Family Nursing Process:

Family Nursing Assessment

Models

 Families are complex social systems. Therefore, the use

of logical, systematic approaches to family clients is
essential for several reasons:
(1)to assure that the needs of the family are met,
(2)to uncover any gaps in the family plan of action,
(3)to offer multiple supports and resources to the family.
()Nurses use a variety of assessment models to collect
information about families.

Family Nursing Process

Each step of working with families, whether applied to individuals

within the family or the family as a whole, requires a thoughtful,
deliberate reasoning process.
Nurses decide what data to collect and how, when, and where
that data are collected.
Nurses determine the relevance of each new piece of information
and how it fits into the emerging family story.
Before moving forward, nurses decide whether they have
obtained sufficient information on problem and strength
identification, or whether gaps exist that require additional data
gathering.
Each family situation evolves as it is analyzed, and each item of
new information must be evaluated for accuracy, clarity, and
relevance.

The steps of the Family Nursing Process include:

Assessment of the family story: The nurse gathers data from a
variety of sources to see the whole picture of the family
experience.
Analysis of family story: The nurse clusters the data into
meaningful patterns to see how the family is managing the
health event. The family needs are prioritized using a Family
Reasoning Web.
Design of a family plan of care: Together, the nurse and family
determine the best plan of care for the family to manage the
situation.
Family intervention: Together, the nurse and family implement
the plan of care incorporating the most family-focused, costeffective, and efficient interventions that assist the family to
achieve the best possible outcomes.

 Family evaluation: Together, the nurse and family

determine whether the outcomes are being reached,
partially reached, or need to be redesigned. Is the care
plan working well, does a new care plan need to be put
into place, or does the nurse/family relationship need
to end?
Nurse reflection: Nurses engage in critical, creative, and
concurrent reflection about the family and their work
with the family.

Assessment of the Family Story

Every family has a story about how the potential or actual health event
influences its individual members, family functioning, and management of the
health event.
Nurses filter data gathered in the story through different views or approaches,
which affects how they think about the family as a whole and each individual
family member.
Nurses might use different strategies if the patient is in the acute hospital
setting, is in an assisted living center, or is living at home.
Data collection, which is part of assessment, involves both subjective and
objective family data that are obtained through direct observation,
examination, or in consultation with other health care providers (HCPs).
The specific assessment strategies nurses use depend on the reason they are
working with the family.
In all cases, family assessment begins from the first moment that the family is
referred to the nurse

Making Appointments

As soon as the family is identified, nurses begin to collect data

about the family story.
Sources of data that can be collected before contacting a family
for a home or clinic appointment, such information:
The reason for the referral or requested visit
The family knowledge of the visit or referral
Specific medical information about the family member with the
health problem
Strategies that have been used previously
Insurance sources for the family
Family problems identified by other health providers
The need for an interpreter

 Before contacting the family to arrange for the initial

appointment, the nurse decides whether the most
appropriate place to conduct the appointment is in the
familys home or the clinic/office.
The type of agency where the nurse works may dictate
this decision. For instance, home health agencies
provide nursing in the home, or mental health agencies
require family meetings to occur in the neighborhood
clinic office.

Setting up Family Appointments

Introduce yourself.
State the purpose of the requested meeting, including who
referred the family to the agency.
Do not apologize for the meeting.
Be factual about the need for the meeting but do not provide
details.
Offer several possible times for the meeting, including late
afternoon or evening.
Let the family select the most convenient time that allows the
majority of family members to attend.
Offer services of an interpreter, if required.
Confirm date, time, place, and directions.

Using Interpreters With Families

It is critical for the nurse to determine whether an

interpreter is needed during the family meeting.
Language barriers have been found to complicate
many aspects of patient care, including comprehension,
adherence to plans of care, adverse health outcomes,
compromised quality of care, avoidable expenses,
dissatisfied families, and increased potential for medical
mistakes.
The types of interpreters that nurses solicit to help work
with families have the potential to influence the quality
of the information exchanged.

Family Meeting
During the initial interaction with families, it is critical for
nurses to introduce themselves to the family, meet all the
family members present, learn about the family members
not present, clearly state the purpose for working with
the family, outline what will happen during this session,
and indicate the length of time the meeting will last.
By introducing themselves, nurses set the tone for a
therapeutic nurse family client relationship, and send the
message that all family members are important and
affected by the health event(s) (Wright & Leahey, 2009).
The nurse needs to develop a systematic plan for the first
and all reoccurring family meetings.

 Nurses who use a therapeutic approach to family meetings have

found that their focus on family centered care increased, and that
their communication skills with families became more fluid with
experience.
When nurses use therapeutic communication skills with families, the
families report feeling a stronger rapport with the nurse, an
increased frequency of communication between families and the
nurse occurs, and families perceive these nurses to be more
competent.
Conducting family interviews not only requires skilled
communication strategies but also requires knowledge of family
assessment and intervention models.
Nurses use a variety of data collection and assessment instruments
to help gather information in a systematic and efficient manner.
Therefore, it is important that the instruments be carefully selected
so they are family friendly and render information pertinent to the
purpose of working with the family.

