In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of family dynamics in order to:

  • Assess barriers/stressors that impact family functioning (e.g., meeting client care needs, divorce)
  • Assess family dynamics to determine plan of care (e.g., structure, bonding, communication, boundaries, coping mechanisms)
  • Assess parental techniques related to discipline
  • Encourage the client's participation in group/family therapy
  • Assist the client to integrate new members into family structure (e.g., new infant, blended family)
  • Evaluate resources available to assist family functioning

As more fully detailed in the previous section entitled "Identifying Family Structures and the Roles of Family Members", family structures are numerous and becoming more numerous and varied than any other time in the past. These family structures, which are not necessarily mutually exclusive, are:

  • The Traditional Nuclear Family
  • The Nuclear Family
  • The Extended Family
  • The Foster Family
  • The Adoptive Family
  • The Binuclear Family
  • The Single Parent Family
  • The Childless Family
  • The Communal Family
  • The Gay and Lesbian Family
  • The Blended Reconstituted Family

Assessing Barriers and Stressors that Impact Family Functioning

Families, like individual clients and other groups, are often impacted with stressors and barriers that adversely affect individual members of the family as well as the family itself as an open dynamic system. The stressors that impact on family functioning include physical, or biological or physical, emotional and psychological, social, cultural and spiritual stressors as well as situational and maturational crises. These stressors and crises can be acute or chronic.

Family dysfunction, as defined by the North American Nursing Diagnosis Association (NANDA), is the "psychosocial, spiritual, and physiological functions of the family unit are chronically disorganized , which leads to conflict, denial, of problems, resistance to change, ineffective problem solving, and a series of self perpetuating crises".

Some of the many stressors and crises that can impact on the family unit include poverty, homelessness, abuse, neglect, substance related abuse including alcoholism, divorce, separation, psychological illness, maturational and developmental crises such as the birth of a new baby, role changes, power shifts, and physical illnesses.

Some of the barriers that prevent meeting client needs when the family is impacted with stressors that require the need for nursing and health care services include the inaccessibility and unaffordability of needed health care resources, the lack of needed transportation and a lack of willingness to seek out and use health care resources. The assessment of potential barriers and the correction and amelioration of these barriers must be incorporated into the plan of care for the family unit.

Assessing Family Dynamics to Determine the Plan of Care

Families are assessed for their family dynamics, the family's structure, which was previously discussed and detailed, patterns of communication, boundaries that separate the family unit from other groups, parenting patterns, roles, methods of coping and bonding and attachments.

Communication, as detailed with the section entitled "Integrated Process: Communication", consists of both verbal and nonverbal communication and body language. Communication patterns among family members and the patterns of communication between the family unit and other living systems outside of the family can vary greatly. Some communication patterns are healthy and adaptive and others are not. Impaired verbal communication, as defined by the North American Nursing Diagnosis Association (NANDA), is the "decreased, delayed, or absent ability to receive, process, transmit and use a system of symbols".

Communication patterns, like communication in organizations, can be can be formal and informal, from the top down to the bottom and from the bottom up to the top, and from side to side in any other pattern. For example, some families have a philosophy that the leader of the family, rather than the subordinate children, is the one who is the communicator and that "Little pictures should be seen and not heard".'

Boundaries that separate the family unit from other groups can be flexible and rigid and inflexible, closed and open, exclusionary and inclusionary, wide and very narrow. For example, as supported by the Systems Model of Neumann, natural protective boundaries around the family unit include lines of resistance, the normal lines of defense, and the flexible lines of defense which protect the open system from environmental stressors and penetration to this open system.

Boundaries around the family unit can be open, inclusive and wide to accommodate for changes within the family to the exchange of energy and information with others, including other groups, while other families are characterized with narrow, exclusionary boundaries that are closed off to the influences of others. For example, the family unit may be highly accepting and welcoming of the help, support and ideas of the health care team and others are not open and receptive to these things.

