37.2: Family Framework

Learning Objectives

By the end of this section, you will be able to:

• Analyze the structure of family
• Understand the functions of family
• Recall the stages of the family life cycle

When assessing families, nurses must consider many aspects of family structure and how this affects disease prevalence, response to illness, and coping strategies. Important aspects of family structure include family composition, gender roles, birth order, and family member relationships. These interactions include immediate and extended family members in a traditional family structure. In unconventional family groups, individuals still function within the social construct of a family. Applying family systems theories, nurses may use genograms or ecomaps to help define and conceptualize individual families and their members. After all, understanding the family structure and associated tasks helps the nurse offer meaningful interventions to families.

Family Structure

The internal and external makeup of families is known as family structure. These structures include the type and number of family members, living arrangements, and interactions. Legal or census definitions of family structures may not match cultural or social definitions of family. Definitions of the family may include individuals living within the same household, individuals related by blood or kinship, and individuals functioning financially as a family. Some groups of individuals function as a family regardless of living location or kinship. For nurses, the critical part of understanding family structure is accepting families as they perceive themselves. Respecting family units is crucial in providing comprehensive care to patients.

The internal and external structure of families directly affects the health of family members. Different family structures are associated with various long-term health outcomes, depending on the circumstances. Some evidence suggests that marriage combined with nonviolence and stability are associated with better outcomes in children (Bzostek & Berger, 2017). According to census records, 65 percent of children in the United States live with two married parents, 5 percent live with two cohabitating parents, 22 percent live only with their mothers, and 5 percent live only with their fathers (ChildStats, 2022).

Internal Structure

Internal family structure relates to the relationships among family members, including gender roles and sibling order. Subsystems within families refer to the various interpersonal relationships, such as parent-parent, parent-child, sibling, and grandparent-child, and the interplay among these relationships.

Family Composition

The design of a family structure, including relationships between members, known as family composition, is not static and is influenced by births, deaths, marriage, and divorce. Family composition is also influenced by life circumstances that may affect living arrangements. The family composition may consist of a nuclear, blended, or extended family, which may fluctuate over time. The family composition may influence health outcomes because of financial resources, living situations, emotional stability within the family, and coping strategies. Family composition evolves as children are born, grow up, and create new family structures outside their family of origin.

Real RN Stories

Sandwich Generation

Nurse: Alice, RN
Clinical setting: Public Health
Years in practice: 22
Facility location: Pennsylvania

I’ve been a public health nurse at the county health department for 18 years. I work with children, teens, adults, and families struggling with access to health care. I do a lot of home visits evaluating the needs of families with children with special needs. Most of these children have autism spectrum disorder (ASD). One of the most exciting cases I encountered was an extreme case of a married couple struggling in the sandwich generation—middle-aged adults caring for their own children as well as their aging parents. The family had four children, with the third child diagnosed with ASD. The father worked outside the home, and the mother performed all of the family and care duties within the home. The father’s mother also lived in a small, attached apartment with the family. The grandmother developed mild cognitive impairment, which slowly progressed to more severe dementia. The mother was pulled in many directions caring for a young child with a disability as well as a cognitively impaired older adult family member. Finding resources for this family was challenging, particularly securing respite care to allow the mother to attend school events and functions with her other children.

Caring for a young family and an additional older family member also strained this family financially. We were able to set them up with some resources and care options to provide financial and stress relief. Many adults in midlife struggle with the burdens of being the sandwich generation. Our job as nurses is to help them navigate this difficult time and support them in their efforts to provide the best care for their families.

Gender Roles

Gender role theory posits that males and females learn gender role behaviors and attitudes from the family and overall culture in which they grow up and that non-physical gender differences are a product of socialization. Social role theory proposes that social structure is the underlying force behind gender differences and that the division of labor between two sexes within a society motivates the differences in their respective behavior. Division of labor creates gender roles, which, in turn, leads to gender-specific social behavior.

Family is the most important agent of socialization because it is the center of a child’s life. Socialization theory tells us that primary socialization—the process that occurs when a child learns the attitudes, values, and actions expected of individuals within a particular culture—is the most important phase of social development and lays the groundwork for all future socialization. Therefore, the family plays a pivotal role in the child’s development, influencing the attitudes the child will adopt and the values the child will hold.

