Family prevention interventions and theory

Topic 1: Introduction to the Family

A. The Family Unit

The family unit is vital to the survival of society.  Success or failure of individuals in society is dependent upon stability of the family unit.  Children’s reality is based upon patterns of socialization and exposure provided by parents, who are by far the most important role models and teachers in this family unit. According to Friedman, Bowden, and Jones (2003), the family has 2 purposes:

1 . Meeting the needs of society

2. Meeting the needs of the individuals in the family

An interdependency exists between family members and society.  External forces can dominate family function and efficacy, but in turn individual behavior can determine societal norms. It is vital to utilize resources in working with families that promote health within individuals and families.  Promotion of wellness within a whole family lessens the overall risk for negative outcomes in individuals.  This interrelationship of family and health status prevails throughout the life cycles of each family member. A holistic approach to family health can identify patterns of disease and risk factors.

The definitions of family health differ according to discipline and nursing theorist.  Healthy families, according to Beaver and Hampton (as cited in Friedman et al. 2003), exhibit the following characteristics:

· Effective skills for negotiating problems

· Are clear, open and spontaneous in expressing emotions and decisions

· Respect the feelings of others

· Encourage others to be independent

· Hold others personally accountable for their actions

· Display warmth and closeness toward each other

Well-adjusted families support individual family members in reaching their potential by balancing independence and security.

B. 6 Stages of Health/Illness and Family Interaction

The previous section introduced the concept of interdependency as it applied to the family unit.  To further demonstrate the impact family has on an individual’s health during times of health promotion and illness, the following 6 stages are outlined:

Stage 1: Family Efforts at Health Promotion-Many lifestyles that affect health are learned in the family. Tobacco use is an example of this. Health promotion, prevention, and risk reduction are impacted by families. Three causal relationships that can alter family health status include marriage, parenthood, and social support systems.  The effects can have either negative or positive consequences.

Stage 2: Family Appraisal of Symptoms-This stage begins when a family member has symptoms. Family members embark on the process of understanding the symptoms or illness; dealing with the emotions of the illness begins. The mother usually becomes the caregiver and leader in determining the plan of care.

Stage 3: Care Seeking-A decision is made to seek medical care. Family members are consulted as needed for advice and recommendations, which may include on home remedies and self-medication.

Stage 4: Referral and Obtaining Care-Contact with a health care provider is initiated. This can be based upon the severity of the patient’s condition, family’s culture, health beliefs, availability, and  accessibility.

Stage 5: Acute Response to Illness by Client and Family-The patient takes on the “sick role” and adaptation in this role begins with the patient and family. At this time the patient also becomes dependent on the care provider and recommendations for care.  Chaos may occur in the family unit during this stressful transition.

Stage 6: Adaptation to Illness and Recovery- Support of the patient by the family unit begins for convalescing and rehabilitating. Coping and adaptation about the illness begins at this stage. Challenges vary and are dependent upon the role of the patient in maintaining optimum family function (Friedman et al., 2003).

C. Defining the Family

The definition of family is determined the specialty or discipline presented. Definitions transcend traditional forms and now include postmodern perspectives. The US Bureau of the Census defines the family traditionally and includes “the family is composed of persons joined together by bonds of marriage, blood, or adoption and residing in the same household” (Friedman, et al., 2003, p. 9). In contrast, a broader definition of the family that is nontraditional includes “two or more persons who are joined together by bonds of sharing and emotional closeness and who identify themselves as being part of the family” (Friedman et al., p.10).

The recent influx of change and diversity has changed the American family over the years. Summarized below are a few of these influences:

· Economics: rising costs; and disparity between rich and poor;

· Technological advances: increase in availability of knowledge; ability to prolong life; environmental hazards, automation, birth control advances, and electronics

· Demographic trends: population growth and aging population

· Sociocultural trends: changing racial and ethnic composition

· Changes in the family: decrease in size of households; delays and decline in marriage; increased divorce rates; lower remarriage rates; increase  in first births to older mothers; increase in nontraditional living arrangements for children and single-parent families; increase in women’s employment; post- modern family forms representing all types of lifestyles;  and change in gender roles in families.

