INTRODUCTION
It’s undeniable that the family stands as one of the most ancient institutions in society. Since the dawn of humanity, individuals have formed familial units to seek emotional, physical, and communal support [1]. From this inception, the family has been the cornerstone of societal and cultural structures [2].
Families can have various impacts on individuals and can be seen as structural groups that operate with diverse characteristics. In family dynamics, many events can be emerged and sometimes several events may become crises. Family crises manifest in various problems such as domestic violence [3]. These crises play a crucial role in one’s mental health [4].
For an extended period, a medical viewpoint has been utilized to address issues within families. This method has traditionally emphasized a focus on deficits, disorders, or problems in clinical and nursing intervention [1]. However, this deficit-focused approach in clinical settings leads to two significant issues. Firstly, it overlooks the inherent strengths and capabilities families possess, which enable them to navigate through crises. Secondly, it portrays families as incapable of resolving their challenges or reaching their objectives without professional intervention. In this perspective, caregivers must always give solutions for family’s crises. This approach has been considered a disadvantage in that it ignores the power inherent in the family and that the medical teams take the lead in solving the family’s problems.
For these reasons, many professionals have sought to approach family crises from different perspectives, and positive psychological perspectives have become a major acceptance point. Positive psychology is defined as the scientific exploration of life experiences that lead to increased positive functionality and reduced negative impacts [5]. It examines the conditions and processes that promote the thriving or optimal performance of individuals, groups, and institutions [6]. Within this framework, and similar to the strengths-based approach, a key characteristic of families considered is their inherent strengths. There’s a growing movement towards transitioning clinical and nursing intervention with families from focusing on their deficits to highlighting and building upon their strengths [7,8].
As previously mentioned, families are basic units that play a central role in one’s life and have a set of various characteristics. Family strength is a characteristic commonly observed in strong families [1]. Strong families play a pivotal role in shaping vibrant communities and cultures, which in turn, contribute to the nurturing of families [2]. Furthermore, individuals raised in strong families are likely to find it easier to establish their own resilient family units in adulthood [9]. Hence, comprehending the essence of family strength is vital for nurturing resilient individuals and constructing a resilient society.
Family strength is not about structure, it’s about function [2]. It is an independent property of family structure such as single-parent, nuclear, and so on. While there are various family structures, family strength is not a characteristic based solely on structure, and even families with deficits can exhibit strength. In summary, family strength is that cannot be conceived outside of the family. That is, family strength appears to be influenced insignificantly by its structure, even though it is fundamentally based on the family, which is the most basic group across all sociocultural contexts [10].
Despite the existing definitions of family strength and the development of various tools in previous studies from 1970s to present [11,12], the need for a concept analysis of family strength remains crucial. Various definitions and tools related to family strength are often used interchangeably, leading to a situation where these tools measure different sub-factors and sometimes assess consequences or empirical referents rather than core attributes. This indicates that the concept of family strength can be interpreted in various ways within academic discussions, necessitating a definition that includes common and essential attributes.
Although social context and family structure may change, the core attributes of family strength are thought to be continuous. This study aims to provide a stable framework for evaluating and improving family strength by establishing well-defined characteristics that consistently represent family strength, regardless of changing social norms or family configurations. By employing a consistent definition, researchers and practitioners can communicate using the same language, evaluate family strength uniformly, and develop effective intervention strategies. For example, to prevent confusion caused by the mixed use of similar concepts such as family health or family resilience, it is essential to clearly define and distinguish these concepts.
This analysis not only strengthens the theoretical foundation of family resilience but also ensures that interventions and policies are built on a solid and unchanging foundation. This approach will provide continuity in understanding family strength across different generations and cultural changes, thereby supporting effective strategies for universal and applicable family well-being that endure over time. Therefore, this study aims to clarify the ambiguous attributes of family strength using the Walker & Avant method for concept analysis [13].
METHODS
1. Study Design and Method
This is a concept analysis study using Walker & Avant’s method to identify the clear attributes of ‘family strength’ and clarify the concept [13].
2. Data Collection: Searching Strategy
For the analysis, the initial literature search was conducted from April 23rd to May 20th, 2023, using ‘family strength’ and ‘family strengths’ in all fields from the following bibliographic databases: Pubmed, CINAHL, EMBASE, PsycARTICLES, MEDLINE. The inclusion criteria for literature in this study were articles (1) written in Korean or English, (2) provided a full text, and (3) detailed the concept and characteristics of family strength. The exclusion criteria were papers that (1) didn’t explain the concept and (2) were conference presentation materials.
