chapter 2

Family Structure, Family Nursing, and Family Assessment

• Family: 

  • A primary social group and support network 

    • members influence each other

  • primary unit of socialization

  • central unit of care for maternal and newborn nurses

Family organization and structure

• Nuclear family: 

  • Husband

  • wife

  • biologic or adopted children 

• Extended family: 

  • nuclear family plus relatives 

• Multigenerational family: 

  • (+)3 generations of relatives

• Nonbiologic-parent family: 

  • Children live in foster care

  • kinship care

    • living with relative

• Married-blended family: 

  • family formed through divorce and remarriage

    • Step family

• Cohabiting-parent family:

  • Parents are unmarried

• Single-parent family: 

  • unmarried biologic or adoptive parent

• LGBTQIA family: 

  • single LGBTQIA parent(s)

Nursing implication: 

• Do not assume

• Identify whom pt considers family

Family theories

• Purpose: 

  • describes families

  • explains how family unit responds to events w/n and outside family

• Application: 

  • Theories help guide family assessment and nursing interventions

  • Each theory has:

    • assumptions

    • strengths

    • limitations

  • nurses often combine more than one approach

Family assessment and the Calgary Family Assessment Model

• Assessment emphasis: 

  • Use health-promotion approach for low-risk families

  • address both illness-related needs and health promotion in high-risk perinatal families

• Calgary Family Assessment Model (CFAM): 

  • framework with 3 major assessment categories:

    • structural

    • developmental

    • functional

• Structural assessment: 

  • Identify:

    • family members

    • relationships

    • household composition

    • extended family

    • larger systems

    • ethnicity

    • race

    • social class

    • religion or spirituality

    • environment

• Developmental assessment: 

  • Assess:

    • family life-cycle stages

    • developmental tasks

    • transitions

    • attachments

• Functional assessment:

  • Evaluate how family members interact and function

    • Instrumental functioning concerns:

      • activities of daily living

    • expressive functioning includes:

      • communication

      • problem solving

      • roles

      • influence

      • power

      • beliefs

      • alliances

• Individualize the interview: 

  • Focus on interactions w/n family

  • do not ask every possible question during initial encounter

  • recognize that assessments reflect one perspective at single point in time

• Genogram: 

  • family-tree representation showing relationships across at least 3 generations

  • helps understand family composition and relationships

• Ecomap: 

  • visual representation of family’s social relationships and available support systems

  • helps identify family’s social environment and community connections

Acculturation and assimilation

• Acculturation: 

  • Changes that occur when people from different cultures come into contact; a person may adopt practices of the dominant society while retaining aspects of the original culture

• Clinical relevance: 

  • During pregnancy, birth, illness, or other stressful transitions, an acculturated person may return to familiar cultural practices or traditions.

• Assimilation: 

  • The process in which a cultural group loses its distinct cultural identity and becomes part of the dominant culture.

• Key distinction: 

  • Acculturation allows retention of some original cultural identity; assimilation involves loss of that distinct cultural identity.

Ethnocentrism and cultural relativism

• Ethnocentrism: 

  • The belief that one’s own way of doing things is best. In nursing, it can occur when Western biomedical expectations are treated as the only acceptable standard for pregnancy and birth.

• Clinical consequence: 

  • Judging unfamiliar beliefs or practices against only the nurse’s own cultural standards can lead to frustration, misunderstanding, stereotyping, and care that does not fit the patient.

• Cultural relativism: 

  • Learning about and applying another culture’s standards when interpreting behavior within that culture; recognizes that different cultural backgrounds shape different viewpoints.

• Key distinction: 

  • Ethnocentrism judges other practices by one’s own standards; cultural relativism interprets them within their own cultural context without requiring the nurse to adopt those beliefs.

• Culturally congruent nursing: 

  • Examine personal assumptions, respect diversity, assess the individual family’s beliefs, and adapt care to the family’s needs without stereotyping.

Communication: interpreters and translators

• Why communication matters: 

  • Differences between the patient’s language and the provider’s language can interfere with assessment, understanding, safe care, and culturally appropriate services.

