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Definitions :
Definitions Stress = Tension resulting from depleted family resources - an imbalance that must be corrected. Stressors = Drastic life events that change the family system (death of spouse, financial crisis, unemployment. Distress = extreme psychological pressure resulting from facing repugnant and/or unenjoyable challenges. Eustress = extreme psychological pressure resulting from facing enjoyable and/or beneficial challenges. The prudent family member will feel stress, look for the stressor(s), determine whether or not Distress or Eustress is happening, and make appropriate adjustments in the family system

Some facts about Stress :

Some facts about Stress Stress is normal Stress disturbs equilibrium. Coping is used to maintain equilibrium. Individuals and families view stressors and resources according to their own perception Individuals and families adapt to stress Adaptation is influenced by Perceived stressors Perception of the situation Resources or coping strategies available Important to consider the contexts of family stress within community and cultural contexts in which a family resides to understand why and how families are stressed, and how they respond

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Family stress comes in many forms Normal stressors - Getting married, adjusting to living in a new group, having babies, unemployment Abnormal stressors,- Famine, war, natural disasters, massive economic collapse, murder, assault, incest The individual is prepared by family & society

If it ain't broke - Don't fix it! :

If it ain't broke - Don't fix it! Most families live long and relatively happy lives

The Family Stress Theory. :

The Family Stress Theory. Explains how families react to stressful events Suggests factors that promote adaptation to stress

Family stress theory :

Family stress theory Acute stressors when accumulated can lead to family crises (physical, emotional, or relational) Eg., Domestic violence, substance abuse (relapses), illness from weakened immune systems, divorce, accidents, children being abused, or neglected, etc. Significant factors to look for - : the changes in daily routines, the number of changes in daily routines, the length of time since there were changes in daily routines, (i.e. the family stressors)

Conceptual Model of Family Stress :

Conceptual Model of Family Stress

Impact of Stress on Family :

Impact of Stress on Family Can be muted, or buffered with protective factors which help families to survive multiple contextual stressors, and to continue to competently parent despite chronic and acute stressors. These protective factors are Social relationships (B Factor) - Within family variables, e.g. attachment, positive family bonds, effective communication Across family variables: i.e. social isolation vs. informal and formal social support networks; Perceptions (C Factor) Include Range in cognitions and attitudes between hope and personal effectiveness vs. despair Helplessness. These two complex factors relate together with the acute stressors and ongoing social context of chronic stressors, to predict family crises.

Adaptation to stress :
Adaptation to stress Bonadaptation (regenerative power ) Maladaptation (vulnerability)

Positive relationship between illness and stress. :

Positive relationship between illness and stress. Stressors when too many (at a time) i.e., too many changes in their daily routines and circumstances, are at increased risk within one year for having an accident, for becoming physically ill, for having an impaired immune system, for becoming violent, or for relapsing Not only individuals, but families that experience too many stressors at one time are at increased risk for experiencing aggravated family crises. However, not ALL families with multiple stresses have crises. Why not? What are the factors which protect a person or family unit from having a family crisis.

Professor Reuben Hill's theory of family stress :

Professor Reuben Hill's theory of family stress Two complex variables act to buffer the family from acute stressors and reduce the direct correlation between multiple stressors and family

crisis. These are formulated as the ABCX theory of family stress "B" variable - The complex of internal and external family resources and social support available to the family, i.e., the social connectedness within the family, as well as social connectedness outside the family. Social isolation would significantly increase the impact of the multiple stresses on the family functioning; in contrast, positive social supports would minimize the impact. "C" variable - The perception factor, is the second predictor of the extensiveness of the impact of stress on the family - the shared family cognition and perceptions held about the stressors, e.g., the extent to which the family perceived the changes as a disaster vs. an opportunity. Hill suggested that some families had positive appraisals which they could make of changes, which increased their ability to accept their circumstances. This theory has been expanded by Mc Cubbin


HILL'S ABCX MODEL OF FAMILY STRESS (B) Internal Family Resources & Informal/Formal Social Supports Family (A) -----------------------> Family Crisis (X) Stressors (C) Family Perception & Parental Self-Efficacy

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High stress + social isolation (the "B" variable) for families >>> dysfunctional family outcomes. Lack of "B" and "C" variables are similarly potent and equally predictive of a family crisis. If a family experiences multiple stressors and 1) they are socially isolated and emotionally disconnected to one another, and 2) they are depressed, hopeless, and disempowered, Then, they will be at increased risk for illness, accidents, child abuse and neglect, and substance abuse, delinquency and school failure . With a positive set of cognitions, an empowered attitude, and an active informal and formal support network, there would be a reduction in the likelihood that the stressful life experiences would result in a family crisis.

Recovery of family from stressor events and return to previous level of functioning :
Recovery of family from stressor events and return to previous level of functioning however, the process does not always result in this outcome

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Sometimes families find that overcoming and surviving a crisis actually makes them stronger and more resilient due to the realization of talents and abilities unseen before

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Logically, some families find that recovery is beyond their grasp, Either they stagnate at a lower level of functioning, or find themselves dealing with new crises before repairs can be made on the initial disturbance:

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Theorists after Hill, such as McCubbin, refer to this phenomenon as crisis "pile-up", in which additional crisis situations further reduce the family's ability to cope and function.

