Family-Focused Nursing Care: ‘Think Family’ and Transform Nursing Practice
Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
Chapter 5: Family Assessment
Sonja J. Meiers, Norma Krumwiede, Sharon A. Denham, & Sue Bell
Chapter Objectives
1. Differentiate between individual, family, and community assessment.
2. Discuss assessment that includes the predictive and protective factors that influence the health
and illness of individuals, families, communities, and populations.
3. Explain ways that genograms, eco-grams, and eco-maps can be used to assess family from an
ecological point of view.
4. Describe ways that computer-based geographic information systems can be used to
understand family, community, and population health needs.
5. Evaluate ways that personal and family health records might improve health care outcomes.
6. Recognize ways that family history information, genetics, and genomics influence health,
disease prevention, treatments, screening, and outcomes.
Chapter Concepts
Assessment
Clinical Nursing Judgments
Ecomap
Family Unit Assessment
Family Pedigree
Genetics
Genogram
Geographic Information Systems
Individual Assessment
Nursing Process
Social Capital
Spiritual Assessment
Chapter Introduction
When nurses meet individuals in any type of care setting, nurses prepared to think family are apt
to be most comprehensive in their assessments. Historically, the focus of health and illness
assessments has been on the factors that influence individuals. Several nursing theorists have
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Family-Focused Nursing Care: ‘Think Family’ and Transform Nursing Practice
Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
2
discussed the role of families in health and illness care (Neuman & Fawcett, 2011), but nurses
have often viewed the family as the context of care. Although family members might be included
in discussions if they are present, traditional practices mean that these discussions are seldom
intentionally planned with family units. Documentation of the family conversations or
assessments is not often found in the person’s record. The accuracy and breadth of assessment
data might be improved by purposely including family member input and family member
perceptions of things like the health alterations, illness events, symptoms, or disease
management. A comprehensive family assessment might provide better understandings about
situations. Thinking family could increase awareness of the breadth of possible causative factors
for symptoms (Tanner, 2006). An intentional approach to family assessment includes the
individual linked with the family unit and household perspectives. These things could provide a
clearer more accurate picture of individual’s needs and describe risk factors, environmental
threats, community and social networks, availability or lack of resources, and family strengths.
Chapter five of the textbook introduces nurses to ideas of intentionally thinking family during
clinical assessments. Holistic assessments go beyond physiological systems and include a
holistic perspective of the family (e.g., dynamics, communication, interactions).
Assessments that include the family household and neighborhood or community
perspectives have potential to address problems linked with the family unit. This chapter
proposes that health outcomes can be improved when the predictive factors (those that cause risk
or benefit to health) and protective factors (those that provide a buffer to illness, injury, or
disability) are simultaneously considered. This chapter reviews critical aspects of individual,
family, and community assessments and describes ways to do a more comprehensive approach to
Family-Focused Nursing Care ©2015
Family-Focused Nursing Care: ‘Think Family’ and Transform Nursing Practice
Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
3
assessment. Risk assessments that take into account predictive factors, protective factors, and the
social determinants of health are explained.
Using a Family Framework or Theory to Guide Assessment
Family nursing scholars have developed tools that can assist nurses approach family assessment
systematically. Assessments can provide insights about family types or structure, ways members
function or accomplish family work, and interactive processes that influence health and illness.
When considering the family type or structure, the nurse may need to identify the key members,
how they are related or emotionally connected and who would most likely be caregivers. Persons
that will fulfill these functions will be important when it comes to goal setting and strategy
development. Knowing family members’ typical roles and actions can help understand the
household where individuals live, places where health is enacted and illness care given. This
valuable information can assist nurses as they inform, educate, and coach the individual and
family unit prepare for new roles to manage things like an acute care injury or a chronic illness.
Nurses that think family assess typical member processes, determine whether open or closed
communication occurs, and identify whether boundaries will support or hinder care outcomes.
As students learn more about the ways unique families function, they can better choose care