The American family today can be:

· Nuclear Family/Adoptive Family

· Dual- Earner Family

· Childless Family

· Foster Family

· Extended Family

· Single-Parent Family/Single Adult Living Alone

· Unmarried Teenage Mother

· Stepparent Family

· Binuclear Family

· Nonmarital Heterosexual Cohabiting Family

· Gay and Lesbian Family

Pages 17-28  in Friedman et al. (2003), provide further details of these various forms of the American family.

Reference

Friedman, M.M., Bowden, V.R., & Jones, E.G. (2003). Family nursing: Research, theory, and practice (5th ed.). Upper Saddle River, NJ: Prentice Hall.

Topic 2. Family Nursing: Focus, Evolution, and Goals

A. Family Nursing: Why it is a Specialty?

Family nursing is a new specialty area for nursing and transcends education, practice, and research of other areas in nursing. Friedman, Bowden and Jones (2003) define family nursing as “the provision of care to families and family members in health and illness situations” (p. 54). Nurses conceptualize each family in the context of their interactions. Five models are presented for conceptualizing the family, guiding the ongoing definition of family nursing and diagrams for review are on page 37, figure2-1:

1. Family as Context: The patient is an individual with family members who are usually the primary resource for them. The individual is the primary receiver and the family is secondary for assessment and intervention of care.

2. Family as Sum of its Members: The family is a sum of all family members. Family healthcare is operational when all members of the family receive care.

3. Family Subsystems as Client: The subsystem of a family can be defined as a dyad or triad and be comprised of a married couple, parent-child, and sibling-sibling, for example. They are the recipients of care.

4. Family as Client: The entire family is in the foreground. Dynamics of the family, subsystems, and relationships with external sources are the focus.

5. Family as a Component of Society: The family is a subsystem of society. Families are considered an institution of society equating to religion and educational institutions for example.

Family nurses place priority on the needs of families, which defines the role of the specialty. Goals of family health evolve from the needs of families. Family nurses are cognizant and accepting of diversity in the family unit. They work with each family unit as defined by the patient.

B. Prevention Levels of Care

Family healthcare nursing goals unfold according to the 3 levels of prevention, which are primary, secondary and tertiary. Primary prevention is a key activity for the family nurse to promote within the family unit. According to Friedman et al. (2003), 7 factors are revitalizing an interest in primary prevention:

1. Need for a change in focus and national initiatives

2. Consumerism and popular demand for increased self-control

3. Wellness movement

4. Growing acceptability of alternative health modalities

5. Lack of access to health services

6. Growing emphasis on health in advanced nursing practice

7. Growth in managed care and  cost-effective, quality outcomes

The following table is a summary of the 3 levels of prevention and how the family unit is impacted by the role of the family nurse.

Levels of Prevention	Definition	Role of the Family Nurse-Functions	Role of the Family Nurse-Challenges
Primary	Prevent the occurrence of disease.	Health promotion and disease prevention Most exciting role for the family nurse Teach families to take responsibility for health and attain health   goals by enjoying a healthy lifestyle	Monetary/lack of financial resources Attitudes of health care providers Health care professional as poor role models Environmental hazards Lack of health knowledge in patients Access to healthcare Education Employment
Secondary	After the disease occurrence Early detection, diagnosis, treatment of signs and symptoms	Conduct screening assessments Make referrals Determine patterns of dysfunction Health teaching	Denial of health issues Maladaptation of family members—lack of coping skills Dysfunction of communications
Tertiary	Recovery and rehabilitation Maximize the level of functioning	Provide support to families in the rehabilitation process. Case manager, advocate, teacher and counselor	Disability and chronic disease

Topic 3: Theoretical Foundations for Family Nursing

A. Nursing Models/Theories

The current profession of nursing evolved from nursing models and theories. Specific nursing models, as outlined in the following table, are appropriate for application to family nursing. As the specialty of family nursing expands, a theory will evolve to represent observations in clinical practice, research and education.