Socialization can be intentional or unintentional; the family may not be conscious of the messages it transmits, but these messages contribute to the child’s socialization. Children learn continuously from the environment that adults create, including gender norms. For example, a child who grows up in a two-parent household, with a stay-at-home female parent and a male parent who works outside the home, might internalize these gender roles, regardless of whether the family is teaching them directly (see Gender Role Expression for more on gender roles). Gender roles within families are changing based on the changing structure of families in same-sex and other LGBTQIA+-parent families. These families show that gender stereotypes do not always apply, and gender roles within a family may be shared and dynamic over time.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Patient-Centered Care, Respecting Family Differences

Definition: Recognize the patient as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient’s preferences, values, and needs.

Knowledge: Nurses must understand the multiple dimensions of patient-centered care. Involving the family, friends, and other members of the patient’s support network is crucial. The nurse must understand differences in cultural beliefs related to family and respect all family structure types.

Skill: During the family interview, nurses can identify patient preferences and understand their values and beliefs. This will help the nurse create an atmosphere of inclusion, respect, and sensitivity to family differences.

Attitude: Nurses can encourage patients to express their values and seek healthcare options aligning with them.

Sibling Rank Order

The effect of sibling rank order in interpersonal family interactions varies between individuals and families. While some theories attempt to relate personality to birth order, this does not hold true for every person or in all families. Evidence does suggest that family factors, such as financial resources, social interactions, and the number of children, affect children differently based on their birth order and the circumstances within the family during their early years (Yan, 2023). Other factors affecting sibling order are parental values that change and adapt over time and interactions based on specific child personalities. Nurses can keep birth order in mind and consider factors that may affect an individual’s perceptions of health. Still, it must be viewed in the context of various other factors.

Real RN Stories

Sibling Rank Order After Death

Nurse: Gabe, RN
Clinical setting: Hospice
Years in practice: 10
Facility location: Florida

As a hospice RN, I interact regularly with families struggling with death, loss, and grief. I’ve encountered some families on multiple occasions. I cared for one large family during the final months of their youngest daughter, Erin’s, struggle with osteosarcoma. I cared for the family several years later during the grandfather’s battle with colon cancer. Most of the surviving children were young adults at that time. I remember the oldest son commenting on how the youngest surviving sister, Jessica, had taken on the role of “the baby of the family.”

During their interactions, the mother, father, and older siblings were seen doting on Jessica, making travel arrangements for her, and changing plans based on her preferences. There was palpable tension among some of the siblings during these instances. Some family members seemed to recognize the preferential treatment, while others, particularly the parents, did not. When the topic was approached in a conversation, the mother became tearful and the father defensive.

When I asked the oldest son about this dynamic, he said the family had never really gotten over Erin’s death. Some individual family members attended counseling independently, but no group counseling was pursued by the parents when the siblings were younger. He said, “This is just something else we have to deal with as part of her death.” Without bringing up this topic directly, I explained that the impending death of another family member would likely bring up past emotions related to Erin’s death. I encouraged family members to express their concerns with each other and make their individual needs known. I explained that discussing their grief coping strategies with one another may be beneficial for the whole family. In addition, I encouraged the family to seek counseling as a group to work through past and current grief.

Subsystems

Family subsystems refer to interpersonal relationships within the family unit. These include the following:

• sibling relationships
• parental relationships
• parent-child relationships
• grandparent-parent relationships
• grandparent-child relationships

These relationships are guided by boundaries, communication techniques, shared experiences, and unspoken connections. Health subsystems within a family help buffer conflict between other members’ relationships and increase individuals’ abilities to cope and maintain resilience in the face of illness or adversity. These subsystems are primarily beneficial but can become toxic if dysfunctional interactions lead to coalitions or triangulation in which family members team up against another family member.

