meet with health care providers or genetic coun-
selors to learn more about this type of testing and
its accuracy and applicability to health care. Fur-
thermore, nurses and other health care profession-
als should be aware of the reliability of DTC
genetic testing. In 2010, the U.S. Government Ac-
countability Office (GAO) conducted a study of
DTC genetic testing to determine its reliability.
Using fictitious names for consumers, they submit-
ted samples to several DTC companies. The results
that the donors received about disease risk predic-
tions varied across the companies, showing that the
identical DNA samples submitted yielded contra-
dictory results. Sometimes, the DNA-based predic-
tions conflicted with their actual medical conditions
(U.S. Government Accountability Office, 2010).
People who are considering a DTC genetic test
should first talk about this type of testing with their
health care provider or a genetic counselor. The
concern is that without guidance from a health care
190 Families Across the Health Continuum
Table 7-1 Types of Genetic Tests
Diagnostic
Carrier
Predictive or presymptomatic
Prenatal diagnosis
Pharmacogenetic testing
Direct-to-consumer genetic
testing
Performed when signs and/or symptoms of a genetic condition are present. Confirms whether
or not an individual has the suspected condition.
Detects whether a person is a carrier of either an autosomal recessive or an X-linked disorder.
A carrier of an autosomal recessive condition usually has no signs of the condition and will be
at risk for having an affected child if the other parent is also a carrier. He has one normal copy
of the gene in question and one mutated copy.
A female carrier of an X-linked condition has one normal copy of the gene on the X chromo-
some and one mutated copy of the gene on the other X chromosome, and generally has no
signs or very mild signs of the condition. Her sons have a 50% chance of having the condition,
and her daughters have a 50% chance of being carriers.
Performed on healthy individuals; detects whether they inherited a mutation in a gene and,
therefore, whether they will or may develop a condition in the future.
Genetic test performed on the fetus. Indicates whether the fetus has inherited the gene mutation
that causes a specific condition and, therefore, whether the child will develop that condition.
Analyzes a person’s genes to understand how drugs may move through the body and be bro-
ken down. The purpose of pharmacogenetic testing is to help select drug treatments that are
best suited for each person.
Direct-to-consumer (DTC) genetic tests are marketed directly to the general public, usually via
the Internet. DTC genetic testing provides access to an individual’s genetic information, usually
without involving a health care professional.
3921_Ch07_187-204 05/06/14 11:00 AM Page 190
provider or genetic counselor, the individual may
make significant decisions about prevention or a
particular treatment that is based on incomplete
or inaccurate information (Genetics Home Refer-
ence, 2012; National Human Genome Research
Institute, 2013).
Disadvantages of Predictive
Genetic Tests
Nurses should understand the differences in the
types of genetic tests that families may consider and
the potential advantages or disadvantages of pre-
dictive genetic tests summarized in Box 7-2. Nurses
who participate in discussions about genetic testing
must maintain current knowledge on these tests, as
well as on new technology for testing and interpre-
tations of results.
Genetic tests have limitations that vary accord-
ing to the specific test. For some tests, not all per-
sons who want the test may qualify, which occurs
when their family history does not suggest that the
disease has a major genetic component, or where
the genetic mutation that causes the disease has
not been identified. For some tests, it is possible
that a result may be difficult to interpret. For some
conditions, genetic mutations have been discov-
ered that are associated with the disease in that
family. Because many genes may be associated
with one condition, or a number of different mu-
tations may be possible in a gene, it is often neces-
sary to test an affected family member first to try
to identify which gene is involved and which type
of mutation is causing the disease in that family.
A sample is taken from the affected person to de-
termine whether a genetic mutation can be iden-
tified that is associated with that disease. This may
not be possible if the affected person in the family
has passed away or if the affected person refuses to
undergo the genetic testing to help other family
members.
Another limit to genetic testing is the fact that
results may not be definitive. For example, a test
result of an infant screened for cystic fibrosis may
be in the positive range for a screening test. A pos-
itive screening test simply means, however, that a
diagnostic test is required to determine whether the
infant has the condition. It is important for parents
to understand that, in some infants, a diagnostic
test result can indicate that the infant has a genetic
condition and will need further evaluation and
treatment, and in other cases, subsequent tests will
be normal. When an infant has further evaluation,
and is found not to have the condition, the first test
result is sometimes referred to as a false positive,
or an out-of-range result that required further test-
ing. Parents who understand the reason for the re-
peated testing tend to experience less stress than
those who do not (Hewlett & Waisbren, 2006).
