chapter 3 The Evolving Family 47
moving toward evidence based practice (continued) were identifi ed, which were condensed into 11 common themes.
The themes were subdivided into three broad headings: parent- ing philosophies; infl uence of American culture and perceived opportunities for children; and parenting practices. Similarities were identifi ed among families in all categories.
Findings from the study indicated that a sense of commu- nity, family, and spirituality or religion was strong among all cultures, as was the importance of teaching values, respect, and the need for strict discipline. Television was considered to be an educational infl uence and parents believed that opportunities existed for jobs and higher education for their children. Parents expressed concern for child safety when playing alone outside
and mistrusted nonfamily babysitters. Parents also indicated a preference for medical treatment rather than home remedies during episodes of acute illness. They expressed concern regard- ing the desire for preserving individual cultural heritage versus becoming assimilated into American society.
1. Based on this research, do you believe that suffi cient evi- dence exists to generalize the study fi ndings to all culturally diverse populations?
2. How useful is this information to clinical nursing practice?
See Suggested Responses for Moving Toward Evidence-Based Practice on the Electronic Study Guide or DavisPlus.
Introduction
This chapter addresses the assessment of families and highlights interventions for families encountered in a vari- ety of nursing settings. Viewed through the lens of the media, actual and perceived changes that have taken place in the American family since the 1940s are explored.
Modern-day family structures and challenges are described and various theories from psychology, sociology, and nursing are presented to provide a reference point for fam- ily assessments and interventions. A nursing diagnosis is presented and described in detail to illustrate the possible goals, interventions, and evaluation criteria that could be used with a family that is experiencing problems with daily functioning.
Concepts such as developmental and group stages of the family, communication, roles and relationships, and special need families are presented to assist with the planning and implementation of family centered care. Cultural character- istics and comparisons of American family orientation with families from various ethnic backgrounds provide the nurse with a starting point for the delivery of culturally sensitive care for American and international families.
48 unit one Foundations in Maternal, Family, and Child Care
or the family of choice (the family adopted through mar- riage or cohabitation). A single person belongs to a family of origin, but may choose not to become a member of a family of choice. A single individual cannot constitute a family. Instead, most defi nitions of family include a prereq- uisite of at least one other person who is self-defi ned as being a part of the family (Harmon Hanson et al., 2005;
Friedman et al., 2003; Wright & Leahey, 2005).
Nursing Insight—
Differentiating among various family confi gurationsIn contemporary society, the traditional nuclear family, which consists of a male partner, female partner and their children, actually represents only a small number of families. Other fam- ily members, termed extended family, may also live in the same household. According to the Urban Institute, there are fi ve categories of families (Wherry & Finegold, 2004):
1. The married-parent family includes biological or adoptive parents. This family structure accounts for approximately 64% of American families. It describes 69% of Caucasian, 55% of Hispanic, and 26.6% of African American families (Wherry & Finegold, 2004).
2. The single-parent family consists of an unmarried biological or adoptive parent who may or may not be living with other adults (Wherry & Finegold, 2004). The homo sexual family (lesbian and gay) consists of same-sex partners who live together with or without children. This family structure may also consist of single gay or lesbian parents or multiple parenting fi gures (Friedman et al., 2003).
3. The married-blended family, formed as a result of death or divorce, consists of unrelated family members who join together to form a new household.
4. The cohabiting-parent family describes one in which children live with two unmarried biological parents or two adoptive parents.
5. The no-parent family is one in which children live independently in foster or kinship care, such as living with a grandparent or aunt.
Ethnocultural Considerations—
Patterns of family structurePatterns of family structure tend to be culturally infl uenced.
For example, Hispanic children are more than twice as likely as African American children to live in cohabiting-parent families and they are approximately four times as likely as Caucasian children to live in this type of family confi guration (Wherry & Finegold, 2004).
THE CHANGING FAMILY AS REFLECTED IN THE MEDIA
Family changes and adaptations from the Cro-Magnon era to the present day have been well researched and docu- mented, but it is useful to examine the more recent changes that have taken place over the past 20 to 40 years.
During this time, family structure and roles have changed rapidly and at present seem to be in a state of fl ux. As American families transition and evolve, television and theater often provide useful insights into the predominant family themes of the time.
For example, in the 1950s and 1960s, a nuclear family was presented with little emphasis on the extended family.
Programs such as Ozzie and Harriet, Leave It to Beaver, The Dick Van Dyke Show, and Father Knows Best portrayed the typical family as one that included the mother and father along with one to three children. Family roles typically portrayed a father-dominated household and a homemaker mother who would occasionally fl ex her decision-making authority when the father’s advice did not work. Issues were generally simple and resolvable with an occasional foray into societal issues such as racism or mental health.
