Chapter 3. Family Assessment
The assessment guidelines outlined in this chapter are adapted from those outlined by Wright and Leahey (2000) in the Calgary Family Assessment Model (CFAM) and reflect its strongly supported systems approach to family care.
Rationale
The family should be viewed as interacting, complex elements. The decisions and activities of one family member affect the others, and the family has an impact on the individual. Understanding family members’ interactions and communications, family norms and expectations, how decisions are made, and how the family balances individual and family needs enables the nurse to understand the family’s responses and needs during times of stress and well-being. This understanding can enrich the relationship between the nurse and family. The nurse’s positive, proactive responses to family concerns and capabilities can help the family promote the development and well-being of its members.
General Concepts Related to Assessment
The primary premise in family systems assessment is that individuals are best understood in the context of their families. Studying a child and a parent as separate units does not constitute family assessment because it neglects observation of interactions. The parents and children are part of subsystems within a larger family system, which in turn is part of a larger subsystem. Changes in any one of these systems components affect the other components, a characteristic that has been likened to the impact of wind or motion on the pieces of a mobile.
The analogy of a mobile is useful for considering a second concept in family systems assessment. When piece A of the mobile strikes piece B, piece B might rebound and strike piece A with increased energy. Piece A affects piece B and piece B affects piece A. Circular causality assumes that behavior is reciprocal; each family member’s behavior influences the others. If mother responds angrily to her toddler because he turned on the hot water tap while her infant was in the tub, the toddler reciprocates with a response that further influences the mother. It is important to remain open to the multiple interpretations of reality within a family, recognizing that family members might not fully realize how their behavior affects others or how others affect them.
All systems have boundaries. Knowledge of the family’s boundaries can help the nurse predict the level of social support that the family might perceive and receive. Families with rigid, closed boundaries might have few contacts with the community suprasystem and might require tremendous assistance to network appropriately for help. Conversely, families with very loose, permeable boundaries might be caught between many opinions as they seek to make health-related decisions. Members within family systems might similarly experience extremely closed or permeable boundaries. In enmeshed families, boundaries between parent and child subsystems might be blurred to the extent that children adopt inappropriate parental roles. In more rigid families, the boundaries between adult and child subsystems might be so closed that the developing child is unable to assume more mature roles.
Families attempt to maintain balances between change and stability. The crisis of illness might temporarily produce a state of great change within a family. Efforts at stability, such as emphatic attempts at maintenance of usual feeding routines during the illness of an infant, might seem paradoxical to the period of change; however, both change and stability can and do coexist in family systems. Overwhelming change or rigid equilibrium can contribute to and be symptomatic of severe family dysfunction. Sustained change usually produces a new level of balance as the family regroups and reorganizes to cope with the change.
Change and stability are integral concepts in development. Like individuals, families experience a developmental sequence, which can be divided into eight distinct stages.
Stage One: Marriage (Joining of Families)
Marriage involves the combining of families of origin as well as of individuals. The establishment of couple identity and the negotiation of new relationships with the families of origin is essential to the successful resolution of this stage. The new relationships will vary with the cultural context of the couple.
Stage Two: Families with Infants
This stage begins with the birth of the first child and involves integration of the infant into the family, design and acceptance of new roles, and maintenance of the spousal relationship. The birth of an infant brings about profound changes to the family and offers more challenges than any other stage in family development. A decrease in marital satisfaction is common during this stage, especially if the infant is ill or has a handicapping condition, and is influenced by individual characteristics of the parents, relationships within the nuclear and extended families, and division of labor.
Stage Three: Families with Preschoolers
Stage three begins when the eldest child is 3 years of age and involves socialization of the child(ren) and successful adjustment to separation by parents and child(ren).
Stage Four: Families with School-Age Children
This stage begins when the eldest child begins elementary or primary school (at about 6 years). Although all stages are perceived by some families as especially stressful, others report this as a particularly stressful stage. Tasks involve establishment of peer relationships by the children and adjustment to peer and other external influences by the parents.
Stage Five: Families with Teenagers
This stage begins when the eldest child is 13 years of age and is viewed by some as an intense period of turmoil. Stage five focuses on the increasing autonomy and individuation of the child, a return to midlife and career issues for parents, and increasing recognition by parents of their predicament as the “sandwich generation.”
Stage Six: Families as Launching Centers
Stage six begins when the first child leaves home and continues until the youngest child departs. During this time, the couple realigns the marital relationship while they and the child(ren) adjust to new roles as parents and separate adults.
Stage Seven: Middle-Age Families
Stage seven begins when the last child leaves home and continues until a parent retires. (This is often a stage for maximum contact between the marriage partners.) Successful resolution depends on development of independent interests within a newly reconstituted couple identity, inclusion of new and extended family relationships, and coming to terms with disabilities and deaths in the older generation. Within some cultures, such as the Vietnamese culture, parents might be incorporated into a multigenerational household.
Stage Eight: Aging Families
This stage begins with retirement and ends with the death of the spouses. It is marked by concern with development of retirement roles, maintenance of individual/couple relationships, aging, and preparation for death.
Tasks and Characteristics of Stepfamilies
Stepfamilies face unique challenges as they attempt to build a new family unit from members who all bring a history of relationships, expectations, and life experiences. Intense conflict can arise as marriage partners attempt to cope with instant children without the benefit of instant affection. The parents move from a fantasy stage, in which they dream of fixing everything that went wrong in previous marriages, to a reality stage in which the challenges and losses of transition are realized.
Guidelines for Communicating with Families
▪ Display a sincere sense of warmth, caring, and encouragement.
▪ Demonstrate neutrality; perceptions of partiality toward particular family members can interfere with assessment and assistance.
▪ Convey a sense of cooperation and partnership with the family.
▪ Promote participatory decision making.
▪ Promote the competencies of the family.
▪ Encourage the family’s use of natural support networks.
Assessment of the Family
Assessment of the family usually involves the entire family, except when the infant or child is too ill to participate.
| Assessment | Findings |
|---|---|
| Internal Structure | |
| Use a genogram (see Chapter 2) to diagram family structure. The genogram is often useful in helping the family to clarify information related to family composition. | |
| Family Composition | |
|
Refers to everyone in the household.
Ask who is in the family.
|
Extended families and multigenerational households are common among many cultures such as Vietnamese, Chinese, and South Asians.
Clinical Alert
Losses or additions to families can result in crisis.
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| Rank Order | |
| Refers to the arrangement of children according to age and gender. | |