When a family receives an abnormal newborn
screening test result, it is crucial for the nurse to
help the family understand that abnormal results
from a screening test do not necessarily mean that the
child is ill or has the disease (Hewlett & Waisbren,
2006). The waiting period between the newborn
screening result and the diagnostic testing is known
Genomics and Family Nursing Across the Life Span 191
BOX 7-2
Potential Advantages and Disadvantages
of Predictive Genetic Tests
Potential advantages of testing include:
■ Opportunity to learn whether one has an increased
likelihood of developing an inherited disease; in those
who prefer certainty, this can help resolve feelings of
discomfort, even if the result shows the person has in-
herited the condition
■ Relief from worry about future health risks for a specific
disease if the test is negative
■ Information that can be used for making reproductive
decisions
■ Information to inform lifestyle choices (e.g., food
choices, smoking, alcohol use, contraceptive choice)
■ Information to guide clinical surveillance or manage-
ment of the condition
■ Information for other family members about their own
status
■ Confirmation of a diagnosis that has been suspected
(i.e., that early or nonspecific signs and symptoms are
due to a specific condition)
Potential disadvantages are that the test results may
provide:
■ A source of increased anxiety about the future
■ Guilt at having survived when others in the family are
affected, if the result is negative (“survivor’s guilt”)
■ Concern about potential discrimination based on
genetic test results
■ Regret about past life decisions (such as not having
children)
■ Changes in family attitudes toward the person who
has been tested (such as less reliance on them for
support)
3921_Ch07_187-204 05/06/14 11:01 AM Page 191
to be especially difficult for parents (Tluczek,
Koscik, Farrell, & Rock, 2005).
FAMILY DISCLOSURE OF GENETIC
INFORMATION
Communicating information about the genetic as-
pects of a condition to families at the time of diag-
nosis and over time is an important role for nurses
and other health care professionals (Gallo, Angst,
Knafl, Twomey, & Hadley, 2010). Having an ef-
fective partnership and communication between
health care professionals and families is essential to
the success of developing both collaborative and
therapeutic working relationships (Levetown &
American Pediatric Committeee, 2008). Nurses
work with families through a cascade of decisions
and information about the genetic disorder (Reid
Ponte & Peterson, 2008).
Gallo et al. (2010) describe four main themes
relative to how health care professionals share ge-
netic information with parents of children with a
genetic condition:
■ Sharing information with parents
■ Taking into account parental preferences
■ Understanding the condition
■ Helping the parents inform others about the
genetic condition
Sharing information with parents should be ini-
tiated at the time of diagnosis and then tailored
over time based on the parents’ particular needs,
the characteristics of the child’s condition, and the
environmental factors (Gallo et al., 2010). Impor-
tant roles of nurses in this process include reinforc-
ing the information to help parents understand the
condition, coordinating the patient’s care, educat-
ing parents on expectations, discussing potential
management of the care for their child at home,
and helping the parents to inform others about
their child’s genetic condition (Gallo et al., 2010).
Access to genetic information gained from ge-
netic testing, as well as from family history, raises
a host of questions for the family regarding confi-
dentiality that includes the following: who to tell,
what and when to tell them, and how much to
share. Nurses must maintain the confidentiality of
each family member’s genetic testing information.
It is completely up to the individual to determine
whether or not to reveal information about genetic
risks, testing, disease, or management. Results of
genetic tests are private, and in the United States,
they cannot be disclosed to other family members
without the tested person’s consent (U.S. Depart-
ment of Health and Human Services, 1996). In the
United States, the Health Insurance Portability and
Accountability Act (HIPAA) permits disclosures of
health information if there is an immediate and se-
rious threat to the person and if the disclosure
could reasonably lessen or prevent the threat (U.S.
Department of Health and Human Services, 1996).
In most cases, however, the choice of disclosure of
genetic information is an individual decision that is
made in the context of the family.
Discovery of health problems in more than one
family member should be accompanied by a dis-
cussion with family members regarding their un-
derstanding of risks for potentially inherited
disorders. Disclosure can be a challenging task, as
the person with the genetic mutation must decide
who to inform, what to say, and when to talk about
this finding (Gaff et al., 2007).
Family members may prefer to maintain pri-
vacy regarding their decision about predictive
testing, even within the family. This decision may
reflect an attempt to avoid disagreements within
the family, an attempt to protect others in the
family from sadness or worry, or an attempt to
prevent discrimination or bias. For example, peo-
ple who have predictive Huntington’s disease test-
ing may be reluctant to share this information
with their primary care provider. This reluctance
may be because they fear that any notation in their
medical record may be accessed by an employer
or insurance provider, which may lead to loss of
employment or insurance. Although laws have
been passed that prohibit insurance or employ-
ment discrimination based on a person’s geno-
type, some individuals may be concerned that
revealing their genotype may place them at risk
for discrimination (Penziner et al., 2008).