When problems such as alcoholism were presented, they tended to be in the context of an outsider who temporarily touched the family and then left. Rarely was there depiction of a serious internal family mental health problem. Instead, scenarios involved events such as girlfriend–boyfriend situ- ational crises or friend-related peer pressure. Occasional variations in family structure were offered in weekly pro- grams such as Bonanza, Family Affair, and My Three Sons that portrayed households run by males who received assis- tance from a housekeeper or relative.
Programming during the 1960s and early 1970s refl ected a growing trend toward themes that included blended families with shows such as The Brady Bunch.
These weekly programs tended to present upper income families with housekeepers and stay-at-home mothers who deferred major decisions to the father. Widowhood, as opposed to divorce, usually constituted the reason for remarrying, and this situation neatly sidestepped the unpleasantness of a broken home resulting from divorce.
Family issues continued to relate primarily to diffi cul- ties associated with school and dating. Major breakthroughs were achieved with All in the Family, The Jeffersons, What’s Happening, and other sit-coms in the 1970s that dealt with the turbulent issues of civil rights and sex equality and changing views on race and gender.
During this time, there were also shows that began to present selected variations of family. For example, The Mary Tyler Moore Show centered on a career woman whose close work relationships served as a central compo- nent of family. Gilligan’s Island presented family-like asso- ciations that dealt with work or survival issues as a team and shared support and platonic love and loyalty that would have normally been received from a family. The 1990s to 2000s version of this theme was expanded in Friends and Seinfeld, programs that introduced the idea that people could remain single longer without the expec- tation that a family was defi ned by marriage and procre- ation. This trend is again refl ected in more recent pro- grams such as Grey’s Anatomy, where unrelated individuals form a family with “ties” that sometimes are actually stronger than those with their biological relatives who may not always “be there” for them.
Television programs during the 1980s and 1990s also began to address variations in social class and politics with shows such as Family Ties, which explored social issues such as premarital sex, dealing with the death of friends, and Alzheimer’s disease. Interestingly, the episodes did not always present a clean resolution of an issue but instead focused on the importance of family closeness and support in dealing with the problem within the context of battling political views. The Cosby Show depicted a black upper middle-class family in which both parents were white- collar professionals.
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chapter 3 The Evolving Family 49
The 1990s brought increased awareness of the chal- lenges facing families dealing with poverty, alcoholism, and abuse within their own ranks rather than as a problem that occurred only outside of the family. Grace Under Fire presented a single head of household who was a recover- ing alcoholic. Roseanne revolved around a matriarchal family structure in a lower economic setting where both parents had to work to make ends meet. One particular episode in this series dealt with how to write a check in a way that delayed cashing (and subsequently, “bouncing”) it, to allow extra time for suffi cient funds to be deposited into the account.
Television sitcoms in the new millennium continue to refl ect trends consistent with societal changes. Family structures such as the binuclear arrangement (two intact nuclear families sharing a home), and the divorced family living with a brother and sharing responsibility for rearing a son (Two and a Half Men) are examples of alternate fam- ily themes that have emerged in recent times. Programs such as these may be preparing the way for shows that depict same-sex unions with or without children.
Also refl ective of contemporary society is the trend of sitcoms that feature extended family members such as the live-in father in King of Queens and the very intrusive par- ents in Everybody Loves Raymond. The success of the movie My Big Fat Greek Wedding opened the door for depicting ethnic families that were keeping their own val- ues and beliefs separate from those of the prevailing cul- ture. Hispanic, Jewish, Asian, and other ethnic groups have revealed their differences in humorous but culturally sensitive ways. The media, however, generally provides only a superfi cial representation of the varied and com- plex challenges faced by the modern-day family.
Collaboration in Caring—
Five functions of the family1. Physical Needs: Meets the primary basic needs such as food, water, clothing, and shelter.
2. Economic Needs: Access to enough fi nancial resources to adequately meet the family’s needs and wishes.
3. Reproductive Needs: Ways that add new life to the family unit and maintain a healthy sexual relationship between parents.
4. Affective and Coping Needs: Strategies to deal with everyday stresses of life and encourage a nurturing environment.
5. Socialization Needs: Processes whereby families acquire the skills, knowledge, attitudes, and values necessary for performing their social roles.
STRESSORS ON FAMILIES TODAY Health Care
Today’s families face varied and complex challenges.
Baby boomers are aging and entering retirement. This shift in the contemporary workforce leaves openings and shortages in critical areas such as education and health care and at the same time adds increased demands on a health care system already burdened with an aging popu- lation. For many, insurance coverage changes and often becomes more expensive as retirees transition from employment insurance to retirement insurance options
such as Medicare and Social Security. In many instances, families have no options for insurance because of part- time work or unemployment.