Theory	Application for Family Nursing   Practice
Nightingale’s Environmental  Model	Did not present a theory of nursing or family nursing Emphasized the presence of environmental factors in health and   wellness Nurses care for the whole family unit in the home environment
King’s Theory of Goal   Attainment	Included family-as-context Collaboratively the nurse and family members identify complete assessment to determine goals and a plan of care The family unit provides socialization and establishes norms of   behavior across the life cycle.
Roy’s Adaptation Model	Family is a unit of analysis, in the same context as the individual The family unit is adaptive and interacts with the external environment and internal and external stimuli.
Neumann’s Health System’s   Model	The client is an open system where family is defined Family is comprised of subsystems with relationships among the family members The ability to maintain wellness when exposed to stressors occurs through a series of exchanges in the open system of the model Appropriate model for community-based health care.
Orem’s Self-Care Model	The family unit needs to sustain self-care Nursing works with individuals to achieve self-care in the family   unit; the family unit is not the direct receiver of the health care services. Self-care of the family can incorporate health beliefs of the family
Rogers’s Science of Unitary   Human Beings	A family has energy fields that respond to the environment similar to individuals. Families have stages of development and progress in one direction Permeability of boundaries determines the degree of responsiveness required from environmental input
Newman’s Expanding   Consciousness Model	Expansion of consciousness defines health. Individuals move unidirectionally to expand consciousness and allow this inside and outside of the family unit; can incorporate the family with community energy fields. As the individual of a family moves towards consciousness, he/she can explain the internal dynamics of the family.

B. Family Social Science Theories

Family social science disciplines grew midway through the 20th century. The field of Sociology was the largest contributor towards this expansion, but at that time there was little focus on using these theories for clinical practice. Since the early 1950’s, aggressive attempts have occurred to organize  conceptual knowledge of families.

Theory	Focus on the Family	Strength(s) for Family Nursing	Limitation(s) for Family   Nursing
Structural-Functional (is presented in-depth in Chapter 4/Unit 3)	Family as a social system Identifies how the family interacts with other institutions of   society Identifies how family members interact with each other in family   relationships and support each other effectively to perform their functions	Comprehensive and recognizes the family within the context of the   community	Views the family unit as static or individual moments and not as a   dynamic process
Systems Theory (is presented  in -depth in Chapter 6/Unit 5)	The family as a set of interacting elements distinguishable from the   environment it interacts.	Grand theory Views family in context of suprasystems  and subsystems Interactionally focused Holistic	Broad and general Cannot be applied to individuals
Family Developmental  Theory (is presented in -depth in Chapter 6/Unit 5)	Explains the developmental changes of family members through the   years	Provides the ability to make predictions of family needs according   the life cycle	Emphasis is on the traditional nuclear family
Family Interactional Theory	Family members assign meaning to events in their world; this is   impacted by the relevancy of the situation	The focus on internal dynamics of families	Interactionalists  may consider   families to be closed unit with little influence from society
Family Stress Theory	Illness causing stress that changes family dynamics Resources in the family for dealing with the stressor(s) Implications/reality of the event on families and how they will adapt	Easy to understand Clinical applicability for family nursing practice	Limited application for meeting needs of healthy families-health   promotion and disease prevention
Change Theory	The effect of change on the family unit and health behavior	Strong family support is predictive of success with new health   behaviors	Lack of family support and adaptive relationships

C. Family Therapy Theories

Family therapy theories combine social science and practice theories. Family therapists work with families on communication and clarity and meaning of messages sent and received.