When one person in a family has a condition that
is caused by an alteration in a single gene, such as a
gene associated with hereditary breast or ovarian
cancer, the person with the mutation is asked to no-
tify others in the family that they too may have this
same DNA mutation. In general, the family mem-
bers themselves pass on this information, but occa-
sionally, with the consent of all concerned, direct
conversations can occur between the nurse and
other family members. Because families vary in
192 Families Across the Health Continuum
3921_Ch07_187-204 05/06/14 11:01 AM Page 192
their adaptability regarding health challenges, fam-
ilies vary in how they decide to share information
(McDaniel, Rolland, Feetham, & Miller, 2006).
Both individual and family relationship factors
can influence communication among family mem-
bers. Nurses should, therefore, have a good under-
standing of their patient’s personal beliefs about
sharing genetic risk information with family mem-
bers. Nurses work closely with the individual to
explore relationships with relatives to identify po-
tential areas of difficulty and provide support for
communication of accurate genetic information
(Wiseman, Dancyger, & Michie, 2010). The fam-
ily communication style may affect disclosure and
sharing of genetic information. For example, a
family with a disengaged communication pattern
may share affection for each other but actually
speak relatively infrequently with each other
(McDaniel et al., 2006). For families with this style
of communication and lack of closeness, sharing
information about one’s personal medical history
may be especially difficult (Stoffel et al., 2008). In
contrast, families with an enmeshed style of family
communication frequently talk with others in the
family about personal health matters (McDaniel et
al., 2006). Gender may influence the sharing of ge-
netic information with family members. Women
were noted to have more difficulty in sharing ge-
netic information with older parents, brothers, or
fathers (Patenaude et al., 2006). Men expressed
difficulty disclosing genetic information to all fam-
ily members (Gaff, Collins, Symes, & Halliday,
2005). Box 7-3 depicts an example of family com-
munication of genetic information.
Parents: To Tell or Not to Tell
Parents of a child with a genetic disorder take into
consideration what to tell their children about the
condition based on the developmental level of the
child and the child’s extent of interest in knowing
about the genetic condition. Thus, parents whose
children had a single gene disorder described shar-
ing genetic information with their children as an
unfolding process that was not a one-time occur-
rence but continued throughout childhood as their
cognitive stage of development progressed (Gallo,
Angst, Knafl, Hadley, & Smith, 2005).
Parents, usually, believe that they are the most ap-
propriate people to inform their children about ge-
netic risks. Still, when no current effective treatment
or cure exists, parents struggle with balancing “the
right” of individuals to know about their potential
genetic risks with their natural instinct as parents
to spare their children from undue anxiety (Tercyak
et al., 2007). In some cases, individuals delay telling
other adults in the family because they worry that
they will accidently say something to the child or
that they may be overheard by the child (Speice,
McDaniel, Rowley, & Loader, 2002).
Parents of children with genetic conditions may
choose not to share information because they have
concerns about school issues, obtaining health care
for their children, and insurability or employability
of their children. Parents worry that their child
could feel different from other children because of
food or activity restrictions, or visible signs of the
genetic condition (Gallo, Hadley, Angst, Knafl, &
Genomics and Family Nursing Across the Life Span 193
BOX 7-3
Family Communication of Genetic
Information
Brian, a 46-year-old man, is the oldest of three siblings.
He is married but has no biological children. Brian was
aware that his mother died of bowel cancer at the age of
38 years, and although this worried him, he hid his anxi-
ety from both friends and relatives. He never discussed
his mother’s death with his wife or siblings. Brian had
been experiencing abdominal pain for some months
when he collapsed at work one day and was taken to his
local hospital emergency department. He was found to
be anemic and suffering a bowel obstruction. A tumor
located near the hepatic flexure of the large colon was
removed successfully. Brian was informed that his family
and medical history indicated that it was likely he had in-
herited a mutation in an oncogene that predisposed him
to bowel cancer. He was advised to share this finding
with his siblings, and recommend that they seek advice
and screening for themselves. Brian was reluctant to dis-
cuss the issue with his siblings but did tell his wife. Brian
chose not to disclose this information to his siblings. Sev-
eral months later, at the encouragement of his wife, they
met with the cancer nurse to discuss the situation. The
cancer nurse helped Brian decide what information to
share with his siblings. They created a plan for how and
when to share the information. Subsequently, both
Brian’s sister and brother had genetic testing. Brian’s sis-
ter was found to carry the mutation. She was screened,
and she worked with the nurse to devise a plan to tell
her children about their possible risk when they reached
18 years of age.