• Interpreter: 

  • Converts spoken or oral communication from one language into another.

• Translator: 

  • Converts written words or educational materials from one language into another.

• Preferred qualifications: 

  • An interpreter should understand the patient’s language or dialect, possess health-related language skills and experience, help bridge cultural barriers, and be mature enough to protect private information.

• Before the interview: 

  • Identify the information needed, prepare key questions, learn relevant cultural information, and discuss technical terminology and interview priorities with the interpreter.

• During the interview: 

  • Address questions directly to the woman rather than the interpreter; create a quiet, respectful, private setting; maintain confidentiality; speak clearly; encourage questions; and verify that important information is conveyed.

• If relatives or children interpret: 

  • The chapter allows that emergencies or limited availability may make a relative, neighbor, or child necessary; confirm that the patient agrees and is comfortable, and consider embarrassment, privacy, and inaccurate history.

• Written education: 

  • Provide understandable, culturally and linguistically appropriate materials translated by someone with appropriate training.

Personal space

• Meaning: 

  • Cultural traditions influence the distance and physical contact considered appropriate during social and health care interactions.

• Potential sources of distress:

  •  Touching, placing the patient close to others, removing personal possessions, or making decisions for the patient may reduce security and heighten anxiety.

• Nursing response: 

  • Respect the patient’s preferred distance and autonomy, recognize that necessary nursing touch may still create distress, and adapt care to preserve a sense of security.

Time orientation

• Past-oriented: 

  • Emphasizes tradition and maintaining familiar practices.

• Present-oriented: 

  • Focuses on immediate concerns and day-to-day survival; strict scheduling and future-focused planning may receive less attention.

• Future-oriented: 

  • Emphasizes long-term goals, advance planning, and the future consequences of current actions.

• Clinical significance: 

  • A present-oriented family may have difficulty prioritizing future follow-up appointments, while a future-oriented family may plan ahead; either family can be equally concerned about the newborn’s well-being.

Family roles

• Meaning: 

  • Expectations and behaviors associated with a person’s position in the family, such as mother, father, partner, or grandparent.

• Cultural variation: 

  • Social class and cultural norms influence decision-making roles, gender expectations, and whether a partner participates in pregnancy, labor, or birth.

• Nursing response: 

  • Assess the family’s expectations instead of assuming that Western patterns of paternal involvement or individual decision making apply to every family.

Vulnerable Populations

• Vulnerability: 

  • Certain groups experience a greater burden of preventable disease, disability, death, and barriers to care because of adverse social determinants and unequal access to resources.

• Contributing factors: 

  • Poverty, discrimination, structural racism, limited insurance, provider bias, poor communication, low health literacy, transportation barriers, and restricted access to preventive or prenatal care.

Women

• Why vulnerable: 

  • Women often coordinate family health decisions while facing barriers to meeting their own health needs and those of family members.

• Major sources of disparity: 

  • Gender, socioeconomic status, race or ethnicity, and lack of access to acceptable-quality health care, including basic prenatal services.

• Nursing priorities: 

  • Improve access, identify barriers, provide health education, and support the woman’s ability to obtain appropriate care.

Racial and ethnic people of color

• Health inequities: 

  • Women of racial and ethnic minority groups experience a disproportionate burden of disease, disability, premature death, and delayed or inadequate prenatal care.

• Root causes: 

  • The chapter identifies systemic racism and social, economic, and cultural barriers rather than inherent biologic differences between racial groups.

• Maternal and infant risks: 

  • Chronic disease and underlying health conditions may contribute to preterm labor or birth, gestational hypertension, intrauterine growth restriction, and infants who are small for gestational age.

• Nursing priorities: 

  • Recognize provider bias and communication barriers, promote early prenatal care, provide culturally responsive care, and address social determinants affecting access.

Adolescents

• Risks: 

  • Unprotected sexual activity, misinformation about sexually transmitted infections and HIV, unintended pregnancy, and substance use can compromise health and perinatal outcomes.