Theory	Focus on the Family	Strength(s) for Family Nursing	Limitation(s) for Family   Nursing
Interactional/Communication Family Therapy	Therapy consists of    communication skills and the intent of    messages sent and  received;   how  communication effects behavior	Attention is on patterns of communication in the family unit	Looks only at internal structure of family and not impact of external   variables
Structural Family Therapy	Family interactions are altered by change in the structure of the   family as facilitated by therapy	Concepts are valid and well-developed	Therapists take an intense approach which may not be acceptable to   family members and therapists
Family Systems Therapy	The self is differentiated; intellect and emotion are fostered in the   individual unit of each family	Can develop a family genogram from discussion on family tree with   therapist Intellect leads over emotion	Families do not complete the term of the therapy and are unable to   see the benefits of the outcomes

D. Integrated Family Nursing Theories

It is acceptable for family nursing to interface with nursing theories, family social science theories, and family therapy theories until a comprehensive framework for family nursing is available to guide  practice, education, and research. Information on the following 3 integrated theories is found on pages 81-82 in Friedman, Bowden, and Jones (2003).

1. Family Assessment Intervention Tool (Family Systems Stressor-Strength Model)

2. Calgary Family Assessment Model and Calgary Family Intervention Model

3. The Friedman Family Assessment Model

Reference

Friedman, M.M., Bowden, V.R., & Jones, E.G. (2003). Family nursing: Research, theory, and practice (5th ed.). Upper Saddle River, NJ: Prentice Hall.

Topic 4: Family Developmental Theory

A. An Overview of Family Developmental Theory

The Family Development Theory focuses on the family career or family life cycle. This is defined as the career of the family over the years of togetherness. The term family life and family career are used in the same context in Friedman, Bowden and Jones (2003). As the family progresses through these careers, they  re-examine family roles and tasks. Each stage of family development is distinct and described by intervals of time.

There are both limitations and strengths to this theory. Limitations include homogeneity, middle class bias, and lack of information on how families transition through the stages. This theory enables family health care workers professionals to assess the developmental stage and its appropriateness to the family for planning health promotion needs.

Evelyn Duvall initiated the developmental stages/tasks of the family life cycle and integrated 8 stages for the framework. Family transition occurs between each developmental task. These tasks are specific to the family in this theory, and as each family progress through these tasks to meet biological requirements, cultural imperatives and identified aspirations and values. These family tasks assist individuals, each other, the family unit and the community with meeting needs. Two other family development theories highlighted in the Chapter 5 include Changing Life Cycle and Family Life Cycle Framework. Tables 5-2, 5-3 and 5-4 outline the family development of these characteristics.

Family development is influenced by illness and disability. Stress creates an environment where family members are overloaded with demands. Family functioning is faced with challenges creating outcomes that impinge family development tasks. Some factors that interfere with family development tasks include:

· Present life cycles/stage

· Which family member is affected

· Presence or absence of resources

Family nurses as care providers need to be informed of the impact illness has on developmental tasks to  intervene and plan appropriate care. A future topic explores family assessment and vital information obtained of developmental stage and history of family.