3921_Ch07_187-204 05/06/14 11:01 AM Page 193
Smith, 2008). Nurses have a significant role in
helping parents decide what information to share
with their children about their genetic condition
based on their developmental level. Another role
of family nurses is helping parents determine how
much information to share with outside sources,
such as schools, day care, or employers, about their
child’s genetic condition.
Concealing Information: Family Secrets
Some families are quite open, whereas others choose
to keep genetic information a secret, even from
other immediate family members (Peters et al.,
2005). Families choose to keep genetic information
a secret for a variety of reasons. Sometimes informa-
tion is kept a secret out of a desire to protect other
family members. Some keep a secret because they
feel shame. Still other families may choose to keep
information secret because the exploration of ge-
netic inheritance may reveal other personal infor-
mation. For example, consider a family with four
sisters who want health advice because their father
has a form of familial colon cancer. In the course of
obtaining the family history, the mother confides to
the nurse that her husband is not the biological par-
ent of the oldest daughter, and that others in the
family do not know this history. In this situation, the
nurse recognizes that the oldest daughter does not
share the same risk for this disease as her sisters, but
the nurse would not be permitted to reveal that in-
formation to any family member without the
mother’s permission. This family secret can create
conflict for the nurse, because the lack of disclosure
might mean the eldest daughter is exposed to un-
necessary procedures, such as a colonoscopy (which
carries a risk for morbidity). The nurse would dis-
cuss the issue of risks for procedures with the mother
so that the she can consider all the information in
deciding to tell her daughter the family secret. The
mother would have to decide if the benefits of dis-
closure outweigh the distress the daughter may ex-
perience by learning about her parentage.
Family Reactions to Disclosure
of Genetic Information
Families are unique and respond to genetic discov-
eries differently. Even within the same family, fam-
ily members will respond differently. Some
members seek predictive testing to determine
whether they have inherited the genetic condition.
Others choose not to seek testing. Some members
react to genetic discoveries with grief, loss, and de-
nial. The nurse’s role is to support all family mem-
bers in their reactions and ultimate choices.
Children, regardless of age, may wonder if they
will have the same condition as their parent. For
example, this may be the case for teens who have a
parent or grandparent with Huntington’s disease,
an autosomal dominant condition. Guidelines do
not recommend predictive testing until a teen is old
enough to provide informed consent. Teens may
want to protect their parents from their concerns
and are reluctant to share their thoughts with their
parents (Sparbel et al., 2008). Thus, nurses should
offer the opportunity for them to ask questions and
discuss their concerns, including offering to facili-
tate a family discussion. Box 7-4 depicts a family
managing decisions about teenager.
Elders in the family often are keen to contribute
to genetic studies to help their offspring (Skirton,
194 Families Across the Health Continuum
BOX 7-4
Working With an Adolescent About Genetic
Testing
Susan is a 17-year-old young woman whose mother de-
veloped breast cancer at age 42 and had to have a dou-
ble mastectomy. She is now recovering from her surgery
and doing well. Susan’s maternal grandmother and one of
her maternal aunts died from breast cancer in their forties.
Susan’s mother chose to have genetic testing to learn
about the possible genetic cause of her breast cancer. The
test results revealed that she has a BRCA1 gene mutation,
which significantly increases a woman’s lifetime risk of de-
veloping breast cancer. At her annual health care appoint-
ment Susan tells the nurse about her family history of
breast cancer and that her mother has a BRCA1 gene mu-
tation. Susan says that she would like to know what her
risk is for inheriting this gene and that she would like to
have the genetic testing to find out if she carries the same
BRCA1 gene as her mother. She says that she is worried
about her younger sister too. She tells the nurse that she
does not want to worry her mother or family by talking
with them about her concerns. The nurse informs Susan
that she is free to express her concerns with her and her
physician and that they can talk with her about how best
to talk with her mother and express her concerns. She
also lets Susan know that when she is 18 she will be old
enough to provide informed consent to have genetic test-
ing for the BRCA1 mutation that her mother has. She rec-
ommends that when she is 18, she consider genetic
counseling with a genetic specialist to learn more about
her risk and the BRCA1 genetic testing.
3921_Ch07_187-204 05/06/14 11:01 AM Page 194
Frazier, Calvin, & Cohen, 2006) and serve as an in-
formation source of family history. Advances in ge-
nomics will make susceptibility testing for common
diseases of middle and old age (such as coronary ar-
tery disease or cancer) more common.
