NUR350 : The Class : Family Nursing : Theories : Assessment

Family Theory as a Framework for Assessment

© Copyright Cynthia Beckett, 2000

Family Stress Theory is a developmental theory borrowed from family science which explores why some family systems adapt and even grow and thrive when faced with situational stressors or transitional events, while other family units deteriorate and disintegrate under similar circumstances (McCubbin, 1993, p. 46). The theory is defined in nursing's metaparadigm of person, environment, health, and nursing in terms used for family nursing. McCubbin and McCubbin in 1989 defined the concept of person as:

Person, or family, is viewed as encountering hardships and changes as an inevitable part of family over the life cycle. Families also develop strengths and capabilities to enhance the development of individual members and to protect the family unit from major disruption during times of transition and change, (p. 6).

In studying Navajo parents it is important to identify how they define family. Family, for this population, can be nuclear, extended, or clan. It is important to determine the primary child rearing persons within each family in order to know with whom the questions should be addressed. The participants might be biological parents, grandparents, or identified significant others who are responsible for the child rearing practices of the family.

Environment within the family system is "viewed as an open system and a component of the larger community and society, with the assumption that families benefit from and contribute to the network of relationships and resources in the community" (McCubbin & McCubbin, 1989, p. 6). Harmony is necessary for balance within the individual, family, and community (Sobralske, 1985). Achieving and maintaining harmony with oneself, family, and community are important social goals.

McCubbin and McCubbin (1989) defines health as: "family resiliency or the ability of the family to respond to and eventually adapt to the situations and crises encountered over the family life cycle" (p. 6). Resilience is seen as a characteristic families use to achieve that balance and harmony (Allen, 1998).

    The role of nursing within the Family Stress Theory is defined by McCubbin and McCubbin as to: not only promote family members' health, recovery from illness, or maximum functioning within specific health limitations, but also to support and enhance family strengths, to assist families in maintaining linkages with community supports, and to aid families in arriving at a realistic appraisal of what is the best "fit" for them in their particular situation...Through these efforts nurses can assist families in the process of adaptation (1989, p. 6).
Resiliency Model of Family Stress, Adjustment, and Adaptation
Family adaptation is described in the Resiliency Model for Family Stress, Adjustment, and Adaptation as the "outcome of the family's efforts over time to bring a fit at two levels: the individual to family, and the family to community. This process ranges on a continuum from optimal bonadaptation to maladaptation " ( McCubbin, 1993, p. 50). The model is comprised of two distinct parts: the Adjustment Phase and the Adaptation Phase. Each phase describes the family's ability to cope with illness, or stressors looking at family strengths, resources, and coping/problem-solving abilities.

There were four assumptions within the original family stress model developed by Rueben Hill in 1949 (Friedman, 1998). These were:

  1. Unexpected or unplanned events are usually perceived as stressful.
  2. Events within the families, such as serious illness, and defined as stressful, are more disruptive than stressors that occur outside the family, such as war, flood, or depression.
  3. Lack of previous experience with stressor events leads to increased perceptions of stress.
  4. Ambiguous stressor events are more stressful than non-ambiguous events (Friedman, 1998, p. 88).
McCubbin and McCubbin expanded on this original family stress model and created the Resiliency Model of Stress, Adjustment, and Adaptation in 1989 (Freidman, 1998; McCubbin & McCubbin, 1993). The expanded model included five propositions that described relationships within the model itself. These propositions describe that in family crisis:
  1. The pileup of family demands (stressors, strains, transitions) is related to family adaptation, and this is a negative relationship;
  2. Family typologies based on specific strengths of the family system (cohesion, adaptability, family hardiness, family time and routines) are related to family adaptation, and this is a positive relationship;
  3. The family resources are related to family adaptation, and this is a positive relationship;
  4. The family's positive appraisal of the situation is related to family adaptation, and this is a positive relationship; and finally
The range and depth of the family's repertoire of coping and problem-solving strategies when employed to manage a crisis situation are related to the level of family adaptation, and this is a positive relationship (McCubbin, 1993, p. 55).