Parenting patterns among families are also diverse. Some families employ democratic, participative, laissez faire or authoritarian parenting. Psychologist Kurt Lewin developed a theory of leadership and leadership styles that closely align with the different parenting styles. Lewin describes these styles as:

  • Autocratic Leadership (Authoritarian) Leadership: Autocratic leaders make independent decisions without communicating, collaborating and consulting with others. These leaders state what has to be accomplished, when it must be done, and how it should be done. Families who use an autocratic or authoritarian parenting are typically strict and the leader has control and authority over the other family members. Some families that use the autocratic or authoritarian parenting style are considered patriarchal, with the father as the leader, and others are considered matriarchal with the mother as the person with the power and control over other members of the family.
  • Democratic Leadership (Participative) Leadership: Democratic and participative leaders provide guidance to family members and they also elicit and welcome the thoughts, beliefs and opinions of other family members, including the children within the family unit, in the terms of the decision-making process.
  • Laissez-faire Leadership (Delegative) Leadership: Quite contrary to popular opinion, laissez-faire leaders are NOT lazy "do nothing" leaders. Laissez-faire leaders give team members a great amount of freedom and autonomy in terms of what, how and when tasks are done but they are readily available to provide necessary resources, including guidance and support when needed.

During the not so recent past, roles within the family unit were gender based; now these roles are not usually based on gender. For example, many families have two working parents, when in the past, the male in the family went to work and was the bread winner; now females also perform and fulfill this role. Additionally, some families have stay at home dads while the mother leaves the home for gainful employment.

As more fully discussed and detailed previously, methods of coping for the individual client are also shared by the family as a client. Some methods of coping are adaptive and effective in terms of the family's coping with and dealing with stressors and others are not. The later requires the interventions of the nurse and other members of the health care team.

As also described more fully in the section "Assisting the Client with Performing/Learning Newborn Care", parental bonding and attachments are essential to the infant's growth and development of the new baby, their development of trust and the newborn's feelings of intimacy with others.

Assessing Parental Techniques Related to Discipline

Nurses assess families in terms of parenting styles and parental techniques that are related to discipline. Some of these approaches to parenting and discipline are learned, others are attached to culture and still more, such as abusive and neglectful parenting, is intergeneration and perpetuated with the Cycle of Violence.

Regardless of the etiology of the parenting style and methods of discipline, nurses and other health care providers assess these family dynamics and incorporate these assessments into the plan of care. For example, abusive parents must be educated about the dangers of abuse and alternative methods of discipline such as a time out.

Encouraging the Client's Participation in Group/Family Therapy

In addition to a wide variety of family interventions, group and family therapy is often indicated when the family unit is affected with stressors and dysfunction. Some of the challenges associated with gaining a client’s participation in group and family therapy revolves around the fact that many families are not only closed to the support and help of people outside of the family unit, but also because family members may not fully understand the need for the entire family unit to participate when only one member of the family is adversely affected with a stressor and poor coping. This belief should be explored with the family members and then the nurse should intervene by educating the family members about the fact that all family members are affected when only one member of the family unit is adversely affected.

Assisting the Client to Integrate New Members into the Family Structure

All changes within the family unit lead to the lack of homeostasis and balance, therefore, even the addition of a new person into the unit is a stressor and one that the family will have to effectively cope with. Examples of new additions to the family can include the introduction of an elderly grandparent or great grandparent, a new baby, and new children from a previous marriage or union into the blended family.

Individual and family responses to these changes vary among the individual family members and also for the family as a unit. Nurses assess these families, and their members, related to these changes and they plan care accordingly. For example, a young sibling who is resentful of a new baby may require the need for individual counseling and therapy and the family as a whole may need group and family therapy when the family unit itself is adversely affected with the integration of new members into the family structure.

Evaluating Resources Available to Assist Family Functioning

After a complete and comprehensive assessment of the family assessment, the nurse generates a plan of care with the family to meet the family's assessed needs.

Some of the interventions that are included in this plan of care can include the care of the nurse, the utilization of available community resources, and referrals to others in the health care community who are able to meet the identified needs of the family.


SEE – Psychosocial Integrity Practice Test Questions

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