Family members possess beliefs about their own
risks and who in the family will develop a genetic
condition. These beliefs are termed preselection
(Tercyak, 2010). Preselection beliefs are often based
on the family’s previous experience. For example, if
only male relatives have been affected by an autoso-
mal dominant condition that could affect either sex,
female members in the family may believe they are
not at risk. Sometimes preselection beliefs are based
on the fact that the person thought to have inherited
the condition physically resembles the affected par-
ent or shares a physical characteristic (such as hair
color) with other affected relatives. A preselection
belief may influence the person’s self-image and
overall functioning. For example, those who believe
they will develop a condition may make different ca-
reer choices, avoid long-term relationships, or de-
cide not to have children. Box 7-5 depicts a case
study that demonstrates preselection beliefs.
DECISION TO HAVE GENETIC
TESTING
In some circumstances, family members may want to
know the likelihood that they will develop a condi-
tion in the future, which is referred to as either pre-
dictive or presymptomatic testing. Typically the physical
risk for undergoing genetic testing is minimal, but
not so for the emotional risk. The test results may
have a significant effect on a person emotionally, in-
fluence medical decisions, and result in discrimina-
tion. Undergoing genetic predictive testing requires
nurses to work with clients so that they make this de-
cision in a way that meets their specific needs, alert
to the nonphysical risks. Nurses involved with these
families should be able to identify the sources of
emotional distress and offer effective strategies to
help mediate distress, make informed decisions about
medical interventions, and handle possible discrimi-
nation (Williams et al., 2009).
Emotional Health
Family members seek or avoid genetic testing for
a variety of reasons. Some elect to know whether
or not they carry a mutation so they can reduce
their fear of the unknown, or make life choices,
such as having children. Some people decide not to
have predictive testing because they believe this
knowledge would increase their level of anxiety and
would prompt a constant watch for developing
symptoms (Soltysiak, Gardiner, & Skirton, 2008).
Test results mean different things in different sit-
uations, which makes these decisions to undergo
testing even more complex and multifaceted. For
example, a positive test for a BRCA1 or BRCA2
breast cancer mutation does not mean the individ-
ual has a 100% chance of developing breast cancer,
so taking precautionary measures requires weigh-
ing costs and benefits. In other situations, such as
in the case of Huntington’s disease, if an individual
carries the autosomal dominant condition, he will
develop the disease. Some choose not to be tested
for fear that they would lose hope.
Even adjustment to a negative result—meaning
that a person does not have the genetic pattern of
Genomics and Family Nursing Across the Life Span 195
BOX 7-5
Preselection Beliefs
John is a 21-year-old young man who has recently grad-
uated from college and is trying to decide what career he
wants to pursue. John has a family history of Hunting-
ton’s disease (HD) on his mother’s side. His mother’s
brother and her father have both passed away from HD.
His mother, age 45, is currently in good health. John is
very worried that he will develop HD because it is in his
mother’s family. John makes an appointment with his
health care provider so that he can talk with him about
his concerns. As the nurse is taking his vital signs, John
tells her about his concerns that he will develop HD. He
says that he doesn’t know if his mother has it and he is
worried because it seems to be in the males of the fam-
ily, and he looks like his uncle who died from HD. John
says that he would like to go to medical school but he is
scared that he will develop HD when he is young and it
will greatly affect his career. He also tells the nurse that
he has a girlfriend to whom he is very attached, but he is
afraid to consider getting married because he does not
want to put her through the experience of losing him to
HD. He says that he has not even told her about his
family history. The nurse tells John that she understands
his concerns and encourages John to talk with his doctor
about how he can learn more about his risk for HD. She
tells him that he could consider having genetic counsel-
ing to talk further about his risks and available genetic
testing for HD to learn more. John thanks her for her
support and suggestions and says that he will surely talk
with his doctor further about his concerns and options.
3921_Ch07_187-204 05/06/14 11:01 AM Page 195
the disease—can be difficult. Some people who find
that they are not at risk of developing a genetic
condition experience “survivor guilt,” which can be
described as a sense of self-blame or remorse felt
by a person who, in this case, will not develop a
condition that others in the family will develop.
Evidence exists that when individuals have a ge-
netic test that indicates that they will develop a
condition, other family members may rely on them
less than previously, in an emotional sense. These
individuals experience feelings of loss of place in
the family well before developing disease symp-
toms (Williams & Sobel, 2006). Some experience
a deep sense of grief and loss of a potential future.
Medical Decisions
Physicians and nurse practitioners are in an excel-
lent position to work closely with clients in making
medical decisions about their health based on the
individual’s genetic and genomic information.
