Introduction

A family is the basic unit of the social organization, around which health-related behaviors and decisions are initially established. It is thus drawing increasing attention from health professionals, especially nurses, for the analysis, design, and planning related to the care of family units and health. ^1,2. A family is considered the primary social support network of individuals. Therefore, it has a buffer function against the tensions emerging between members and the outside world throughout life. Moreover, it provides the ideal space to strengthen its members' values, principles, norms, and interaction guidelines, thereby enabling their social development when a functional family process is taking place ^3-6.

A functional family maintains adequate communication, is united, and supports and promotes the comprehensive development of its members with a positive health condition, adequate personal growth, and educational success in children and adolescents ^5-8. The North American Nursing Diagnosis Association (NANDA) taxonomy of assessment by functional patterns defines dysfunctional family processes as chronically disorganized psychosocial, spiritual, and physiological functions of a family unit. All these can lead to conflicts, problem denial, reluctance to change, communication failures, ineffective problem solving, and behavioral, school, and health disorders, which makes their assessment relevant for their care ⁹.

Among the functions of the nursing process is family care, considered one of the most important management standards, through which appropriate clinical decisions that integrate scientific reasoning and critical thinking to solve problems and provide holistic and quality care are made ^10-15. In the nursing process, during the assessment stage, the following family health instruments are applied: genogram-analysis of the structure and/or composition of the family, the family APGAR-evaluating the family function globally, and the ecomap-the interaction of the family with the environment and the context, which provides information on relationships, functionality, communication level, accompaniment, support and environment. These instruments allow diagnoses to be made, according to the problems or health situations and create a care plan according to the specific needs of each family ^5,9,16-18.

In the diagnostic stage, a conclusion is made about the findings. During the assessment and planning stages, the nurse selects the expected outcomes. In the intervention stage, care and interventions are determined and implemented, and in the evaluation stage, the family's condition is compared with the expected outcomes. During this process, adequate communication is used, which is key to maintaining a good relationship within the family, using standardized language that allows for the integration of a theoretical frame work to identify problems, interventions, and care outcomes. The NANDA taxonomy of assessment by functional patterns, the nursing diagnoses, the Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC) are part of the language, which allow for the provision of quality, comprehensive and coherent care and/or attention to the individual, the family, and the community ^9-12,19-21.

Considering the family as the social axis par excellence in students' lives and their professional training, the researchers conducted this study to develop the nursing process: assessment, diagnoses, planning, execution, and evaluation of a care plan for the families of Nursing students.

Methodology

Study Design: Initially, a descriptive cross-sectional study was conducted for the characterization, evaluation, and diagnosis of the families of a group of university students. Next, the nursing care plan was developed, and families were intervened; the final evaluation was then conducted.

Study Population: The study population comprised families of third-semester students from a nursing program at a private university in Cali, Colombia, obtained through convenience sampling according to the following criteria: Families of university students enrolled as per the university guidelines, men and women over 18 years old, and families that agree to participate in the study by signing the informed consent. Exclusion criteria: Families of students who, while enrolled, were ill at the time of the assessment.

Measurements: Information was collected regarding housing, location, utilities, number of members, and characteristics of the environment. The family was assessed using the genogram, the family APGAR, and the ecomap. The genogram, also known as familiogram, is the graphic representation through symbols of a family's composition and the development of at least three generations over time as what happens in one of them affects the relationships and behaviors of the others. It is useful for risk factor identification, problem-solving, education, and promotion of individual and family health as preventive counseling and crisis resolution are carried out. It is an effective instrument to identify the type of family and the stages of the family life cycle ^17,22,23.

The family APGAR is an instrument that helps establish how each family member perceives the level of functionality, and it is applicable to children. It assesses five basic functions of the family: Adaptation, participation, personal resource gradient, affection, and resources. These are key elements given its structure, development, integration, or demographics; these indexes showed a correlation of between 0.71 and 0.83 ¹⁶. The ecomap is a simple tool that helps recognize the presence or absence of social support resources in a person or family; it allows for identifying interrelationships with the environment and the sociocultural context in which they live, as well as detecting the deficiencies the family is going through and the problems within or beyond family relationships ^17,18,24.

Each family was visited twice. These instruments were applied in the first visit, which allowed for establishing the diagnoses on the nurse's perception of the family's care needs, considering the NANDA classification and taxonomy, and the related factors and defining characteristics ⁹. Once the diagnoses were identified, the care plan was developed, applying the NANDA nursing care plan template, which makes communication between health professionals and patients easier ^10,20. In the second visit, the care plan was implemented, applying the necessary NIC interventions so that each nursing diagnosis was improved or solved. The care plan was evaluated using the NOC criteria ^9,12,21.