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The interaction between (a) stressors, (b) family resources, and (c) perception of events as stressors is what defines a crisis for any individual family. A family that is aware of its resources, will not perceive the most devastating events as crises. If stressors are adequately dealt with by family resources, the stressor will be perceived as a minor thing

Effect of Stress on Family :

Effect of Stress on Family Perception of crisis Temporary disorganization of members The angle of recovery determines the return to normal Perception of crisis acc to the level of functioning & perceived magnitude Family with many resources Fewer crises, shorter disorganization, steep angle of recovery & returns to pre or higher than pre crises level of functioning Suffer more frequent crises, longer periods of disorganization, flatter angles of recovery, and are less likely to return to their former functionality. Family with less resources

Stressors? :
Stressors? Events that cause stress & have potential to affect a change in a family Predictable (parenthood) & Unpredictable (illness, unemployment..) Are cumulative Involves simultaneous demands from work, family & community life Too many in a short time Can overwhelm familys ability to cope - Risk of breakdown / crisis Change in life style/ structure >>>>ADAPTATION

Resiliency Model of Stress (Adjustment, and Adaptation)- McCubbin and McCubbin :

Resiliency Model of Stress (Adjustment, and Adaptation)- McCubbin and McCubbin Emphasizes - Stressful situation is not necessarily pathologic/ detrimental to family Demonstrates Need of family to make fundamental/ structural / systemic changes to adapt

Resilience :

Resiliency Model of Stress :

Resiliency Model of Stress In family crisis - The pileup of family demands (stressors, strains, transitions) is related to family adaptation, and this is a negative relationship; 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; Family resources are related to family adaptation, and this is a positive relationship; 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 problemsolving strategies when employed to manage a crisis situation are related to the level of family adaptation, and this is a positive relationship

Family Health defined.. :

Family Health defined.. It is the 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" Resilience A characteristic that families use to achieve that balance and harmony

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Patterns of resilience can be assessed at the individual and/or family level. Resilience of a child assessed through responses and behaviors of the child Resilience of family - Through family process, i.e., patterns of successful coping and adapting, intrafamily relationships, and family support systems. Nine aspects of resilient families dealing with a chronic illness situation have been identified. These include: balancing the illness with other family needs, maintaining clear family boundaries, developing communication competence, attributing positive meanings to the situation, maintaining family flexibility, maintaining a commitment to the family as a unit, engaging in active coping efforts, maintaining social integration, and developing collaborative relationships with professionals (Patterson, 1991

Role of nursing :
Role of nursing Promote family members' health, recovery from illness, or maximum functioning within specific health limitations Enhance family strengths, assist families in maintaining linkages with community supports, and aid families in arriving at a realistic appraisal of what is the best "fit" for them in their particular situation. Thus, assist families in the process of adaptation

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Resiliency Model of Family Stress, Adjustment, and AdaptationFamily 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.

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There were four assumptions within the original family stress model developed by Rueben Hill in 1949 (Friedman, 1998). These were: Unexpected or unplanned events are usually perceived as stressful. 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. Lack of previous experience with stressor events leads to increased perceptions of stress. Ambiguous stressor events are more stressful than non-ambiguous events (Friedman, 1998, p. 88).

DEVELOPMENTAL THEORY An outgrowth of several theories of development Duvall (1977) described 8 developmental tasks of the family through out its life span Family A small group, a semi-closed system of personalities that interacts with the larger sultural social system Changes in one part effects a series of changes in the other parts

Duvalls Developmental Theory :

Duvalls Developmental Theory Based on the predictable changes in structure, function and roles of the family Age of the older child id the marker for stage transition Arrival of first child marks the transition from Stage I to Stage II As the first child grows and develops, the family enters subsequent stages At every stage family is at a developmental task At the same time, each member of the family must achieve individual developmental task

Duvalls Developmental stages of the Family :

Duvalls Developmental stages of the Family Stage I Marriage & independent home The joining of families Reestablish couple identity Realign relationships with extended family Make decisions regarding parenthood

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Stage II Families with infants Integrate infants into family unit Accommodate to new parenting and grand parenting roles Maintain marital bond

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Stage III Families with preschoolers Socialize children Parents & children adjust to separation

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Stage IV Families with Schoolchildren Children develop peer relations Parents adjust to their children's, peer and school influence

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Stage V Families with teenagers Adolescents develop increasing autonomy Parental focus on midlife marital and career issues Parents begin shift toward concern for older generation

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Stage VI Families as launching centers Parents & young adults establish independent identities Renegotiate marital relationship

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Stage VII Middle aged families Re-invest in couple identity with concurrent development of independent interests Re-align relationships to include in-laws and grand children Deal with disabilities & death of older generation

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Stage VIII Aging families Shift from work role to leisure and semiretirement or full retirement Maintain couple and individual functioning while adapting to the aging process Prepare for own death and dealing with the loss of spouse and/ or siblings and other peers

Application in Nursing Practice :

Application in Nursing Practice Assess the level of accomplishment of the families Assess the effect of illness on family development Plan means to assist families to achieve the developmental task for that stage

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Include family in the work plan Anticipatory guidance Crisis intervention


FAMILY NURSING INTERVENTIONS Behaviour modification Case management & coordination Collaborative strategies Contracting Counseling Empowering through active participation Environmental modification Family advocacy Family crisis intervention Networking (self-help groups, social support) Providing information & technical expertise Role modeling Role supplementation Teaching strategies stress management, lifestyle modification, anticipatory guidance