• Nursing priorities: 

  • Provide accurate sexual-health education, prevention programs, community outreach, and guidance that helps adolescents make informed decisions.

Older women

• Health vulnerabilities: 

  • Compared with men, older women are more likely to have chronic illnesses, less likely to use preventive services, and likely to spend more on health care.

• Nursing priorities: 

  • Engage older women in primary, secondary, and tertiary prevention and support access to preventive care.

Incarcerated women

• Common background concerns: 

  • Histories may include intimate partner violence, physical or sexual abuse, HIV, substance use, separation from family, and emotional distress.

• Health and pregnancy risks: 

  • Risky sexual relationships, illicit drug use, and smoking increase the likelihood of sexually transmitted infections, HIV/AIDS, other communicable or chronic disease, and high-risk pregnancy or birth.

• Family impact: 

  • Unstable relationships, limited family support, and repeated incarceration can interfere with secure housing, emotional stability, and healthy role modeling for children.

Immigrant, refugee, and migrant women

• Immigrant: 

  • A person who moves from one country to another in an effort to establish legal residency.

• Refugee: 

  • A person forced to leave the home country, often in search of a safer, more stable living environment.

• Migrant worker: 

  • A person who works outside the home country or moves within a country seeking seasonal employment.

• Barriers to care: 

  • Fear of deportation, restricted eligibility for public coverage, poverty, limited transportation, language and cultural barriers, unstable housing, and limited access to health and social services.

• Migrant health concerns: 

  • Financial instability, child labor, poor housing, limited education, poor dental health, diabetes, hypertension, malnutrition, tuberculosis, skin disease, and parasitic infection.

• Reproductive and pregnancy risks: 

  • Less consistent contraception, higher rates of sexually transmitted infections, delayed prenatal care, inadequate pregnancy weight gain, and exposure to partner abuse.

• Nursing priorities: 

  • Provide culturally and linguistically appropriate care, connect families with prenatal and community services, involve immigrant communities, and use outreach workers or camp volunteers when available

Rural versus urban settings

• Rural access barriers: 

  • Rural communities may have fewer physicians, greater poverty, limited insurance, transportation difficulties, higher out-of-pocket costs, and poorer access to prenatal and other health services.

• Maternal–infant effects: 

  • Reduced prenatal access contributes to higher rates of preterm birth, low birth weight, and infant mortality in rural communities.

• Clinical distinction: 

  • The chapter primarily contrasts poorer rural access and health outcomes with urban settings; it does not provide a detailed independent profile of urban-specific maternity risks.

Homeless women

• Why vulnerable: 

  • Lack of stable housing, resources, preventive care, and safety; some women experience homelessness after escaping domestic violence.

• Common health concerns: 

  • Chronic illness, infectious disease, asthma, circulatory problems, diabetes, substance use, and mental illness.

• Pregnancy risks: 

  • Inadequate nutrition, inadequate weight gain, anemia, bleeding problems, preterm birth, and adverse perinatal outcomes.

• Barriers to prenatal care: 

  • Transportation problems, distance, waiting times, and underuse of available prenatal services.

• Nursing priorities: 

  • Treat the woman and family with dignity, coordinate services through case management, offer screening and preventive care whenever contact occurs, strengthen social supports, and advocate for accessible services.

Perinatal Home Care and Continuity of Care

• Perinatal continuum: 

  • Care begins with family planning or preconception and continues through prenatal, intrapartum, postpartum, newborn, and interconception care.

• Continuity of care: 

  • Coordinate services across life stages and settings so the woman and family receive connected care at home, in the community, in outpatient clinics, and in the hospital.

• Home care: 

  • Technical, psychological, and other therapeutic support provided in the woman’s home rather than an institution; professional care is usually intermittent rather than continuously present.

• Why home care is increasing: 

  • Shorter hospital stays, interest in family-centered birth alternatives, home-based assessment and treatment technology, and third-party reimbursement.