The process of literature selection was carried out by reviewing the search terms, titles and abstracts, and full text sequentially. The database search resulted in a total of 829 articles at first. After eliminating all duplicates and applying inclusion and exclusion criteria, and including researches verified through additional searches in ERIC and PMUSE, from April 22nd to May 20th, 2024. As a result of additional searches, a total of 136 articles were found, and ultimately 4 articles were selected and included. Finally, a total of 35 pieces of literature were reviewed (Figure 1).
3. Process of Analysis
The concrete analysis process using Walker & Avant’s methods as follows [13]:
(1) Select a concept.
(2) Determine the aims or purposes of analysis.
(3) Identify all uses of the concept that can be discovered.
(4) Determine the defining attributes.
(5) Identify a model case.
(6) Identify borderline, related, and contrary cases.
(7) Identify antecedents and consequences.
(8) Define empirical referents.
In this study, the step (1) and (2) were described in the introduction. The next steps will be considered in the results.
RESULTS
1. Uses of the Concept: Family Strength
1) In dictionary
“Family strength” is a compound term, and to understand it, we can break it down and examine the meanings of each word. The term “family” is defined by Oxford Press as (1) a group of one or more parents and their children living together as a unit,(2) all the descendants of a common ancestor,(3) a group of related things [14]. Collins Dictionary defines it as a primary social group consisting of parents and their offspring, the principal function of which is provision for its members. From an ecological perspective, it is defined as a group of organisms of the same species living together in a community [14].
On examining the term “strength,” Oxford Press primarily defines it as (1) the quality or state of being physically strong, encompassing (a) the influence or power possessed by a person, organization, or country, (b) the degree of intensity of a feeling or belief, (c) the extent to which an argument or case is sound or convincing, and (d) the potency, intensity, or speed of a force or natural agency. It also defines it as (2) the capacity of an object or substance to withstand great force or pressure and mentions (a) the emotional or mental qualities necessary in dealing with difficult or distressing situations. Other meanings include (3) the potency or degree of concentration of a drug, chemical, or drink, (4) a good or beneficial quality or attribute of a person or thing, and (5) the number of people comprising a group, typically a team or army [15].
Therefore, from the dictionary definitions, we can infer that “family strength” refers to the characteristics possessed by a primary ‘social’ group, the family, which can include psychosocial and objective potency, resistance to stressors, and a group of members who typically form a team.
2) In nursing science
In nursing, the concept of ‘family strength’ is often used as a critical characteristic in patient care, especially in family-focused. This concept reflects the innate power of families in responding to health challenges. Nursing researchers assess this to develop interventions. It can be improving family health outcomes. By identifying what makes some families resilient in the face of health challenges, researchers can design interventions to foster those qualities in other families.
In nursing articles, definitions of . Xyrakis N, family strength are various but similar. Emphasizes positive interactions between family members, rational resolution of conflicts, and positive interactions with the outside of the family, relationships, moving forward in the face of adversity, stability and flexibility within the family system, and so on [10] (Table 1). By reviewing this perspective, it is same as the definition in the dictionary.
3) In psychology and family therapist
From this perspective, the use of the concept ‘family strength’ is essentially similar to its application in nursing. Both psychologists and family therapists strive to resolve inherent issues within the family through counseling, which parallels the viewpoint of nurses providing care. They understand that harnessing family strength can promote healthier coping strategies, resilience, and overall wellbeing of the family. And this approach emphasizes a shift from a problem-centered perspective to a strength-based one, encouraging families to recognize, build upon, and leverage their inherent strengths to enhance their ability to manage difficulties and promote healthier family dynamics.
In studies, definitions of family strength are as follows. Role flexibility, protection against adversities, family bonding, doing health activities with one another, keeping children safe, supporting individual and family well-being, education, emotional health, interpersonal skills and so on [16,17] (Table 1).