approaches, identify optimal ways to share difficult news, and gain skills in sharing information
when families face difficult illness or disability trajectories.
Nurse that think family use family models to describe complex family lives and factors
that influence health and illness experiences (Table 5.1). For example, the Calgary Family
Assessment Model (CFAM) is a comprehensive family assessment that can guide examination of
structural, developmental and functional dimensions (Wright & Leahey, 2009). The Family
Management Style Framework encourages nurses to consider implications of complex family life
Family-Focused Nursing Care ©2015
Family-Focused Nursing Care: ‘Think Family’ and Transform Nursing Practice
Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
4
and parenting goals as individual’s needs are considered during the assessment at various
developmental stages (Knafl, Breitmayer, Gallo, & Zoeller, 1996). In 1995, the Family Nursing
Research Team at Minnesota State University, Mankato began development of the Family
Nursing Construct Framework to guide the delivery of family focused nursing actions based on
an initial grounded theory study with families managing side effects of chemotherapy for
treatment of cancer (Krumwiede, et al., 2004). Three constructs were identified (i.e., Family
Information, Family Vigilance, Family Waiting) that suggest ideas about assessments and
nursing actions (Table 5.2). This framework continues to be informed by discovery and
clarification of other constructs to use during assessments. As nurses learn about various family
constructs, they can incorporate them into a plan of care and address them through intentional
individual-nurse-family partnerships. Family focused nurses collaborate with individuals and
their family units to identify goals and care strategies aligned with their values and needs.
Nursing actions or interventions are used to support the family in valued ways.
Table 5.1 Family Models: Attention to Family Structure, Functions, and Processes
Model
Structure
Functions
Processes
Family Health Model • Family microsystem • Family economic
Core processes:
• Caregiving
• Family data
status
(Denham, 2003)
• Developmental
• Cultural assessment • Cathexis
information
• Neighborhood data • Celebration
• Change
• Household niche data • Larger community
• Family health
• Family mesosystem • Communication
routines
• Family macrosystem • Connectedness
• Family rituals
• Chronosystem
• Coordination
(normative and nonnormative events)
Family-Focused Nursing Care ©2015
Family-Focused Nursing Care: ‘Think Family’ and Transform Nursing Practice
Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
• Family genogram
•Instrumental
• Expressive
Calgary Family
• Family ecomap
functioning:
functioning
Assessment Model
• Family development Routine activities of • Emotional
(Wright & Leahy,
• Family lifecycle
daily living (e.g.,
communication
2009a)
eating, sleeping,
• Verbal and
preparing meals,
caregiving activities,
health promotion,
appraisal of symptoms
and management of
illness)
Family Systems
Stressor-Strength
Inventory (FS3I)
(Hanson, & Mischke,
1996)
nonverbal
communication
• Circular
communication
• Problem solving
• Role enacting
• Influence and
power
• Beliefs
• Alliances and
coalitions
• Family demographics • Family systems
• Family systems
(name, member
stressors (general and
completing assessment specific)
form, ethnic and
• Family systems
religious backgrounds) strengths
• Family reason for
seeking assistance
stressors (general
and specific)
• Family systems
strengths
The Friedman Family •Identifying data
•Developmental stage
Assessment Model
and history of family
(Short Form)
•Environmental data
(Friedman, 1998)
Family-Focused Nursing Care ©2015
• Affective functions
• Socialization
• Communication
patterns
functions
• Power structure
• Health care functions • Role structure
• Family stress and
• Family values
coping
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Family-Focused Nursing Care: ‘Think Family’ and Transform Nursing Practice
Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
Table 5.2 The Family Nursing Construct Framework
Family Nursing
Nursing Assessment
Family Nursing Action
Construct
Family Information Ask “Which family member Complete family assessment, family
keeps track of family health genogram and ecomap.
information?”
Identify family member who retains
Note how rapidly the
health information.
individual is identified.
Explain health care team’s goal of sharing
Once you begin to interview family health information that is useful to
the family informant, note how patient and family health.
freely this information is
shared.
Consider priority of family for
information and giving essential
Assess the family’s need for information while considering HIPPA
information.
rules and regulations in the institution.
Recognize that HIPPA was written for
protection related to insurance portability,
not to withhold information from family
members.
Family-Focused Nursing Care ©2015
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Family-Focused Nursing Care: ‘Think Family’ and Transform Nursing Practice
Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
Family Vigilance
Observe the absence and/or
presence of family members.
Encourage Family Presence