Genograms

A genogram is a written or digital diagram showing relationships between family members. Genograms are useful in understanding kinship among family members. Genograms often indicate divorce and remarriage, as well as stepsibling relationships. More detailed genograms may note types of relationships, such as close and strained relationships. Using genograms in addition to understanding the basics of family structure will help the nurse in understanding each individual family.

Link to Learning

Visit this website on creating a family health portrait reflecting a family health history to learn more.

External Structure

The external family structure relates to how a family interacts with their community and extended family. In some families, day-to-day interactions include extended family members. In these families, multiple nuclear families may live near one another, and individual family members play important roles in the lives of others. Roles may differ in these families or may include different roles that fill childcare needs, emotional support, or financial needs. In interactions with the wider community, families support one another and seek out families with similar views and preferences. These family groups often enjoy meals together and care for each other as a family.

Extended Family

The extended family is typically made up of at least three generations: grandparents, parents, and children. In families with traditional marriages or two-partner families, there are parallel generations on the mother’s and father’s sides. Extended families vary significantly based on culture. This variation can also affect the individual family members living within a household. In some cultures, the extended family includes cousins, aunts, uncles, great-grandparents, and any combination of these individuals. In addition, blended families will have a variety of extended family structures depending on relationship patterns. Nurses must keep these considerations in mind in promoting culturally competent care.

External Systems

In addition to extended family, the external family structure encompasses how the family interacts within the community. This may include religious or spiritual connections, friend groups, neighborhoods, childcare connections, volunteer projects, and school/work interactions. These factors may affect individuals’ health based on illness exposure, varying beliefs about health or health care, and shared interests. These community interactions also vary depending on logistics in providing care for children, individuals with disabilities, individuals with mental health disorders, or older adults.

Ecomaps

An ecomap is a useful diagram that shows connections between families or family members and their social environment. Unlike genograms, which show primarily kinship relationships between family members, ecomaps can focus on one or more individuals to help understand how this person interacts with their environment, including their family. An ecomap illustrates family dynamics and social support systems, such as church, therapists, counselors, friends, teachers, and co-workers. Social support systems may also include sports teams, hobby clubs, and spiritual influences other than church. Ecomaps can help nurses identify family strengths as well as gaps in resources or barriers to attaining quality health care. For example, in discharge planning, nurses can rely on an ecomap to help identify support resources for an older adult after a hip fracture, including close proximity to family members, supportive friends, church support, and community services, such as Meals on Wheels or library book delivery. An ecomap can also outline healthcare resources, such as primary care providers, social workers, financial representatives, medical specialists, and physical therapists. The nurse can rely on these members of the healthcare team to promote quality care for the individual. Ecomaps are dynamic tools and can be changed and adjusted as circumstances change for the family or individual (Figure 37.2).

Figure 37.2 This sample ecomap displays a patient’s diverse support network. Ecomaps can help nurses identify family strengths and outline healthcare resources for patients. (CC BY 4.0; Rice University & OpenStax)

Link to Learning

Watch this video on how to create an ecomap to learn more.

Functions of Family

The primary function of the family is to ensure the continuation of society, both biologically through procreation and socially through socialization. Given these functions, the nature of one’s role in the family changes over time. Beginning in early childhood, the family plays a pivotal role in socialization. Children learn where they fit within the social construct of their family and how their family fits within the wider social world. The parental role includes guiding and socializing children. In blended families, marriage sometimes alters legal parenthood and creates joint parental arrangements. Marriage also establishes a relationship between the extended families of the husband and wife. None of these functions are universal but depend on the culture in which the family is established.

Environment

Family plays an important role in creating a home and community environment. Healthy interactions in the home lead to healthy long-term relationship patterns. All family relationships are reciprocal but not always equal in the ways they affect physical and emotional health. A healthy home is crucial for providing a sense of security during times of health crisis. A home environment that promotes health is free from abuse and neglect and promotes a sense of physical and emotional safety for family members. All families have interpersonal struggles, but an overall atmosphere of respect and cooperation supports a healthy emotional environment. Families that promote shared interests, support differences, and encourage shared values among family members create a foundation for strong relationship patterns outside the family unit.