These health care providers have the ability to re-
fine and personalize medical care that is based on
the client’s genetic makeup. For example, there is
an increased probability that treatment outcomes
will result in fewer adverse effects from medica-
tions, such as pain management being determined
on the basis of whether a client is a known fast me-
tabolizer or slow to metabolize certain kinds of
drugs. But just because there are many tests avail-
able does not mean that the best option is for the
client to have genetic testing done. Advanced prac-
tice nurses need to work closely with the individual
and family in deciding to have genetic testing that
would include what the test would show, how spe-
cific the results might or might not be, and explore
what options are possible based on the outcome of
the testing.
After conferring with the health care provider,
some clients may not choose to have genetic test-
ing at that time. Instead, these clients may elect to
undergo regular checkups and screenings, such as
more frequent mammograms. In contrast, when a
person has genetic testing and tests positive for a
specific disease, a cascade of decisions then befalls
that person, including and involving preventive or
prophylactic treatments, degrees of treatment,
risks of treatment, and benefits of treatment. For
example, a woman may decide to undergo surgery,
such as sterilization, so as to not pass on to off-
spring a condition such as cystic fibrosis or sickle
cell anemia; or someone with positive results for
BRCA1 breast cancer mutation may elect to have
a bilateral mastectomy.
Discrimination
Even though there is little evidence that genetic dis-
crimination is a current problem (Feldman, 2012),
many individuals choose not to undergo genetic
testing because they fear discrimination. For exam-
ple, a person may have concerns that she may be by-
passed for promotion if it was known she tested
positive for a medical condition. The Genetic In-
formation Nondiscrimination Act (GINA) of 2008
protects individuals from discrimination initiated by
an employer or health insurance company.
Under GINA, insurers may not use genetic in-
formation to set or adjust premiums, deny cover-
age, or impose preexisting conditions, and they
may not require any genetic testing. Unfortunately,
the GINA law does not apply to employers with
less than 15 employees and it does not include pro-
tection against discrimination when an individual
seeks to obtain life insurance, short-term disability
insurance, or long-term care insurance. GINA does
not protect members of the military, veterans, fed-
eral employees, or the Indian Health Service. Each
of these sectors of society is protected against dis-
crimination by other laws and statutes.
Under GINA, an employer may not make any
decisions about hiring, firing, promoting or pay or
assignment based on any genetic information. The
Patient Protection and Affordable Care Act of 2010
also prohibits denial of insurance coverage based
on genetic information. The GINA law is signifi-
cantly more stringent and specific in preventing
discrimination by employers and health care insur-
ance agencies (Feldman, 2012), however, because
it defines genetic information as including medical
history.
ROLES OF THE NURSE
When there exists a genetic risk, nurses, together
with others on the health care team, have two
major responsibilities: (1) to help families under-
stand that the risk is present, and (2) to help family
members make decisions about management or
surveillance. In every case, the nurse’s role is to
support families to make decisions that are most
196 Families Across the Health Continuum
3921_Ch07_187-204 05/06/14 11:01 AM Page 196
appropriate for their particular circumstances, cul-
tures, and beliefs (International Society of Nurses
in Genetics, 2010). This section suggests ways that
nurses should review their own beliefs and values
when working with families. It covers how to con-
duct a risk assessment and genetic family history,
the importance of working with a couple in precon-
ception education, and the role of nurses as genetic
information managers.
Personal Values: A Potential Conflict
Nurses must become aware of cultural values that
differ from their own family cultural values. Cul-
tural awareness allows nurses to tailor their prac-
tices to meet the needs of the family. Box 7-6
demonstrates how a nurse who does not under-
stand a family’s cultural values could contribute to
a poor outcome.
It is a difficult emotional situation when nurses’
personal values conflict with those of families. One
example of this type of conflict occurs when the
nurse personally does not agree with the family de-
cisions relative to the potential risks of having a
child who is genetically predisposed to having a ter-
minal disease. It is unethical, however, for nurses to
try to influence the decisions of the family or family
members because of their own personal views.
Another type of conflict occurs when opinions
within the family vary. In this type of situation, the
role of the nurse is to facilitate family members ex-
pressing their views. In clinical genetics, more than
one family member may be involved in decision
making, and nurses should respect each person’s
autonomy.