B. Family Career or Life Cycle

Family Career or Life Cycle Stages	Developmental Tasks	Health Concerns for the Family Nurse
2-Parent Nuclear Transitional Stage: Between   Families	Personal life goals Develop intimate relationships Discovery of self	Family planning; birth control Accidents and suicide Mental health Access to health care
Stage I:  Beginning Families	Formation of couples Planning a marriage and family	Sexual, marital role adjustment Family planning education Prenatal/preconception planning
Stage II: Childbearing   Families	Transition to parenthood New role development as parents Reconstruct family organization/tasks	Family planning Child care access/working mothers Parenting issues
Stage III: Families with   Preschool Children	Strengthen marriage partnership Establish needs of growing children and parents-for example living space Husband/father increased role activity with family Integration of new family members Separation of parent-child Socialization outside home	Communicable diseases Common childhood accidents Infectious disease Marital relationships Development of healthy lifestyles
Stage IV: Families with School Age Children	School achievement Marital satisfaction	Emergence of childhood disabilities/handicaps-for example cystic fibrosis Communicable diseases Behavioral issues
Stage V: Families with   Teenagers	Balance of parent-child roles for transition to independence Refocus on marital relationship Open communication of family members Support of family ethics and moral standards	Healthy lifestyle Health promotion: accidents(MVA); drug and alcohol; unwanted pregnancy; sexual education Marital and adolescent-parent relationship
Stage VI: Families Launching Young Adults	Adjustment to employment (parent)	Menopausal issues Development crises Communication issues Role transition Emergence of chronic disease Health promotion Caretaker issues
Stage VII: Middle-Age Parents	Healthy environment Meaningful relationships with grown children Marriage relationship	Same as VI
Stage VIII: Family in   Retirement and Old Age	Maintaining satisfying living arrangements Adjusting to decrease in income Maintaining marital relationship Adjust to death of spouse	Disease and disability Physical endurance Long term care needs
Divorced	See page 135 and Table 5-14 on page 136.
Stepparent	See page 137 and Table 5-15 on page 138.
Domestic	See page 139 and Table 5-16 on page 140.

C. Family Assessment

The developmental history and family assessment can be completed by the family nurse to create a more comprehensive understanding of the family unit dynamics. The developmental assessment according to Friedman et al. (2003) should incorporate:

· Present developmental stage

· Degree to which a family is meeting the appropriate developmental task

· Family history

· Family origin of both parent

Upon completion of the assessment, family nursing diagnoses are determined, along with interventions that promote fulfillment of meeting individual and family developmental tasks.

Reference

Friedman, M.M., Bowden, V.R., & Jones, E.G. (2003). Family nursing: Research, theory, and practice (5th ed.). Upper Saddle River, NJ: Prentice Hall.

Topic 5: Structural-Functional Theory/Therapy

A. An Overview of the Structural-Functional Theory

The discipline of Sociology applies this major theory  of structure-function to care provided to families. Structural organization, along with functions of a family unit, is incorporated in the theory and generates resources for completion of a family nursing assessment. This approach to the family enables family nurses to assess the family holistically, in subsystems, and as members of society. The theory provides a foundation for understanding the internal and external forces of the family.

B. Structure of Families

“Structure” explains the characteristics of families in this theory. Theorists have different viewpoints on the application of this concept. Overall, the description of the family structure is that the family unit is organized and there is interdependency and relationships between each other. Family nurses can identify indicators of adaptation or maladaptation. Family structural dimensions include:  family power structure; family role structure; family communication patterns; and family value structure.  The structure of families determines the potential for successful outcomes. These outcomes not only affect families, but also society.

C. Family Functions

Simply stated, family function explains the contributions of the family unit to society, but also for each other as members of that particular unit. The goal for the family unit is to develop individual family members that have a positive impact on a productive family and also society. Functions identified by Friedman, Bowden, and Jones (2003) include:

· Affective: family members meet the affectionate needs of each other; this is a way the family unit rewards each other.

· Socialization and Social Placement: socialization and the assumption of roles in society is a necessity of the family; moral development occurs with mastering this function.

· Health Care: this is a priority to the family nurse; this function is presented again in Chapter 16, with more detail.

· Reproductive: in the traditional family, reproduction of family members for society was a priority; with the sexual revolution and “choice” and evolution from traditional family forms, reproduction is not the primary priority.

· Economic: the resources of family members such as financial, space, and material; the types of resources a family possesses can exemplify a family value system.

D. The Structural Model

Structural Family Therapy was developed by Salvador Minuchin in 1974.  This model shares with other family system approaches a preference for a contextual rather than an individual focus on problems and solutions. 

The model’s three major thesis:

· An individual’s symptoms are best understood as rooted in the context of family transaction patterns.

· Change in family organization or structure must take place before the symptoms are relieved.

· The therapist must provide a directive leadership role in changing the structure or context in which the symptom is embedded.