Patterns of resilience can be demonstrated at the individual and/or family level. In identifying resilience outcomes, it is necessary to determine the level of the patterns. Are the patterns at the individual level, the family level, or both? While resilience of a child is assessed through responses and behaviors of the child, resilience can be examined through family process, i.e., patterns of successful coping and adapting, intra?family relationships, and family support systems. Nine aspects of resilient families dealing with a chronic illness situation have been identified. These include:

  1. balancing the illness with other family needs,
  2. maintaining clear family boundaries,
  3. developing communication competence,
  4. attributing positive meanings to the situation,
  5. maintaining family flexibility,
  6. maintaining a commitment to the family as a unit,
  7. engaging in active coping efforts,
  8. maintaining social integration, and
  9. developing collaborative relationships with professionals (Patterson, 1991).

Fine (1991) states that," personal perceptions and responses to stressful life events are crucial elements of survival, recovery, and rehabilitation, often transcending the reality of the situation or the interventions of others" (p. 493). Enhanced quality of life, self?confidence, self?transcendence, self?esteem, and an achievement of an expanded growth potential are characteristics of resilience (Haase, 1999).

     Allen, M.T. (1998). Traditional parenting and childrearing: Promoting harmony and beauty for life. Navajo parenting workshop at Northern Arizona Museum. May 15, 1998. Flagstaff, AZ.

     Fine, S. (1991). Resilience and human adaptability: Who rises above adversity? The American Journal of Occupational Therapy, 45(6), 493?503.

     Friedman, M.M. (1998). Family nursing.(4th Ed.). Stamford, Connecticut: Appleton & Lange.

     Haase, J. (1999). Quality of life in children and adolescents with cancer. Quality of life: Theory, research, and practice. (C. King Ed.). Boston: Jones & Bartlett.

     Mc Cubbin, M.A. (1993). Family stress theory and the development of nursing knowledge about family adaptation. In S.L. Feetham, S.B. Meister, J.M.Bell, & C.L. Gillis (Eds.) The Nursing Family. New Bury Park: Sage Publications, 46-58.

     McCubbin, M.A., & McCubbin, H.I. (1989). Families coping with illness: The resiliency model of family stress, adjustment and adaptation. In, C.B. Danielson, B. Hamel-Bissel, & P.Winstead-Fry, Families, health & illness: Perspectives on coping and intervention. St. Louis: Mosby.

     Patterson, J. (1991). Family resilience to the challenge of a child's disability. Pediatric Annals, 20(9), Sept, 491?499.

     Patterson, J.M. (1995). Promoting resilience in families experiencing stress. Pediatric Clinics of North America, 42(1), Feb, 47?63.

     Polk, L. (1997). Toward a middle?range theory of resilience. Advance Nursing Science, 19(3), 1-13.

     Sobralske, M.C. (1985). Perceptions of health: Navajo Indians. Topics in Clinical Nursing, 7(3), 32-39.

Resiliency Model of Family Stress, Adjustment, and Adaptation

Abbreviations and Terms
Adjustment Phase
Illness Stressors (A)
Family Vulnerability Due to Life Changes and Pileups (V)
Family Types and Established Patterns of Functioning (T)
Appraisal of Illness Stressor and Its Severity (C)
Family Resistance Resources (B)
Problem Solving and Coping (PSC)
Bonadaptation (*)
Maladjustment Crisis Situation (X)
Adaptation Phase
Pileup: Stressors, Strains, and Transitions (AA)
Family Crisis Situation (X)
Family Types and Newly Instituted Patterns of Functioning (R)
Family Appraisal, Schema and Meaning (CCC)
Situational Appraisal, Family's Capabilities (CC)
Problem Solving and Coping (PSC)
Family Resources (BB)
Social Support (BBB)
Bonadaptation (*)
Maladaptation Crisis Situation (XX)

Bonadaptation is defined as "meeting the needs of the individual family member to enable them to achieve their maximum potential and also the functioning of the family system and its transactions with the community (work place, school, health care system)" (McCubbin, 1993, p. 50).