Analysis Plan: The data were initially entered in Excel and then imported into the software Epi-Info, version 7.2.4, for the corresponding statistical analysis, describing the study population by means of absolute and relative frequencies for qualitative variables and measures of central tendency (means and medians), with the respective measures of dispersion for quantitative variables, according to their distribution. A bivariate analysis was performed to identify the association between family type, family life cycle (genogram), and the level of perceived family functionality (family APGAR) using the chi² test, with a significance level of 95%.

Ethical Aspects: The project was evaluated and approved by the Research Ethics Committee of the School of Health of Universidad Santiago de Cali through Certificate No. 05 of 04/16/2021. The families read and signed the informed consent form, and the confidentiality of the information collected and the identity of the participants were assured.

Results

Family structure: A total of 101 families were evaluated, with an average of 3.6 ± 1.1 persons per family, 71.3% of which resided in the city of Cali and 87.1% in the metropolitan area. As for the main housing characteristics, the average number of rooms per dwelling was 3 ± 1, ranging from 1 to 6 rooms, 68.3% of families lived in their own homes, and 96% had access to utilities (water, energy, and sewage services). Of the 23 families with a pet at home, 16 had a vaccination card (69.5%). See Tables 1 and 2.

The three-generation genogram identified a predominance of nuclear families (85.1%), and in more than half of the families, the life cycle was expanded (58.4%), with strong relationships among family members prevailing (Table 3).

Family functionality: The family APGAR found that the majority of respondents (60.4%) consider their families to be functional (between 17 and 20 points), whereas the remaining 39.6% perceive some level of family dysfunction, mainly between mild and moderate (Table 4).

When the type of family (genogram) was associated with its functionality (family APGAR), it was found there is no relation between the type of family and how its members perceive the functionality level of the unit (p = 0.3464). However, a statistically significant relation was identified between family life cycle and family APGAR, showing that as the family progresses through the successive stages of the life cycle, members experience changes in the level of perceived family functionality, with an increase in the perception of family dysfunction (p = 0.0176).

The ecomap showed strong interaction with the environment and the socio-cultural context, especially with education, extended family, and work. Weak interaction was mainly related to social groups, free time (leisure) activities, and religion. However, Stressful Interaction was associated with access to transportation services (Table 5).

Diagnoses in the family: Two nursing diagnoses related to the role/relationship domain were identified in the families under study. The first, called dysfunctional family processes (00063), comprises a lack of problem-solving skills and a perception of family dysfunction in 39.6% of the families. The second, impaired social interaction (00052), comprises M/P communication barriers, distancing from social groups and friends, and the inability to receive a satisfactory sense of social participation.

Discussion

In this research, the objective of developing the nursing process was met-the assessment, diagnosis, planning, and execution of a care plan for the 101 families of university nursing students with good members' acceptance and satisfaction. The process was completed, and families were willing to strengthen their self-care. In their initial characterization, it was found that most of them lived in Cali (71.3%), urban areas (87.1%), and homes owned by them (68.3%), with an average of 3.6 ± 1.1 persons per family, and almost all had access to utilities (96%), which, in most cases, shows a favorable environment and context for its proper functionality.

When evaluated through the genogram, most families were made up of parents and children (nuclear structure 85.1%) and almost 60% were in the expansion family life cycle, which begins with the birth of the first child, when the family becomes a trio. This also reflects a stage in most of these families that still presents neither stress nor dysfunction. Prados ²³ mentions that in the early stages of parenting, intense bonds or high levels of family cohesion are required to establish and grow the family. Flórez et al. ⁵ report that family support in the process of formation, in the affective and cognitive aspects of young children, is easier because they accept and comply with rules.

Then, the family APGAR was used, and it was found that 60% of the families were functional. The first nursing diagnosis was some degree of family dysfunction in 39.6% of them, mostly ranging between mild and moderate. When comparing the family life cycle with this APGAR score, it was found that as families progress through the stages of the family cycle, their members have greater perceptions of dysfunction. Quintero ³ points out that a family is a system and an institution undergoing evolution and transformation, which can adjust to social changes and thus recreate the changes in its structure, function, and life cycle.

Prados ²³ mentions the fact that a life cycle is made up of stages of increasing complexity, followed by stages of family simplification, where changes and transformations occur in the family members, in the transition from one stage of the cycle to another. This implies roles, tasks, and behaviors to which not everyone can adapt, altering family dynamics and causing crises; when families make the transition to the complete expansion, as adolescence begins, problems arise in the family, resulting from the emotional development of this life stage. In turn, a dysfunctional family is associated with negative child and adolescent outcomes in school performance, behavioral disorders, and health ^5,25,26.

Villafrade et al. ⁴ assessed 10 parents and children who had started the first semester of college in Bucaramanga and reported a change in the roles played by both children and parents. Parents mentioned that their children were more reserved and private and they isolated themselves from the family group, probably because of their age or because they had started college. However, the children highlighted barriers in relationship management, such as the lack of parental time to discuss their personal needs. They identified their mothers as the most important person in their support network, as they have more time and availability, and their siblings because of greater trust and affinity given their similar age. Therefore, these authors recommend creating and strengthening counseling and training programs for parents of college students.