Selecting Family Assessment Instruments

Because there are approximately 1,000 family focused
instruments that have been developed and used in assessing
family-related variables (Touliatos, Perlmutter, & Straus, 2001),
the selection of the appropriate instrument can be complex.
Sometimes, a simple questionnaire or instrument can be
completed in just a few minutes. One such example is the
Patient/Parent Information and Involvement Assessment Tool
(PINT),which is an instrument that Sobo (2004) designed to
assess the familys perspective on shared decision making.
Other times, more comprehensive family assessment
instruments are necessary, such as the Family Systems
Stressor-Strength Inventory (FS 3 I) (Berkey-Mischke & Hanson,
1991; Hanson, 2001; Kaakinen & Hanso

 The FS 3 I is an instrument designed by nurses to provide

quantitative and qualitative data pertinent to family
stressors, family strengths, and intervention strategies.
To select the most appropriate short assessment instrument,
be sure the instrument has the following characteristics:
Written in uncomplicated language at a fifth grade level
Only 10 to 15 minutes in length
Relatively easy to score
Offers valid data on which to base decisions
Sensitive to sex, race, social class, and ethnic background

 No matter which assessment/measurement instrument

is used, families should always be informed of how the
information gathered through the instruments will be
used by the HCPs.
Two family data-gathering instruments that must always
be used in working with families are the family
genogram and the family ecomap.
Both are short, easy instruments and processes that
supply essential family data and engage the family in
therapeutic conversation.

Family Genogram and Family ECOMAP

Genograms and ecomaps actively engage families in their own care and provide care
providers with visual diagrams of the current family story and situation.
The information gathered from both the genogram and ecomap help guide the family
plan of action and the selection of intervention strategies.
One of the major benefits of working with families with these two instruments is that
they can feel and visualize the amount of energy they are expending to manage the
situation, which in itself is therapeutic for the family.

FAMILY GENOGRAM
The family genogram is a format for drawing a family tree that records information
about family members and their relationships over at least three generations.
This diagram offers a rich source of information for planning intervention strategies
because it displays the family visually and graphically in a way that provides a quick
overview of family complexities.
Family genograms help both nurses and families to see and think systematically
about families and the impact of the health event on family structure, function, and
processes.

 The three-generational family genogram had its origin in Family

Systems Theory According to family systems, people are organized
into family systems by generation, age, sex, or other similar features.
How a person fits into his or her family structure influences his or her
functioning, relational patterns, and what type of family he or she will
carry forward into the next generation.
Bowen incorporates Tomans (1976) ideas about the importance of sex
and birth order in shaping sibling relationships and characteristics.
Furthermore, families repeat themselves over generations in a
phenomenon called the transmission of family patterns.
What happens in one generation repeats itself in the next generation;
thus, many of the same strengths and problems get played out from
generation to generation.
These include both psychosocial and physical and mental health
issues.

 Nurses establish therapeutic relationships with families

through the process of asking questions while collecting
family data.
Families become more engaged in their current situation
during this interaction and as their family story unfolds.
Both the nurse and the family can see the big picture
historically on the vertical axis of the genogram and
horizontally across the family.
The process can help families see connectedness, and
help identify potential and missing support people.

 The diagramming of family genograms must adhere to specific rules and

symbols to assure all parties involved have the same understanding and
interpretations.
It is important not to confuse family genograms with a family genetic
pedigree.
A family pedigree is specific to genetic assessments, whereas a
genogram has broader uses for family HCPs.
The health history of all family members (e.g., morbidity, mortality, and
onset of illness) is important information for family nurses and can be
the focus of analysis of the family genogram. An example of a family
genogram developed from one interview.
Most families are cooperative and interested in completing their
genogram, which becomes a part of their ongoing health care record.
The genogram does not have to be completed at one sitting. As the
same or a different nurse continues to work with a family, data can be
added to the genogram over time in a continuing process. Families
should be given a copy of their own genogram.

Family Genogram Interview Data Collection

1. Identify who is in the immediate family.

2. Identify the person who has the health problem.
3. Identify all the people who live with the immediate family.
4. Determine how all the people are related.
5. Gather the following information on each family member.
Age
Sex
Correct spelling of name
Health problems
Occupation
Dates of relationships: marriage, separation, divorce, living together, living
together/committed
Dates and age of death

6. Seek the same information for the family members on the same generational level and
for those in the preceding generational level.
7. Add any additional information relative to the situation, such as geographic location and
interaction patterns.

FAMILY ECOMAP

A family ecomap provides information about systems outside

of the immediate nuclear family that are sources of social
support or that are stressors to the family.
The ecomap is a visual representation of the family unit in
relation to the larger community in which it is embedded.
The ecomap is thus an overview of the family in its current
situation, picturing the important connections among the
nuclear family, the extended family, and the community
around it.
A simplified version of the family is placed in the center of
the larger circle to complete the ecomap.
This circle marks the boundary between the family and its
extended external environment.