Comparison of Family Theories

* Family Developmenttal Theory
The Eight-Stage Family Life Cycle
(Nuclear Families)

*System Theory (Calgary Family Assessment Model)

(Nuclear Families)

Family Stress and Coping Theory
Resilence Model

(Multiple Family Types)

Transition Stage: Between Families and Concomitant Family Developmental Tasks

  1. Separating from family orgin.
  2. Developing intimate peer relationships.
  3. Establishing work and financial independence

Stage 1: Leaving Home: Single Young Adults (Accepting emotional and financial responsibility)

  1. Differentiation of self in relation to family of origin.
  2. Development of intimate peer relationships.
  3. Establishment of self re: work and financial independence.

Nursing Metaparadigm of Person, Evironment, Health, and Nursing used in Family Theory Development in Nursing.

  1. Persong, "family":viewed as encountering hardships and changes as an inevitable part of family life over the life cycle.
  2. Environment: The family system is viewed as an open system and a component of the larger community and society.
  3. Health: Defined as "family resiliency" or "the ability of the family to respond to and eventually adapt to the situations and crises encountered over the family life cycle."
  4. Role of Nursing: Not only to promote family member's health, recovery form illness, maximum functioning within specific health limitations but also to support and enhance family strengths, to assist families in maintaining linkages with community supports, and to aid families in arriving at a realistic appraisal of what is the best "fit" for them in their particular situation.

Stage 1: Beginning Families (Married couples or stage of marriage)

  1. Establishing a mutually satisfying marriage
  2. Relating harmoniously to the kin network.
  3. Planning a family (decisions about parenthood).

Stage 2: The Joining of Families Through Marriage: The New Couple (Commitment to new system)

  1. Formation of marital system.
  2. Realignment of relationships with extended families and friends to include spouse.

Stage 2: Childbearing families the oldest child is and infant through 30 months).

  1. Setting up the young family as a stable unit (integrating of new baby into family).
  2. Reconciling conflicting developmental tasks and needs of various family members.
  3. Maintaining a satisfying martial relationship.
  4. Expanding relationships with extended family by adding parenting and grandparenting roles.

Stage 3: Families with Young Children (Accepting new members into system)

  1. Adjusting martial system to make space for child/children.
  2. Joining in childrearing, financial, and household tasks.
  3. Realignment of relationships with extended family to include parenting and grandparenting roles.

Stage 3: Families with preschool children (oldest child is 30 months to 6 years of age)

  1. Meeting family members' needs for adequate housing, space, privacy, and safety.
  2. Socializing the children.
  3. Integrating new child members while still meeting needs of other children.
  4. Maintaining healthy relationships within the family (martial and parent-child) and outside the family (extended family and community).
Stage 3: Listed above

* Family Developmental Theory
The Eight-Stage Family Life Cycle

*System Theory (Calgary Family Assessment Model)

Family Stress and Coping Theory
Resilence Model

Stage 4: Families with school children (oldest child is 6 to 13 years of age)

  1. Socializing the children, including promoting school achievement and fostering of healthy peer relations of children.
  2. Maintaining a satisfying marital relationship.
  3. Meeting the physical health needs of family members.

Stage 3: Listed above

Two Phases to Family Response to Life Events and Changes (Resiliency Model)
Phase 1: Adjustment

  1. Illness/stressor
  2. Family Vulnerability due to life changes and pileups
  3. Family types and established patterns of functioning.
  4. Appraisal of illness stressor and its severity.
  5. Problem solving and coping
  6. Family resistance resources
  7. If family has positive coping patterns of resilience, family strengths and resources bonadjusment will occur. (Bonadjustment: Meeting both the needs of individual family members to enable them to achieve their maximum potential and also the functioning of the family system and its transactions with the community (workplace, school, health care system).
  8. If the family is unable to cope, or adjust then the pattern is one of maladjustment, or a crisis situation.
  9. The family then enters the second phase of the stress and coping process: the adaptation phase.