Encourage family members to stay
as close to ill patient as they
choose.

Invite family members to stay
overnight in room.

Invite family members to bedside
and explain equipment and
medical treatment, technology and
nursing interventions.
What are the visiting patterns
of the family members?
Are the family members
exhibiting signs of ‘Family
Hovering’ when at the
bedside?
Utilize Nurse Presence
Family-Focused Nursing Care ©2015

Stay close to patient & family

Explain nursing actions

Interpret medical directives

Reassure family
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Family-Focused Nursing Care: ‘Think Family’ and Transform Nursing Practice
Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
Family Waiting
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Observe family members that Encourage family members to remain
are physically present or are with the patient as they choose.
present from a distance.
Identify the lead family informant.
Ask “Which family member
do you want me to contact?” Encourage family members to create a
phone tree.
Ask “Who is the main
communicator for the family?” Allow family members to remain in the
hospital or other health care setting.
Assess the family’s level of
understanding.
Be careful to give time increments that are
realistic.
Assess the family’s anxiety
level.
Keep family members updated on
patient’s status while in care departments,
Ask family members their
procedures, or surgery.
perceptions of perceived
threats.
Provide updates at regular intervals.
Explain timeframe to expect next update
of information.
Completing a Family Focused Assessment
Best quality and safest health and illness outcomes occur when nurses eliminate personal biases
and assumptions while completing comprehensive assessments. Nurses need to know about
various and relevant forms of assessment that support protection against illness, health
promotion, and reduction of risk factors. Additionally, nurses need to be able to discern social
determinants of health, be prepared for emergencies, and know responses should disaster occur.
Students can be supported in learning strong communication skills during the conduct of
assessments that enhance the individual-nurse-family collaboration. Students might initially find
it difficult to think simultaneously about individual and family needs during assessments. This
approach might seem awkward initially and students will likely need chances to practice these
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Family-Focused Nursing Care: ‘Think Family’ and Transform Nursing Practice
Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
9
skills of simultaneously considering individuals and families. They can be supported in learning
these new and complex behaviors through faculty coaching, role playing, simulation scenarios,
or supervised practice.
Students are exposed to ideas about individual assessment in many nursing courses and
textbook readings. However, assisting students to think family will entail intentional teaching
actions such as considering family unit needs and the influences of member relationships, family
member roles, and family resources relevant to the health or illness care need. Use of an
ecological perspective can help students think family as ideas like community, genetics, culture,
ethnicity, social capital, and spirituality are introduced. Students need guidance as they learn to
think and practice holistically. Tools like the genogram, ecomap, and geographic information
systems (GIS) can also help students think critically about individual and family care needs.
Most often, when nursing assessment of an individual occurs, family is viewed in the
background (Potter, Perry, Stockert, & Hall, 2012). Typical assessments conducted during an
acute episode focus on history of present illness, symptom analysis, physiological system review,
current medication analysis, review of allergies, and analysis of relevant laboratory findings
(Bickley, 2002). However, analysis of potential environmental risk factors predictive of
symptoms or injuries might also be necessary (Jensen, 2011). Nurses may investigate the typical
stimuli influencing symptoms and potential factors at the individual, family, and community
levels that can be altered by nursing actions (Roy, 2009). In other words, as individual
assessments are completed, students are challenged to think family and consider the implications
of family focused assessment during family engagement and in planning collaborative actions
during health or illness experiences. Individuals have strengths and weaknesses, whether
suffering from an illness or simply managing a usual developmental transition. Students also
Family-Focused Nursing Care ©2015
Family-Focused Nursing Care: ‘Think Family’ and Transform Nursing Practice
Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
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need to learn ways to systematically uncover family strengths, weaknesses, and protective factors
whenever assessments are completed (Bellinger, 2012). A health history also focuses on
sociocultural, emotional, and other relevant family factors that may influence the health and
illness experience.
Genetic Information
Advances over the last 30 years have altered knowledge about the human body and disease. In
2003, a 13-year project known as the Human Genome Project was completed by the United
States Department of Energy and the National Institutes of Health (U.S. Dept. of Energy, 2012).
The project, formally started in 1990 and completed in 2003, aimed to identify 20,000 - 25,000
human genes and make them accessible for biological studies. From the beginning of the project,
ethical, legal, and social concerns were raised. Thus, part of the project’s annual budget was
devoted to an office that considered questions around use of genetic information. The project
provides a wealth of information that has profoundly altered the ways human biology is viewed.
It is a new horizon with great potential to reshape many life aspects. Some potential is linked