Conducting a Genetic Family History
All nurses should be able to conduct a risk assess-
ment that includes obtaining a genetic family his-
tory (Consensus Panel, 2008). As described in
Chapter 4, a genogram collects useful information
about family structure and relationships. Nurses
can use a three-generation family pedigree to pro-
vide information about a potential genetic inheri-
tance pattern and recurrence risks. The genetic risk
assessment enables nurses to identify those family
members who may be at risk for disorders with a
genetic component so that they can be provided
appropriate lifestyle advice, screening recommen-
dations, and possibly reproductive options. Infor-
mation on standardized pedigree symbols and the
construction of a genetic family pedigree is avail-
able to the public through the U.S. Surgeon Gen-
eral’s Family History Initiative (U.S. Department
of Health and Human Services, 2005), and re-
sources are available through the National Genet-
ics Education and Development Centre (2008).
The purpose of drawing the family tree using a
genetic family pedigree is to enable medical infor-
mation to be presented in context of the family
structure. Obtaining a genetic family history in this
systematic manner helps ensure inclusion of all
critical information in the analysis (Skirton, Patch,
& Williams, 2005). The process of obtaining a de-
tailed health history and causes of family deaths is
as follows:
■ Start with the client
■ Client’s immediate family members
■ Client’s mother’s side of the family
■ Client’s father’s side of the family
■ Relatives who have died, including their
cause of death
Relatives who are not biologically related, such
as those joining the family through adoption or
marriage, should also be noted with the appropriate
Genomics and Family Nursing Across the Life Span 197
BOX 7-6
Cultural Awareness
Kate is a genetic nurse working in a pediatric clinic for
children with inherited metabolic conditions. She was
scheduled to see a family whose son had a rare inher-
ited metabolic disorder to discuss the parents’ future re-
productive options, including prenatal diagnosis. When
the family entered the room, she noted with surprise
that the parents and the child were accompanied by
both sets of grandparents. She quickly arranged for more
chairs to be brought into the room. Kate was quite dis-
concerted to find that the paternal grandfather repeat-
edly answered questions that were directed to the
parents, and she continued to address the parents. Even-
tually, the child’s father explained that, according to his
culture, the oldest male relative on the father’s side was
responsible for making the decision that would affect the
family; therefore, it was critical that the grandfather be
fully involved in all discussions. While reflecting with her
mentor, Kate realized that, in the future, she would ask
the family at the beginning of the family conference to
share any specific cultural needs she should know about
in order to help meet their family needs.
3921_Ch07_187-204 05/06/14 11:01 AM Page 197
pedigree symbol. The reason that relatives who are
not biologically related are noted in a pedigree with
a special symbol is to identify them as family mem-
bers who are not at risk for passing on or inheriting
harmful genes from the family they have joined.
Obtaining a family genetic history is a nursing
skill that requires technical expertise and knowl-
edge of what needs to be asked, as well as sensi-
tivity to personal or distressing topics and an
awareness of the ethical issues involved. Box 7-7
outlines the components of a genetic nursing as-
sessment. Information given by patients is con-
sidered part of their personal health record and
should be treated as personal and private infor-
mation (U.S. Department of Health and Human
Services, 1996, 2005).
Drawing the genetic family pedigree or family
tree for at least three generations often provides im-
portant data about the potential inheritance pattern.
When a condition affects both male and female
members, and is present in more than one genera-
tion, a dominant condition is suspected (Fig. 7-1).
Conditions that affect mainly male relatives, with no
evidence of male-to-male transmission, increase sus-
picion of an X-linked recessive condition (Fig. 7-2).
When more than one child is affected of only one
set of parents, it may be evidence of an autosomal re-
cessive condition (Fig. 7-3).
Nurses should not assume that a condition is ge-
netic merely because more than one family member
has it. Family members who are subject to similar
environmental influences may have similar condi-
tions without a genetic basis. One such example is
a family with a strong history of lung cancer. Bob,
a 62-year-old man, was affected by lung cancer. His
two brothers and father all died of lung cancer. Bob
expressed deep concern about having a genetic pre-
disposition that he could pass on to his grandsons.
The family history revealed that Bob’s father and
every male member of his family worked under-
ground as coal miners from the age of 14 years. In
addition, they all smoked at least 20 cigarettes a day
from when they were teenagers. None of the
women smoked, nor did they work in the mines,
and none developed lung cancer. In this family, the
cancer could likely be attributed to environmental
rather than inherited causes.
198 Families Across the Health Continuum
BOX 7-7
Genetic/Genomic Nursing Assessment
A genetic nursing assessment includes the following
information:
■ Three-generation pedigree using standardized symbols
■ Health history of each family member
■ Reproductive history
■ Ethnic background of family members (as described by
the family)
■ Documentation of variations in growth and develop-
ment of family members
■ Individual member and family understanding of causes
of health problems that occur in more than one family
member
■ Identification of questions family members have about
potential genetic risk factors in the family
■ Identification of communication of genetic health infor-
mation within the family
Person with autosomal
dominant condition
FIGURE 7-1 Pedigree of autosomal dominant genetic condition.
