Many definitions of family exist, from the traditional U.S. Census—“a family consists of two or more people, one whom is the householder, related by birth, marriage, or adoption and residing in the same housing unit” (2005) to the more inclusive. The nurse’s definition of family is influenced by personal involvement with his or her own family and clinical experiences. Definitions of family vary by professional discipline and type of family described. For example, psychologists may define family in terms of personal development and intrapersonal dynamics; the sociologist has used a classic definition of family in terms of a “social unit interacting with the larger society” (Johnson, 2000). Other professionals have classically defined family in terms of kinship, marriage, and choice: “a family is characterized by people together because of birth, marriage, adoption, or choice” (Allen, Fine, and Demo, 2000, p. 7). Friedman, Bowden, and Jones (2003) incorporate the idea of many nontraditional definitions: “a family is two or more persons who are joined together by bonds of sharing and emotional closeness and who identify themselves as being part of the family” (p. 10). Again, this definition supports the idea of letting the family define their composition and relationships (Wright and Leahey, 2005). The National Institute of Mental Health (2005) defines family simply as a “network of mutual commitment” (p. 2).

In the past, the dominant American definition focused on the intact nuclear family. African-American families focus on a wide network of kin and community. The “nuclear” family does not exist for Italians. To them, family means a strong, tightly knit three- or four-generational family, which includes godparents and old friends. The Chinese go beyond this and include in their definition of family multigenerational family members and ancestors (Li, Lin, and Cao, et al., 2009).

The community health nurse interacts with communities made up of many types of families. When faced with great diversity in the community, the community health nurse must formulate a personal definition of family and be aware of the changing definition of family held by other disciplines, professionals, and family groups. The community health nurse who interacts with Mr. Hudson, the alcoholic who lives in a hotel, must have a broad conceptualization of the family. Both the surveillance activity of the hotel manager and the financial support of the minister could be accounted for in the definition of McDaniel and colleagues: “we define family as any group of people related either biologically, emotionally, or legally. That is, the group of people that the patient defines as significant for his or her well-being” (2005, p. 2).

Regardless of the definition of family accepted, what is evident is the importance of the family unit to society. The family fulfills two important purposes. The first is to meet the needs of society, and the second is to meet the needs of individual family members (Friedman et al., 2003). The family meets the needs of society through procreation and socialization of family members. “The basic unit (family) so strongly influences the development of an individual that it may determine the success or failure of that person’s life” (Freidman et al, p. 4). The family is the “buffer” between individuals and society. The family meets individual needs through provision of basic needs (food, shelter, clothing, affection). The family supports spouses or partners by meeting affective, sexual, and socioeconomic needs. For children, the family is the “first teacher,” instructing the children in societal rules and providing values needed for growth and development.

The characteristics of the U.S. family continue to change. Historically the typical family, the nuclear family, has been defined as “the family of marriage, parenthood, or procreation; it is composed of a husband, wife, and their immediate children—natural, adopted or both” (Friedman et al., 2003, p. 10). The stereotypical view of this family as father, mother, and nonadult children while present currently represents only a portion of U.S. families (Annie E. Casey Foundation, 2009). In 1970, 85% of children younger than 18 years of age were living with two parents, defined as “mother and father.” In 2007, 74% of children younger than 18 years of age were living with two parents, defined as two adults including grandparents, same-sex partners, and other adults as parents (Annie E. Casey Foundation, 2009). In the last decade, recognition of various types of kinship families has resulted in available data that describe common types of families found in the United States. Table 20-1 presents significant family information.

Cohabitation, which is defined as “a living arrangement in which an unmarried couple live together in a long-term relationship that resembles a marriage,” has also increased over time (McLanahan and Percheski, 2008, p. 259). The number of cohabiting unmarried people increased from 523,000 in 1970 to 4.85 million in 2005 (U.S. Census Bureau, 2008). In 2007, 4,849,000 of the cohabiting-couple households included children (Annie E. Casey Foundation, 2009). Wydick (2007) found that 52% of American women currently in their 30s reported that their first relationship was cohabitation. Although these women generally reported that cohabitation was a prescreening situation before marriage, they reported lower relationship satisfaction when compared with the general population of married women and a higher divorce rate when marriage followed cohabitation. Hohmann-Marriott and Amato (2008) analyzed data from the Fragile Families and Child Well-being Study and reported that cohabiting partners were more likely to be what they termed “interethnic.” Interethnic couples were of either different ethnic or different racial backgrounds and were more likely to have relationship difficulties because of complications caused by different values and cultures. This did not mean the couples were less likely to be successful as partners, just that they were considered at risk or fragile. The nurse should be aware of the potential need for family support and intervention.