• Interprofessional team: 

  • May include nurses, obstetricians, maternal–fetal medicine specialists, pharmacists, mental-health professionals, social workers, and case managers.

• Advantages: 

  • Allows care in a familiar setting; helps the nurse observe family interactions, actual resources, safety risks, and living conditions; and permits teaching tailored to the home and family.

• Challenges: 

  • A 60- to 90-minute visit can require 2.5 to 3 hours of nursing time with travel and documentation; additional concerns include limited maternity-trained staff, reimbursement, and nurse safety.

• Common indications: 

  • High-risk pregnancy, hyperemesis requiring parenteral nutrition, preterm labor, hypertension, cardiac disease, diabetes, substance use, postpartum follow-up, and newborns requiring ongoing high-technology care.

Telehealth and telephone-based support

• Telehealth: 

  • Interactive, responsive care delivered through telephone or computer communication to bridge acute-care, outpatient, and home-care settings.

• Examples: 

  • Video communication, telephone assessments, nurse advice lines, community warm lines, remote specialist consultation, and telemedicine assessment of newborns in rural hospitals.

• Warm lines: 

  • Community telephone services offering new parents support, encouragement, and basic parenting education.

• Nurse advice lines: 

  • Telephone consultation services that help answer medical questions, guide callers through urgent situations, suggest treatment options, and provide health education.

• Follow-up applications: 

  • Reassess breastfeeding-related infant hydration knowledge after a postpartum home visit or evaluate caregiver understanding of home phototherapy equipment.

• Clinical value: 

  • Maintains contact between visits, improves access for geographically remote families, and supports timely assessment, education, and continuity.

Referral and determining whether home care is appropriate

• Maternal and fetal or newborn status: 

  • Determine whether the condition is serious enough to need home care but stable enough for intermittent observation.

• Availability of services: 

  • Identify whether qualified professionals, public-health programs, nonprofit organizations, or private agencies can provide the needed care locally.

• Family resources: 

  • Assess caregivers, supportive relationships, psychosocial and economic resources, ability to provide care between visits, insurance coverage, and community assistance.

• Cost-effectiveness: 

  • Consider whether services are more appropriate at home or in an outpatient setting.

• Referral information: 

  • Include physical and psychological status, knowledge of self-management, willingness to learn, available caregivers, social support, comfort with home care, and newborn information when applicable.

• High-technology referrals: 

  • Also collect the diagnosis, prognosis, prescribed therapies, medication history, dosing information, supplies, infusion or access-device information, and available support systems.

Referral and determining whether home care is appropriate - Preparation before the home visit

• Review the record: 

  • Review referral forms, discharge summaries, maternal and fetal or newborn assessments, previous nursing contacts, learning needs, demographics, clinical data, and the existing care plan.

• Coordinate with the team: 

  • Consult the referring nurse, obstetrician, nurse-midwife, pediatrician, pharmacist, or other involved professionals to clarify goals and missing information.

• Contact the family: 

  • Identify yourself, your credentials, and agency role; explain the visit’s purpose; arrange a mutually convenient time; and confirm the address and route.

• Prepare resources and equipment: 

  • Identify relevant community resources and teaching materials; pack supplies needed for assessment, prescribed care, and patient teaching.

• Review practice requirements: 

  • Review agency policies, relevant diagnosis information, and community resources before entering the home.

Referral and determining whether home care is appropriate - The first home visit

• Recognize uncertainty: 

  • The first encounter may cause anxiety for both nurse and family because the environment belongs to the family and expectations may be unfamiliar.

• Establish rapport: 

  • Reintroduce yourself, explain the purpose of the visit, invite the family to clarify expectations, and spend a brief time developing trust.

• Include the family: 

  • Build a positive nurse–patient relationship that includes family members while respecting the family’s home, culture, priorities, and decision-making patterns.

• Model healthy behavior: 

  • Demonstrate appropriate health-related practices while providing the prescribed services within the allotted time.

Referral and determining whether home care is appropriate - Assessment during the home visit

• Core assessment areas: 

  • Demographics; medical, general health, and medication histories; physical assessment; psychosocial assessment; and the home and community environment.