3921_Ch07_187-204 05/06/14 11:01 AM Page 198
Preconception Assessment
and Education
Preconception counseling is an intervention that
includes providing information and support to in-
dividuals before a pregnancy to promote health and
reduce risks (Walfisch & Koren, 2011). It is ideal
when a family has the opportunity to discuss diffi-
cult genetic decisions before a pregnancy. During
a pregnancy, the emotional ties to the existing fetus
may complicate the decision-making process for
the parents. Preconception counseling enables a
couple to explore options without time pressures.
One aspect of preconception education is con-
ducting a health risk profile that includes family
history, prescription drug use, ethnic background,
occupational and household exposures, diet, spe-
cific genetic disorders, and habits such as smoking,
alcohol, or street drug use. When nurses identify
information that may present a health risk in future
Genomics and Family Nursing Across the Life Span 199
FIGURE 7-2 Pedigree of X-linked recessive condition.
Heterozygote (carrier)
of X-linked recessive
condition
Male with X-linked
recessive condition
Carrier (heterozygote) of
autosomal recessive disorder
Person affected with autosomal
recessive disorder
FIGURE 7-3 Pedigree of autosomal recessive genetic condition.
3921_Ch07_187-204 05/06/14 11:01 AM Page 199
offspring, they should explore whether the woman
or family wants a more extensive evaluation from a
genetic specialist. Box 7-8 provides an example of
preconception education for a couple concerned
about genetic risks for offspring.
In addition to identifying inherited conditions,
preconception counseling includes education re-
garding other risk factors that could change the
outcome of a pregnancy. During preconception
counseling, family nurses explain the importance,
for instance, of taking an adequate amount of folic
acid, one of the B vitamins, which is known to de-
crease the number of babies born with neural tube
defects (NTDs) (Centers for Disease Control and
Prevention, 2006). Box 7-9 provides more infor-
mation about NTDs.
Risk Assessment in Adult-Onset
Diseases
Genetic history taking is important in the adult
population to assess for risk factors that are perti-
nent to common diseases, such as cancer and coro-
nary heart disease. The risk assessment is based on
the genetic family pedigree, but additional genetic
or biochemical testing may be used to clarify
the potential risk to each individual. To ensure pri-
vacy, health care providers must obtain consent
from all living relatives before accessing their
medical records and confirming relevant medical
history. Family members who are seeking infor-
mation are advised of their risks and options for
clinical screening and follow-up. One example is
the assessment of risk for cancer when there is a
strong history of cancer in the family (Gammon,
Kohlmann, & Burt, 2007). Individuals who find
through counseling and testing that they have
an increased risk for cancer may experience psy-
chological difficulties (Kenen, Ardern-Jones, &
Eeles, 2006). Nurses must explore feelings of
grief and anxiety about the future, as well as be-
liefs about the inheritance pattern. Providing
explanations enables families to understand the
information and helps them learn possible op-
tions to reduce the risk for cancer in their family
members.
200 Families Across the Health Continuum
BOX 7-8
Preconception Education
Jay and Sara are college students who are planning to be
married. Both are of Ashkenazi Jewish ancestry. Although
both have heard about Tay-Sachs disease, and the avail-
ability of carrier testing, neither has had the carrier test.
When Sara visited the student health office, she talked
with the nurse about her fears that she may not be able
to have healthy babies. She knew that Tay-Sachs disease,
a degenerative neurological condition, is more common
in Ashkenazi Jewish families, and that no treatment will
alter the course of the disease. Sara was interested in
learning more about the carrier test. The nurse offered to
refer Sara to a genetics specialist, who would help the
couple explore the following childbearing options:
■ Decide to have or not have biological children
■ Have a pregnancy with no form of genetic testing
■ Have a preimplantation genetic diagnosis
■ Have a pregnancy and have a prenatal genetic diagno-
sis with an option to terminate an affected fetus
■ Have a pregnancy using a donor gamete from a non-
carrier donor
■ Adopt a child
BOX 7-9
Folic Acid Recommendations to Prevent
Neural Tube Defects
In 1992, the U.S. Public Health Service recommended
that all women capable of becoming pregnant take
0.4 mg/400 g folic acid daily, which is the amount of
folic acid in most multivitamins. Although a daily intake
of folic acid does not completely rule out the possibility
that an infant will have neural tube defects (NTDs), stud-
ies have reported an 11% to 20% reduction in cases of
anencephaly and a 21% to 34% reduction in cases of
spina bifida since this recommendation was issued
(Mosle