Reproductive Function

The role of the family in reproductive function is multifaceted. The family unit is the classic unit of procreation. The creation and birth of children grow families and create additional layers of relationships with immediate and extended family. In addition, the social norms within the family regulate sexual reproduction based on the number of children, how the children are parented, and the value placed on children within the family.

Socialization

The value of children and intergenerational relationships within the family is the basis of socialization within the community. Family is the first place individuals receive information about social norms, cultural values, and spiritual beliefs. The family has a role in social identity, social class, race, ethnicity, and religion. Some aspects of socialization are innate, while others are learned. Socialization can also be a source of conflict. For example, spiritual and cultural beliefs may be challenged as children grow and develop their own thoughts and beliefs.

Economics

Families share financial resources in various ways. Financial resources are necessary to secure basic needs, create long-term security, and fund leisure activities. Families that struggle with low income and low socioeconomic status have higher rates of stress and mental health issues (Abrams, 2023). Increased stress levels are associated with a host of medical disease states, including cardiovascular disease and mental health disorders. Financial strain for families may relate to long-standing socioeconomic struggles and debt or unexpected events, such as job loss, injury, or national economic crises. Financial stability is also important during a health crisis, because funds may be needed for transportation, medical care, medications, or procedures. Mounting medical debt is a common issue for families in the United States. The Kaiser Family Foundation (KFF) reports that up to 41 percent of adults have some amount of debt from unexpected medical or dental expenses (2022). This debt can have long-lasting effects on family finances.

Family Life Cycle Stages and Associated Tasks

The set of predictable steps and patterns families experience over time is referred to as the family life cycle. The family life cycle is used to explain the different processes that occur in families over time. Each stage has its own structure with different challenges, achievements, and accomplishments that transition the family from one stage to the next. For example, the problems and challenges that a family experiences as a married couple with no children are likely much different than those experienced as a married couple with teenagers. The success of a family can be measured by how it adapts to these challenges and transitions into each stage.

Early “stage” theories have been criticized for generalizing family life and not accounting for differences in gender, ethnicity, culture, and lifestyle. Less rigid models of the family life cycle account for changes in family development, such as the fact that in today’s society, childbearing does not always occur with marriage. It also reveals other shifts in the way family life is practiced. Society’s modern understanding of family rejects rigid “stage” theories and is more accepting of new, fluid models.

The family lifecycle can be categorized into five stages: independence, coupling, parenting, launching adult children, and the senior years. This concept of family stages is inclusive of a broader range of family types, such as those that do not move beyond the coupling stage, parenting that does not involve procreation but may include adoption or other circumstances of parenting, such as grandparents parenting grandchildren. In addition, this concept does not focus on marriage, which allows for the inclusion of many family types, including those that do not have a traditional marriage. Based on changing family patterns and boomerang kids (adult children who return to live in their parent’s home after having lived independently for a period of time), the senior years may not always be associated with an empty nest.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Patient-Centered Care for LGBTQIA+-Parent Families

Definition: Integrate understanding of patient and family values and describe how diverse social backgrounds function as sources of family values.

Knowledge: Nurses must consider values and preferences when caring for individuals from LGBTQIA+-parent families. Nurses must keep in mind the wide variety of ways that LGBTQIA+ families may be created, such as through adoption, insemination, or prior heterosexual relationships.

Skill: Nurses can encourage families to explain their family structure during the interview process and incorporate expressed values during care planning and implementation. Nurses must refrain from assuming family structure and preferences based on their own family values.

Attitude: By maintaining sensitivity for family diversity and the challenges LGBTQIA+ families may experience, nurses create an atmosphere of inclusivity. Nurses who take the time to understand different family structures empower the healthcare team to create high-quality patient-centered care plans.

Independence

Most individuals progress through a stage during which they develop independence from their parents. This stage occurs traditionally during later adolescence and young adulthood but varies by culture. This stage often involves children leaving the home, finding new habits, and evaluating the gender and social roles in their family of origin. Making decisions about personal beliefs, spirituality, and values to carry through life is another task during this stage. This independence involves often becoming financially independent as well as emotionally and physically removed from parents. Young adults accomplish this task through relationship building with other adults outside the family circle, establishing work, career, or study commitments, and visualizing themselves as independent while still connected to family.