Cusihuaman et al. ²⁵ applied the family APGAR to 148 adolescents in Paraguay, finding a perception of family dysfunction between mild and moderate (57%), higher than that found in the families studied in this research work, (39.6%), but this is only perceived by adolescents and not from their relatives. This dysfunction is related to adolescent pregnancy, the need for youth to work, school dropout, and the high probability of alcohol and cigarette consumption. Researchers recommended the support of a multidisciplinary group working to provide differentiated care to adolescents. Rojas et al. ⁶ developed the entire nursing care process with a dysfunctional family in Barranquilla, finding weakened parental roles and poor communication, as well as behavioral alterations of aggressiveness and poor academic performance in an adolescent son.

In addition to the crisis that adolescents can cause, other factors can alter family function, such as the parents' cultural and economic level, parents' ignorance of school processes, as well as the assumptions by teachers, the weak participation channels between the two institutions, and the excessive delegation of responsibilities from families to schools, among others ^5,7. In the final stages of the family life cycle, called simplification stages, the common denominator is the loss both in terms of the number of members and of functions, roles, and status. Family reduction leads toward its dissolution: after the children leave, the couple is alone again, followed by retirement and old age, which causes changes in family function ²³.

Changes have also taken place in families in Western societies at a very fast pace in recent decades, which have modified the evolution and timing of the stages of the life cycle ^3,12,23. The massive incorporation of women and other family members into the labor force, female participation in the public sphere, job insecurity, truncated life paths, forced displacement, the impact of information technologies, demographic changes such as population aging and the major trends of change from nuclear family structures to single-parent female family groups ³.

The models of care implemented by countries to achieve comprehensive care of the individual, the family, and the community promote the analysis of the environment and the context of individuals and their families ^12,17,18,25. The ecomap has a set of connected circles representing the systems that interact with the individual or family, and it serves as a visual representation of support, conflict, or disconnection. The 101 families in the study showed strong interaction with extended family, education, and work and a weak interaction mainly with social groups and leisure time. This is the second diagnosis of impairment in social interaction, related to communication barriers and distancing from social groups or friends due to the inability to perceive satisfaction from social participation.

Similar findings are presented by Melo et al. ¹⁸ in 49 families that participated in a community project in the city of Tunja, Boyacá, which identified a strong interaction with work (26.5%) and extended family (20.4%) and weak interactions with recreation and health. In the study conducted by Fuentes et al. ²⁶, with 354 adolescents from co-educational schools in the city of Manizales, Caldas, aged between 8 and 20, whose goal was to search for suicide risk factors, nuclear families were identified (42%), followed by single-parent families (21%). The family APGAR identified the predominance of moderate to severe family dysfunction in 68.4% of the cases. The ecomap identified that the best bond established using a social network is with friends (82.5%), followed by family (79.8%).

The family is the scenario in health promotion in which risk reduction will be represented thanks to family cohesion in the preparation of its members to face crises socially which may affect the structure, functionality, and well-being of the group (e.g., the pressure that university may exert on adolescents). ^15,17,18. In this regard, Medellín et al. ²⁷ report that along with the structure of a family, its functioning is also important, mainly concerning the family and social support network.

Several authors consider that primary health care should be articulated around nurses, the largest human resource group in public health ^12,21,28, allowing the use of the nursing process tool to develop quality clinical practice ^{2,3,10-15,20,21,28-30}. Moreover, nursing professionals are essential in national health systems because they bring about positive changes in the care model and improve people's health and quality of life, besides increasing patient participation in self-care practices and satisfaction to improve communication. Moreover, professionals increase their job satisfaction and self-efficacy through clinical decision-making and critical thinking ^{8,10-15,17,18,20,21,29,30}.

Some studies ^13-15,19 recommend academic nursing programs in higher education institutions to teach the nursing process transversally, involving innovative education strategies such as dramatization and demonstration in supervised practice, promoting ongoing training for teachers, and committing to the formation of critical and reflective professionals, with teamwork, and committing to provide health care in health services. Further, they emphasize the adoption of the nursing process associated with the NANDA taxonomy, both of which are essential for the scientific practice of nursing.

Conclusions

This research allowed nursing program students to understand the nursing process in community practice and health promotion by assessing their families through family health instruments such as the genogram, family APGAR, and ecomap. It also assessed, designed, and implemented a safe, comprehensive, humanized, and individualized care plan for individuals, their families, and the community.

The families in the study participated throughout the nursing process and accepted the proposed interventions; they expressed satisfaction with the process and expressed willingness to strengthen their self-care, based on the care and tools offered, using them for their own benefit.