Stage 5: Families with teenagers (oldest child is 13 to 20 years of age)

  1. Balancing of freedom with responsibility as teenagers mature and become increasingly autonomous.
  2. Refocusing the marital relationship.
  3. Communicating openly between parents and children.

Stage 4: Families with Adolescents (Increasing flexibility of family boundaries to include children's independence and grandparent's frailties).

  1. Shifting of parent-child relationships to permit adolescent to move in and out of system.
  2. Refocus on midlife marital and career issues.
  3. Beginning shift toward joint caring for older generation.

Stage 6: Families launching young adults (covering the first child who has left through the last child leaving home)

  1. Expanding the family circle to include new family members acquired by marriage of children.
  2. Continuing to renew and readjust in the marital relationship.
  3. Assisting aging and ill parents of the husband and wife.

Stage 5: Launching Children and Moving On ( Accepting a multitude of exits from and entries into the family system).

  1. Renegotiation of marital system as a dyad.
  2. Development of adult-to adult relationships between grown children and their parents.
  3. Realignment of relationships to include in-laws and grandchildren and their parents.
  4. Dealing with disabilities and death of parents (grandparents).

Stage 7: Middle-aged parents (empty nest through retirement)

  1. Providing a health-promoting environment.
  2. Sustaining satisfying and meaningful relationships with aging parents and children.
  3. Strengthening the marital relationship.

Stage 6: Families in later life (Accepting the shifting of generational roles).

  1. Maintaining own and/or couple functioning and interests in face of physiological decline; exploration of new familial and social role options.
  2. Support of a more central role of middle generation.

* Family Developmental Theory
The Eight-Stage Family Life Cycle

*System Theory (Calgary Family Assessment Model)

Family Stress and Coping Theory
Resilence Model

Stage 8: Family in retirement and old age (also referred to as aging family members or retirement to death of both spouses)

  1. Maintaining a satisfying living arrangement.
  2. Adjusting to a reduced income.
  3. Maintaining marital relationships.
  4. Adjusting to loss of spouse.
  5. Maintaining intergenerational family ties.
  6. Continuing to make sense out of one's existence (life review and integration)

Friedman, 1998

Stage 6 Continued:

  1. Making room in the system for the wisdom and experience of the elderly, supporting the older generation without overfunctioning for them.
  2. Dealing with loss of spouse, siblings, and other peers and preparation for own death. Life review and integration.

Wright & Leahey, 1984

Phase 2: Adaptation

  1. Family crisis situation
  2. Pile-up: Stressors, strains, and transitions.
  3. Family types and newly instituted patterns of functioning.
  4. Family schema appraisal and family meaning
  5. Situational appraisal of family's capabilities
  6. Problem solving and coping
  7. Social support
  8. Family resources
  9. Bonadaptation (postitive coping and adaptation)
  10. Maladaptation or continued crisis situation and need for referral and assistance.

McCubbin, 1993

*These developmental stages are developed for two-parent, or nuclear style, families. Adjustments for divorced, re-married, extended, and alternate life style families are not included.

The above chart was developed to assist students in comparing three family theories to be used in the process of: assessing families, identifying strengths and needs of families (individuals as well as entire families), and developing plans for referrals, interventions, and evaluation of care. The chart was adapted from the works of: Friedman, 1998; McCubbin, 1993; and Wright & Leahey, 1984 by C. Beckett 09/02/99.

     Friedman, M.M. (1998). Family Nursing. (4th ed.) Stamford, Connecticut: Appleton & Lange.

     McCubbin, M.A. (1993). Family Stress Theory and the Development of Nursing Knowledge About Family Adaptation. In, Feetham, S.L.; Meister, S.B; Bell, J.M.; & Gillis, C.L (Ed.) The Nursing of Families. New Bury Park: Sage. 46-58.

     Wright, L.M. & Leahey, M. (1984). Nurses and Families: a Guide to Family Assessment and Intervention. Philadelphia: F.A. Davis Co.

© Copyright Cynthia Beckett, 2000

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