with molecular medicine and the improvement of disease diagnosis and detection (Drell &
Adamson, 2003). Molecular medicine at this level has resulted in development of new drug
designs and gene therapy to treat disease (Drell & Adamson, 2003). Table 5.3 identifies some
important questions about societal concerns to be considered as a result of emerging genetic
information. Faculty can discuss these ideas with student nurses to enhance student sensitivity to
family focused care that considers issues of privacy, confidentiality, and moral actions that
influence individuals, family unit, and nursing practice.
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Family-Focused Nursing Care: ‘Think Family’ and Transform Nursing Practice
Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
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Table 5.3 Societal Concerns Linked with Genetics
Societal Concerns
Fairness in the use of genetic
information
Questions Raised
Who should have access to personal genetic information?
How will it be used?
Is it fair or right to share information with family
members even though they might not want to have the
information?
Privacy and confidentiality
Who owns and controls genetic information?
What are the implications for health care coverage by
insurance companies if genetic information is
known from generation to generation?
Psychological impact and
stigmatization
How does personal genetic information affect an
individual and society’s perceptions of that
individual? How does genomic information affect
members of minority communities? How will
genetic information influence family
relationships?
Reproductive issues
Do healthcare personnel properly counsel parents about
the risks and limitations of genetic technology? How
reliable and useful is fetal genetic testing? What are the
larger societal issues raised by new reproductive
technologies?
Clinical issues
How will genetic tests be evaluated and regulated for
accuracy, reliability, and utility? How do
educators prepare healthcare professionals for the
new genetics? How do nurses prepare the public to
make informed choices? How does a society
balance current scientific limitations and social
risk with long-term benefits?
Uncertainties
Should testing be performed when no treatment is
available? Should parents have the right to have their
minor children tested for adult-onset diseases? Are genetic
tests reliable and interpretable by the medical community?
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Family-Focused Nursing Care: ‘Think Family’ and Transform Nursing Practice
Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
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Table 5.3 Societal Concerns Linked with Genetics
Societal Concerns
Conceptual and philosophical
implications
Questions Raised
Do people’s genes make them behave in a
particular way? Do genes influence how families
interact? Can people always control their
behavior? What is considered acceptable
diversity? Where is the line between medical
treatment and enhancement?
Health and environmental issues
Are genetically modified foods and other products safe to
humans and the environment? How will these
technologies affect developing nations’
dependence on the West?
Commercialization of products
Who owns genes and other pieces of DNA? Will
patenting DNA sequences limit their accessibility
and development into useful products? Are
vulnerable populations excluded if DNP sequences
become privately owned?
* Adapted from Ethical, Legal, and Social Issues (2011)
<http://www.ornl.gov/sci/techresources/Human_Genome/elsi/elsi.shtml>
Genetic information can also be used to track historic migration patterns. According to
scientists in the International HAPMAP 3 Consortium, over 1,100 individuals representing 11
global populations have been sequenced and progress is being made in identifying human
genetic variants. However, much is still unknown about inherited human diseases and disease
protection (The International HAPMAP 3 Consortium, 2010). Translation of this information
into useful practice knowledge and interventions is just beginning to emerge. People have 99.9%
of their genetic material in common with other humans, but geneticists are working to uncover
the differences and meanings in the remaining 0.1% and their effect on human susceptibility for
disease (National Center for Biotechnology Information, 2011). A goal is the enhancement of
drug effectiveness and therapeutic value. For example, tamoxifen has been used as the endocrine
treatment of choice for estrogen receptor positive breast cancer for over 30 years. Tamoxifen has
Family-Focused Nursing Care ©2015
Family-Focused Nursing Care: ‘Think Family’ and Transform Nursing Practice
Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
13
been found to reduce the incidence of relapse and, in about half of those breast cancer patients
that relapse, it provides a positive clinical response. However, breast cancer can become resistant
and non-responsive to tamoxifen, but no mechanism for this development was understood. It is
possible that human genetic variants play a role. Genetic research recently found that the BRCA4
gene was a predictive factor for poor progression-free survival and clinical benefit in women
with estrogen receptor positive breast cancer (Godinho, et al., 2012). Take some time to help
students become more aware and sensitive to the hopes and issues that genetic research and
related treatment modalities can pose for families and their relationships.
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Family-Focused Nursing Care ©2015
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Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
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Family-Focused Nursing Care ©2015
Family-Focused Nursing Care: ‘Think Family’ and Transform Nursing Practice
Denham, Eggenberger, Young, & Krumwiede
Instructor Guide: Chapter #5 Meiers, Krumwiede, Denham, & Bell
Wright, L., & Leahy, M. (2009). The Calgary Family Intervention Model. In L. Wright & M.
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