At present, more than 45 million families in the United States are uninsured (U.S. Department of Health and Human Services [DHHS], 2005b) and as many as 13.5 mil- lion individuals have been homeless at some point during their lifetime (Harmon Hanson et al., 2005). All too fre- quently, families are counted among these staggering sta- tistics. Health issues among homeless families and individ- uals are numerous and usually result from a lack of preventive care and a lack of resources in general. For example, in addition to the problems associated with extreme poverty, homeless women are at an increased risk for illness and injury and many have been victims of rape, assault, and domestic abuse (American College of Obstetri- cians and Gynecologists [ACOG], 2005).
The rural homeless are more likely to be families who are living with other families or migrant workers who live in vehicles and follow crop harvesting. Access to health care and discrimination in health care practices are major problems for this population. At present, there are approx- imately 3 million migrant and seasonal farm workers in the United States, and of these, 21% are women. Although the workers represent a number of ethnic and cultural groups, 75% were born in Mexico, 81% speak Spanish, their average age is 33, and the majority have not been educated beyond the seventh grade (U.S. Department of Labor National Agricultural Workers Survey, 2005). As the nation becomes more culturally diverse, there is a growing imperative to eliminate racial and ethnic health care disparities by providing ready access to quality care for diverse populations (Weissman et al., 2005).
Nursing Insight—
Health care resources for women without U.S. citizenshipApproximately 26% of women who do not have U.S. citizen- ship lack a regular health care provider and 45.5% have no health insurance coverage. Their access to health care is fur- ther compromised by policies that restrict Medicaid eligibility for this population (Kaiser Commission, 2003a). In a study that compared the health care costs of immigrants to those of U.S. citizens, it was found that total health care expenditures for immigrant adults and children were signifi cantly lower than those of U.S.-born citizens (Mohanty et al., 2005).
Mental Illness
Other problems that arise from both internal and external causes also impact families. In any given year, an esti- mated 57 million individuals and their families deal with mental illness (U.S. Census Bureau, 2005). Affected fami- lies not only face dealing with a potentially chronic illness that continues to be stigmatized by society, but they also must grapple with paying for treatment of a diagnosis that is largely exempt from insurance coverage.
Challenges that come from external forces outside of the family system include environmental assaults such as catastrophic weather, forest fi res, and earthquakes. An entire region of families continues to be affected by prob- lems that follow in the aftermath of hurricanes, fi res, and fl oods.
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50 unit one Foundations in Maternal, Family, and Child Care
Nursing Insight—
Recognizing the relationship between family stressors and poor health outcomes Families may have multiple stressors that increase their vul- nerability to poor health outcomes. Problems such as sub- stance abuse, mental illness, domestic violence, and limited access to medical care due to unemployment, loss of medical insurance, or inadequate insurance coverage can affect fami- lies across all strata of society.Societal Pressures
The family also faces societal pressures. The incidence of violent crimes has decreased in major urban areas, but suicide among children and adolescents continues to rep- resent an important societal issue. The number of families currently affected by AIDS is increasing at a startling rate.
Women and children, a vulnerable population due to bar- riers associated with access to health care, constitute the fastest growing segment of the population to contract HIV. Public education is in a state of crisis as demands increase on teachers who are confronted with diminishing resources.
These and many other issues continue to challenge fami- lies. Meanwhile, family structure and roles are undergoing changes that frequently increase the potential for further family problems. Present trends show a diminishing num- ber of nuclear family households. The traditional family structure is being replaced by one that includes a single head of household, most frequently a divorced or abandoned mother. The number of unmarried mothers continues to increase. Statistics refl ect the current trend: the percentage of children living with two married parents decreased from 85% in 1970 to 68% in 2004. A divorced or single woman is usually the head of household in those families, although recently there has been an increase in single male head of household families from 1% to 5% (Child Trends Data Bank, 2006). In other situations, the head of household is homo- sexual or sharing a home with a same-sex partner.
These trends refl ect increasing opportunities for alterna- tive forms of parenthood within contemporary American society. The nontraditional parenting arrangements result from more liberal social mores as well as the technological and medical advances that now offer the possibility of parenthood to single men and women (Greenfi eld, 2005).
Homosexuality and same-sex partnerships/marriages and their effects on the family raise political, social, and reli- gious issues that have increasingly found their way into present-day discussions. Although the far-reaching impact of same-sex relationships on family structure and function has not been adequately studied, areas that frequently must be addressed concern child custody, legal consent, power of attorney, and confi dentiality. The following case study pro- vides an example of some of the issues and questions that may need to be addressed by the family and the patient’s care providers.
— Effective tools for families Covey (2006) discusses effective tools that may enhance family performance. The nurse can communicate these principles to families that may promote healthy family functioning.
•
Be proactive: Become an agent of change in the family.•
Begin with the end in mind: Develop a family mission statement.•
Put fi rst things fi rst: Make the family a priority in a turbulent world.•
Think “win–win”: Move from me to we.•
Seek fi rst to understand then be understood: Solve family problems through empathetic communication.•
Synergize: Build family unity through celebrating differences•
Sharpen the saw: Renew family spirit through traditionscase study