The structural model of family therapy emphasizes family structure (interactional patterns within a family), subsystems (subgroups within the family) and boundaries (invisible boundaries that surround each family). 

E. Therapeutic Goals of Structural Family Therapy

Because structuralists view symptoms in a family member as emerging from and being maintained by a family structure unable to adapt to changing environmental or developmental demand, they consider that they have reached their therapeutic goal when the family has restructured itself and thus freed its members to relate to one another in nonpathological patterns.  Changing a family’s structure calls for changing its rules for dealing with one another, and that in turn involves changing the system’s rigid and diffuse boundaries to achieve greater boundary clarity.   

Readings:

Jiménez, L., Hidalgo, V., Baena, S., León, A., & Lorence, B. (2019). Effectiveness of Structural⁻Strategic Family Therapy in the Treatment of Adolescents with Mental Health Problems and Their Families. International journal of environmental research and public health, 16(7), 1255. 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6479931/

Reference

Friedman, M.M., Bowden, V.R., & Jones, E.G. (2003). Family nursing: Research, theory, and practice (5th ed.). Upper Saddle River, NJ: Prentice Hall.

Jiménez, L., Hidalgo, V., Baena, S., León, A., & Lorence, B. (2019). Effectiveness of Structural⁻Strategic Family Therapy in the Treatment of Adolescents with Mental Health Problems and Their Families. International journal of environmental research and public health, 16(7), 1255. 

Topic 6:  Family Systems Theory/Therapy

A. An Overview of the Family Systems Theory

This theory was advanced by Murray Bowen and emphasized the family is an emotional unit or network of interlocking relationships but best understood from a historical or transgenerational perspective.  

Transgenerational approaches offer a psychoanalytically influenced historical perspective to current family problems.  This is accomplished by attending specifically to family relational patterns over decades.  Advocates of transgenerational models believe current family patterns are embedded in unresolved issues in the families of origin and persist and repeat in patterns that span generations. 

B. Bowen’s Family Therapy

Murray Bowen’s Family Systems Theory conceptualized the family as an emotional unit which is best understood when analyzed within a multigenerational framework.  This approach emphasized the significance of past family relationships on an individual on one hand, and the systems approaches that focus on the family unit as it is presently interacting on the other. 

C. Bowen’s Eight Interlocking Theoretical Concepts

1. Differentiation of self: Reflects the extent to which a person can distinguish between the intellectual process and the feeling process of what he or she is experiencing.

2. Triangles: A three-person relationship systems in which a two-person system becomes unstable and involves a third party to reduce the tension. 

3. Nuclear family emotional system: Identifies three emotional functioning patterns which consist of physical or emotional dysfunction in a spouse, chronic and unresolved marital conflict and psychological impairment in a child. 

4. Family Projection Process: Poorly differentiated parents, themselves immature, select as the object of their attention the most infantile of all their children, regardless of birth order.  This child receives the parents’ own low levels of differentiation and becomes that way him or herself. 

5. Emotional cutoff: Extreme emotional distancing in order to break emotional ties.

6. Multigenerational transmission process: Severe dysfunction is conceptualized as the result of chronic anxiety transmitted over several generations.  Behavior and emotional issues will repeat themselves in future generations. 

7. Sibling position: Children develop certain fixed personality characteristics based on their birth order.

8. Societal regression: Society, like the family, contains within it opposing forces toward differentiation and towards individuation. 

 

D. Therapeutic Goals of Bowen’s Family System Theory

Family systems therapy is governed by two basic goals: (a) management of anxiety and relief from symptoms, and (b) an increase in each participant’s level of differentiation in order to improve adaptiveness.  The family needs to accomplish the former goal first, before the latter can be undertaken. 

Learn More:

Dr. Bowen- The Bowen Center for the Study of the Family: 

https://www.thebowencenter.org/core-concepts-diagrams

Reference:

Goldenberg, H. & Goldenberg, I. (2013). Family Therapy: An Overview (8th ed.). Cengage Learning