• Maternal and fetal or newborn status: 

  • Assess physiologic adjustment and identify existing or developing complications.

• Family adaptation: 

  • Observe emotional adjustment, family–newborn bonding, sibling rivalry, relationships among family members, and the effects of pregnancy or birth on daily life.

• Support system: 

  • Determine who helps with household tasks, child care, newborn care, maternal rest, health information, emotional support, and emergencies.

• Home resources: 

  • Assess privacy, sleeping and play space, cleanliness, general condition, stairs, cooking facilities, food storage, bathing and laundry facilities, and newborn-care arrangements.

• Environmental safety: 

  • Assess hazardous storage of medications or cleaning products, peeling paint, fall hazards, vermin, unsafe cribs or playpens, and the availability of a fire emergency plan, alarm, or extinguisher.

• Electrical safety: 

  • When home phototherapy, infusion pumps, or other electrical equipment is used, inspect outlets, cords, and extension cords; faulty wiring may require professional repair before use.

Referral and determining whether home care is appropriate - Psychosocial assessment

• Language: 

  • Identify the primary language used in the home and barriers to receiving support.

• Community resources and access: 

  • Assess transportation, health care agencies used, and cultural or psychosocial barriers to care.

• Social support: 

  • Identify household members, help with chores or child care, and whom the woman relies on during problems or crises.

• Interpersonal relationships: 

  • Assess family decision-making patterns, attitudes about home care, and caregiving roles.

• Caregiver capacity: 

  • Identify the primary and secondary caregivers, treatment knowledge, possible caregiver strain, and satisfaction with the caregiver role.

• Stress and coping: 

  • Assess lifestyle changes, their effects on the woman and family, and adjustments made to the health condition or home treatments.

Referral and determining whether home care is appropriate - Nursing management

• Collaborative care plan: 

  • Develop the plan with the woman based on her needs; include demographics, provider orders, home-care goals, and functional level.

• Care-plan maintenance: 

  • The chapter states that agency plans are initiated at referral and updated every 60 days or as specified by state regulations; visit frequency depends on the individual plan and reimbursement criteria.

• Medication management: 

  • Obtain a careful medication history; verify that the woman and caregivers administer medications correctly, understand their intended actions and potential side effects, and know when regimens change.

• Skilled procedures: 

  • Perform needed interventions such as venipuncture and administration of intravenous medications or fluids when ordered and appropriate.

• Emergency preparation: 

  • Ensure that the family recognizes problems requiring help, knows whom to call, and can access resources at all hours; encourage training in cardiopulmonary resuscitation, particularly infant CPR.

• Patient and family teaching: 

  • Supplement spoken teaching with clear written instructions; address nutrition, pregnancy discomforts, birth preparation, activity restrictions or bed rest, infant care, and special needs of preterm infants as appropriate.

• Community support: 

  • Connect the family with support groups, warm lines, social workers, community agencies, and other available resources.

• Infection prevention: 

  • Use appropriate hand hygiene, sharps containers, gloves, personal protective equipment, and safe handling of supplies to protect the nurse and family.

• Nurse safety: 

  • Park to allow a quick departure and do not enter a home where guns are visible.

Referral and determining whether home care is appropriate - Ending the visit and documentation

• Conclude the encounter: 

  • Summarize the visit and teaching, clarify the next appointment and future expectations, provide key instructions in writing, and explain how to reach the nurse or agency.

• Document thoroughly: 

  • Record assessments, problems identified, care provided, treatments and interventions, teaching, and the woman’s response.

• Why documentation matters: 

  • The written record supports continuity, serves as a legal record of the visit, and helps establish the need for skilled nursing services and third-party reimbursement.

• Communicate significant changes: 

  • Promptly inform the health care provider of important changes; when new orders are given by telephone, the chapter states that a written copy must be sent for the physician’s signature.

• Plan the next contact: 

  • Initiate or update the care plan and communicate with the primary provider, other health professionals, or referral agencies as needed.