Disturbance in family organization and structure which fails to support the well-being of its members

• Difficulty dealing with altered community interaction
• Difficulty dealing with altered family role
• Difficulty dealing with hierarchical shift among family members
• Difficulty dealing with power shift among family members
• Difficulty dealing with social role shift among family members
• Excessive stress
• Perceived social discrimination
• Substance misuse
• Unaddressed community violence
• Unaddressed domestic violence

• Mental disorders

• Age of family members
• Family status, including normal patterns of interaction among family members, family members' and patient's understanding of present situation, and support systems available (financial, social, and spiritual)
• Family health history, including history of mental illness, stress-related illnesses, history of substance abuse, and sexual abuse of spouse or children
• Psychological status, including self-image and self-esteem, functional ability, independence level, and problem-solving and decision-making skills
• Family's past response to crises, including coping patterns and communication patterns to express anger, affection, and confrontation

• Altered affective responsiveness
• Altered communication pattern
• Altered family conflict resolution
• Altered family satisfaction
• Altered interpersonal relations
• Altered intimacy
• Altered participation in decision-making
• Altered participation in problem-solving
• Altered sexual partner relations
• Altered somatization
• Altered stress-reduction behavior
• Assigned tasks change
• Collusive alliance within family
• Conflict with community resources
• Decreased contact among family members
• Decreased emotional support availability
• Decreased mutual support
• Disordered alliance within family
• Family reports altered interaction
• Ineffective task completion
• Isolation from community resources
• Limited cooperative coparenting
• Limited familial affection
• Limited family interaction
• Power alliance change
• Ritual change
• Stressed alliance within family
• Unstable family alliance score using standardized, validated instrument

• Family members will agree on who's the primary decision maker.
• Family members will develop adaptive responses by assuming duties carried out by ill member, for example, meal preparation, transportation, shopping, laundry, cleaning, and providing emotional support to other family members.
• Family members will identify support systems to assist them and will participate in mobilizing those systems.
• Patient and family members will voice realistic expectations of each member's role.
• Family members will express need to assume new or altered roles and adapt to changes within family structure.
• Family members won't experience verbal, physical, emotional, or sexual abuse.
• Family members will communicate clearly, honestly, consistently, and directly.
• Family members will establish clearly defined roles and equitable responsibilities.
• Family members will express understanding of rules and expectations.
• Family members will report that methods of solving problems and resolving conflicts have improved.
• Family members will report a decrease in the number and intensity of family crises.
• Family members will contact a community agency or support group for continued assistance (depending on type, severity, and prognosis of illness), for example, American Cancer Society, American Lung Association, Arthritis Foundation, Hospice, Myasthenia Gravis Foundation, Multiple Sclerosis Society, or National Kidney Foundation.
• Family members will share feelings about issues within the family.

Suggested NOC Outcomes

• Identify individual assuming role as head of family to establish family hierarchy and functional ability.
• Provide head of family with information necessary for decision-making, such as updated information on patient's condition. This avoids potential for misinterpretation and places responsibility for communication within family unit.
• Help head of family decide which support systems need to be mobilized and used. This allows opportunity to evaluate head of family's management ability and family's problem-solving ability.
• Provide emotional support to head of family regarding altered role and additional responsibilities. This encourages family member to express feelings, ask questions, seek help, and make decisions.
• Expedite communication within family to allow members to express their feelings about present situation. This encourages supportive behavior to meet reciprocal needs in a crisis.
• Arrange and participate in family conferences as needed. Some families may require help to improve interpersonal communication.
• Arrange with family to spend as much time as possible with patient to allow them to participate in providing care where it is appropriate. This accommodation may fulfill both patient's and family's needs for participation.
• Hold adults accountable for their alcohol or substance abuse and have them sign a “Use Contract” to decrease denial, increase trust, and promote change.
• Assist family to set limits on abusive behaviors and have them sign “Abuse Contracts” to foster feelings of safety and trust.
• Teach family to communicate clearly and honestly to increase their ability to express thoughts and feelings in a positive way.
• Encourage family members to evaluate communication patterns periodically to reinforce benefits of effective communication skills.
• Whenever possible, ensure privacy to family members for their discussions or conferences. These measures allow you to help family identify and work toward mutual goals and facilitate effective family coping.
• Make referrals to social services or community agencies, as appropriate, to provide family with access to additional coping resources.
• Include patient in family conferences and family interaction as often as possible.

Suggested NIC Interventions

• Family members identify family member to be primary decision maker, serving as head of family.
• Family members describe clearly defined roles and responsibilities.
• Family members demonstrate understanding of roles and responsibilities.
• Family members openly share feelings about present situation.
• Family members don't experience any type of abuse.
• Family members report that family communication is clear, honest, and respectful.
• Patient and family members voice realistic expectations about emotional and financial impact on family structure.
• Family members identify problems and work together to solve them.
• Family members report fewer family crises.
• Family members recognize the need for professional assistance.
• Family members identify and contact available resources, as needed.
• Family members contact community support groups and associations and attend at least two meetings.

• Observations of family's reactions to situation
• Interventions to assist family and family's responses to those interventions
• Referrals to outside agencies
• Patient's and family's responses to nursing interventions
• Problems and conflicts described by family members
• Behavioral contracts signed by family members
• Changes in roles and responsibilities and information about how these changes were negotiated
• Evidence of changes in family communication patterns
• Evaluations for expected outcomes

• Conway, E. R., Watson, B., Tatangelo, G., McCabe, M., Haapala, I., Biggs, S., & Kurrle, S. (2018). Is it all bleak? A systematic review of factors contributing to relationship change in dementia. International Psychogeriatrics, 30(11), 1619-1637.
• D'Ippolito, I. M., Aloisi, M., Azicnuda, E., Silvestro, D., Giustini, M., Verni, F., … Bivona, U. (2018). Changes in caregivers lifestyle after severe acquired brain injury: A preliminary investigation. BioMed Research International, 2018, 1-14.
• Monk, J. K., Oseland, L. M., Nelson Goff, B. S., Ogolsky, B. G., & Summers, K. (2017). Integrative intensive retreats for veteran couples and families: A pilot study assessing change in relationship adjustment, posttraumatic growth, and trauma symptoms. Journal of Marital & Family Therapy, 43(3), 448-462.
• Taylor, J. O., Hartzler, A. L., Osterhage, K. P., Demiris, G., & Turner, A. M. (2018). Monitoring for change: The role of family and friends in helping older adults manage personal health information. Journal of the American Medical Informatics Association, 25(8), 989-999.