Coupling

Coupling is the next logical stage and may occur simultaneously with independence. This involves relationships with others, defining one’s sexuality, and finding shared goals with another individual. Often, the goal is creating a family, whether or not this involves having children.

Parenting Through Adolescence

Parenting changes rapidly and drastically as children grow and develop. Parenting in the early years does have some similarities with parenting adolescents and young adults, such as setting boundaries, fostering relationships, and allowing independence; the magnitude and variations are distinct. Young children test boundaries and need clear limits while maintaining their sense of autonomy. For adolescents, parents must hold space for boundaries while allowing youth to test true independence in safe and healthy ways. Relationships are crucial during all stages of parenting but change over time. Parents who work hard to instill a strong foundation of social values in children at a young age reap the benefits of well-adjusted and emotionally healthy young adults. While this does not mean that children always make good choices, a foundation of strong relationships gives children an advantage in developing independence and healthy personal, professional, and social relationships.

Patient Conversations

Health Care as Self-Care

Scenario: Sara is a 47-year-old female who works part-time as a substitute teacher. She and her husband have two teenage sons who participate in tennis, soccer, and ski racing. One son also participates in speech and debate while the other plays in the school orchestra. Sara presents to her PCP for evaluation of fatigue, weight gain, and hair loss.

Nurse: Hello, Sara. It’s been a while since we saw you for a wellness exam. It looks like we already have your fasting blood test results to go over.

Patient: Yes, I finally decided to come in. I just can’t seem to keep up with my sons and all of their activities. And when we have a day as a family, I’m always so tired that I just want to stay home.

Nurse: That must be frustrating. How long have you been feeling this way?

Patient: I think I’ve been feeling poorly for at least a year, but I’ve been so busy going to events and driving my kids around that I thought it was all stress-related. My husband finally told me that I had to make an appointment to find out why I felt so fatigued all the time.

Nurse: Your labs do show thyroid levels that deviate from the normal parameters. Many of your symptoms may be related to a thyroid issue. Your healthcare provider will discuss the results and possible treatment options with you

Patient: So, it’s not just life stress. I almost feel relieved that there is something physically wrong that can be fixed. I guess I need to keep better tabs on my own health so that I can enjoy time with my family.

Launching Adult Children

Launching adult children can be an exciting time for families, particularly the youth embarking on the stage of independence. Parents may struggle with empty nest syndrome as children move out and begin independent lives. Some parents embrace this sense of renewed freedom; for a large portion of parents, however, this time is associated with psychosocial stress and a deep sense of grief. This relates to the physical act of children moving away from home and the emotional changes associated with role and relationship changes. This sense of loss and grief may stem from relationship and role factors as well as gender, cultural background, and current social climate within the country. While the concept of empty nest syndrome is commonly known, there are no set identified patterns of emotional or physical symptoms. Mothers tend to feel the effects of the empty nest more prominently, but this is dependent on the underlying relationship and connectedness with the youth. The risk of depression associated with launching children is increased if the parental role is associated with other prominent role changes, such as in the case of a co-occurring career change, an illness, a financial security change, or a move.

For children, this is a time of increasing independence, and success is largely based on their feelings of safety, security, love, and belonging. Young adults branch out if they have support from parents or other mentors and will attain high self-esteem and a sense of respect for themselves and their uniqueness. Safety and security are still held within the core family but become more the responsibility of the youth to maintain their health, find employment and financial security, and begin to think of a family.

Senior Years

During their senior years, individuals focus on maintaining purpose and finding deeper meaning. They may have time to focus more on intergenerational relationships, such as with grandchildren. While they may experience new health risks and concerns, many may find joy in staying active and working to maintain the best health possible. Older adults still require love, belonging, and family security that may be found in children and their families. Depending on health status and cognition, older adults may need additional care in the home of their children or in facilities with assisted living or skilled nursing. The senior years may bring added grief due to the loss of peers to death, health concerns, loss of independence, and failing health. Intergenerational relationships play an important role in the well-being of older adults as they navigate many physical and financial changes associated with aging.