 The smaller outer circles represent significant people,

agencies, or institutions with whom the family interacts.
Lines are drawn between the circles and the family members
to depict the nature and quality of the relationships, and to
show what kinds of energy and resources are moving in and
out of the immediate family.
Straight lines show strong or close relationships; the more
pronounced the line or greater the number of lines, the
stronger the relationship is.
Straight lines with slashes denote stressful relationships, and
broken lines show tenuous or distant relationships.
Arrows reveal the direction of the flow of energy and
resources between individuals, and between the family and
the environment.

Analysis of the Family History

One of the challenges of data collection is organizing the

individual pieces of information so that the big picture or
whole family story can be understood.
To understand the family picture, the nurse must consolidate
the data that were collected into meaningful patterns or
categories so that the relationships between and among the
patterns of how the family is managing the situation can be
visualized.
Diagramming the family and the relationships between the
data groups assists in the identification of the most pressing
issues or problems for the family.
If the family and nurse focus on solving these major family
problems, the outcome will have a ripple effect by positively
influencing the other areas of family functioning.

 The Family Reasoning Web is an organizational tool to help cluster individual

pieces of data into meaningful family categories.
The components of the Family Reasoning Web are:
1.Family routines of daily living (i.e., sleeping, meals, child care, exercise)
2.Family communication
3.Family supports and resources
4.Family roles
5.Family beliefs
6.Family developmental stage
7.Family health knowledge
8.Family environment
9.Family stress management
10.Family culture
11.Family spirituality

 Once the data have been placed into the categories of the Family
Reasoning Web template, the nurse assigns a family nursing diagnosis to
each category. A nursing diagnosis is defined as a clinical judgment
about individuals, families, or community responses to actual or potential
health problems/life processes.
Nursing diagnoses link information to care planning. Nursing diagnoses
provide the basis for selecting nursing interventions to help achieve
outcomes for which nurses are accountable(Doegnes, Moorhouse, &
Murr, 2008, p. 10).
NANDA Nursing Diagnoses Relevant to Family Nursing: Risk for impaired
parent/infant/child attachment; Caregiver role strain; Risk for caregiver
role strain; Parental role conflict; Compromised family coping; Disabled
family coping; Readiness for enhanced family coping; Dysfunctional
family processes: alcoholism; Readiness for enhanced family processes;
Interrupted family processes; Readiness for enhanced parenting;
Impaired parenting; Risk for impaired parenting; Relocation stress
syndrome; Ineffective role performance; Ineffective family therapeutic
regimen management.

Designing a Family Plan of Care

The family plan of care is designed by the nurse and the family
to focus on the concerns that were identified in the family
reasoning web as the most pressing or causing the family the
most stress.
One of the most crucial aspects of family nursing is encouraging
and seeking family involvement in planning care and in the
decision-making processes.
Universal needs of families include consistency, clarity,
comprehensive information, and involvement in shared decision
making with HCPs.
Shared decision making requires that HCPs tailor their
communication, accommodate their talk to the level of the
family, and present information in a way that allows the family
to make informed choices.

Shared decision making includes the following steps as outlined by Makoul

and Clayman (pp. 305306):
The family and HCP must define and agree on the health problem that is
confronting the family member.
The HCP presents and discusses options of care in a way that invites family
questions.
The family and HCP discuss pros and cons of options, including cost benefits,
convenience, and financial costs.
The family and HCP discuss values and preferences including ideas, concerns,
and outcome expectations.
The family and HCP discuss ability and confidence to follow through with steps
or regimen for each option.
Both the HCP and family should check and clarify for understanding the
discussion and information shared.
Both the HCP and family should reach a decision or defer decisions until an
agreed-on, specified time.
The HCP should follow up to track the outcome of the decision.

Family Intervention

Nurses help families in the following ways: (1) providing direct

care, (2) removing barriers to needed services, and (3) improving
the capacity of the family to act on its own behalf and assume
responsibility.
One of the important aspects of working with the family is the
nurse-family relationship, which is an intervention in and of itself.
The nurse can assume the role of teacher, role model, coach,
counselor, advocate, coordinator, consultant, and evaluator in
helping the family to implement the plan of the care they were
intimately involved in creating.
The types of interventions are limitless because they are
designed with the family to meet their needs in the context of
their family story.

Family Evaluation
In making clinical judgments, nurses engage in critical thinking to determine
whether and to what extent they have met an outcome.
Working with the family, decisions are made about whether to proceed as
originally planned, to modify the family action plan, or to revisit the family
story in total.
As indicated previously, the Family Nursing Process is not linear. In practice, a
constant flow occurs between the components of the Family Nursing Process
model.
If not meeting expected outcomes, nurses should consider whether family
apathy and indecision are the barriers.
Family apathy may occur because of value differences between the nurse and
the family.
The family may be overcome with a sense of hopelessness, may view the
problems or bureaucracy as too overwhelming, or may have a fear of failure.
Nurses also should consider whether they themselves imposed barriers. A
more detailed list of possible barriers to family outcomes.

Barriers to Family Outcomes

Family apathy
Family indecision about the outcome or actions
Nurse-imposed ideas
Negative labeling
Overlooking family strengths
Neglecting cultural or gender implications
Family perception of hopelessness
Fear of failure
Limited access to resources and support
Limited finances
Fear and distrust of health care system