Single parenting has also increased over time. The increase in the teenage birth rate among this group raises concern. During the years 1980 to 2006, the birth rate for unmarried women 15 to 17 years of age increased from 21 to 41.9 per 1000 in the United States, representing a rise in 26 states (Centers for Disease Control and Prevention, 2009). The majority of teen parents raise their children alone. The proportion of children younger than 18 years of age who are living with their grandparents remains constant. In 2007, grandparent-headed families comprised 5% of all families. The American Academy of Child & Adolescent Psychiatry (2009) suggests that this is “due to serious societal issues and problems including increasing numbers of single parent families, the high rate of divorce, teenage pregnancies, AIDS, incarcerations of parents, substance abuse by parents, death or disability of parents, parental abuse and neglect” (p. 3). The gay or lesbian family is made up of a cohabiting couple of the same sex who have a sexual relationship. The homosexual family may or may not have children. Estimates of the number of children who live in lesbian- or gay-parented families, including children conceived in heterosexual marriages, range from 6% to 11% of children (Women’s Educational Media, 2005). These numbers are estimates because the U.S. Census Bureau does not count the number of lesbians and gay men. The University of California at Los Angeles (2009) reports that “more than one in every three lesbians have given birth and one in six gay men have fathered or adopted a child. An estimated 14,100 foster children are living with same-sex couples” (p. 8).

Single parenting is associated with greater risk associated with lesser social, emotional, and financial resources, which affect the general well-being of children and families. In 2007, 32% of all U.S. children lived in single-parent homes. Single parenting is a key indicator of well-being in children (Annie E. Casey Foundation, 2009). Table 20-2 shows statistics for single-parent families by ethnic group, and Table 20-3 shows teen birth rates by ethnic group.

The challenge to the community health nurse is to provide care to communities and populations and not to focus only on the levels of the individual and family. The community health nurse, who traditionally carries a caseload of families, extends his or her practice to the community. To do so, an aggregate, community, and population focus must serve as a backdrop to the entire practice.

For example, families must be viewed as components of communities. The community health nurse must know the community. As stated in previous chapters, a thorough community assessment is necessary to practice in the community. By way of review, the nurse must remember that communities must be compared not only in terms of different health needs but also in terms of different resources to effect interventions that influence policies and redistribute resources to ensure that community and family health needs are met.

Community health nurses must then compare city data with county data and then county data, state data, and national data. In addition, they may need to compare local census tract data and areas of a city or county with other areas of the city or county.

For example, community health nursing students in San Antonio, Texas, who were planning home visits to families of pregnant adolescents attending a special high school, compared local, state, and national statistics on infant mortality rates as a part of a community assessment. They found higher rates of infant mortality in San Antonio in census tracts on the south side of the city in which the population was predominantly Mexican American. They also found the population to be younger, to have a higher rate of functional illiteracy among adults, to be less educated, to be more likely to drop out of high school, to have higher fertility rates, to have higher birth rates among adolescents, and to be more likely to be unemployed. They found that specific health needs varied among census tracts. Common major health needs of this subpopulation were identified from the community assessment, which assisted the students in planning care for these families. For example, their goals were broadened from carrying out interventions at the individual level to interventions at the family and community levels. In addition to targeting good perinatal outcomes for the individual teenage parent, nursing students planned to include assessments of functional literacy at the individual and family levels and arranged for group sessions in clinic waiting rooms that informed and referred individuals and family members to alternative resources to enable teenage parents to complete school, take classes in English as a second language, and use resources for family planning and employment at the community level.

In addition to the cross-comparison of communities, the community health nurse also cross-compares the needs of the families within the communities and sets priorities. The nurse in the community finds that specific health needs vary among families. The nurse must account for time spent with families and choose those families on the basis of their needs compared with the needs of others in the community.