4) In educational science
From an educational perspective, family strength is recognized as a crucial factor influencing students’ overall development and academic achievement. Previous studies indicate that strong families are characterized by possessing family strengths [12,18,19]. These strengths within a family play a significant role in enhancing students’ academic performance by providing emotional stability and economic support [18,20]. Indeed, family strength is utilized to understand students’ home environments and to develop individualized educational strategies. For example, students from families with strong bonds and cooperative relationships are better equipped to overcome academic stress and challenges, serving as a critical support system. Studies have shown that active family involvement and support contribute to higher academic achievement and school engagement [19]. Additionally, family participation is effective in reducing behavioral issues and supporting academic goals. These findings reaffirm the importance of family strength in educational settings and demonstrate that various programs and policies based on this concept support the holistic development of students [18-20].
2. Defining Attributes
Attributes of the concept ‘family strength’ are the characteristics that appear regularly and repeatedly in the literature and are present when the concept occurs consistently [13]. In this study, three attributes were derived through an integrative review of the use of the concept.
1) Family cohesion
This attribute pertains to the strong and flexible emotional bonding, mutual affection, and sense of togetherness among family members. It’s about how family members feel connected to each other, the levels of warmth, love, and emotional intimacy they share. Family cohesion can often reflect the emotional climate of a family and how supportive and secure members feel within their family unit.
There are many definitions and expressions including the attribute, family cohesion. According to these definitions, family strength refers to the qualities within relationships that contribute to the well-being and emotional health of the families. Others say family strength is characteristic such as displaying a commitment to family and cohesive family functioning. And the phenomenon of family strength involves being in connection with both oneself and others. In addition to these, family cohesion appears in various ways such as family bonding. Strong family ties and builds blocks for the family well-being et cetera [16]. Through the integrative review of these definitions, family cohesion was determined to be one of the attributes of family strength.
2) Family coping capacity
Family coping capacity refers to the ability of a family as a whole to effectively manage, adapt to, and overcome stressors, adversities, or crises. It means a potential for maintain family system. Due to this attribute, family strength becomes particularly apparent in times of crisis. This observable characteristic under crisis is based on a coping strategy or mechanism rooted in family coping capacity. This coping ability also repeatedly emerges as an essential feature across various literature. Specifically, family strength enables families to progress in the face of adversity and overcome, protect against harmful effects, and offer the greatest protective effect for youth living in adversity, and so on. Most of the literature defines family strength in a manner similar to what has been previously mentioned. This aligns well with the dictionary definition of strength, which is confirmed as the ability to withstand adversity, indicating that such features of strength are well manifested in adversity. This feature can be seen as a coping capacity.
3) Family engagement
This typically refers to the active involvement of all family members in family decisions, activities, and roles. In other words, it means how family members behave towards each other in terms of cooperation and contribution. It’s about how actually each member contributes to the functioning of the family unit, taking responsibility, and participating in shared tasks or decision-making processes. It is referred to as a set of relationships, connections, and processes that protect and uphold families and their members, interaction patterns, social skills and competencies, working and playing together, and role performing.
3. Model Case
A model case is an actual example of the concept ‘family strength’ that illustrates every the defining attributes [13]. Kate’s original family consists of her parents, her sister, and herself. Kate, being a nurse, left her hometown, Busan, to reside alone in Seoul for her work. Despite the distance, she keeps in constant contact with her family, conversing daily with her parents over the phone and sharing everyday happenings with her sisters through chat using social media. Her family shares events and daily occurrences and support each other consistently (show family cohesion). One day, Kate’s mother was diagnosed with cerebral infarction after experiencing symptoms of weakened strength in one half of her body. She was quickly admitted to the hospital for stent insertion, with her father accompanying her mother to provide additional care. Throughout her mother’s treatment period, Kate’s family swiftly organized their roles to facilitate quick return to normalcy (exhibit family coping capacity). Kate’s sisters decided to take on household responsibilities, and father agreed to oversee their mother’s medical care. Despite the considerable distance between her residence and her parents’ hospital, Kate participated actively in medical consultations and even took leave on the day of the surgery to be by her parents’ side in Busan (illustrating the family engagement). Kate’s family dealt with the experience of their mother’s illness together (exhibit family coping capacity).
4. Other Additional Cases
Identifying additional cases that are completely different the concept or closely resemble to the concept is another method for refining the defining attributes. Following are borderline, related, and contrary cases.
1) Borderline case
Sue lives with her husband and two children, ages five and seven. Both Sue and her husband work full-time but they make a concerted effort to share household chores and ensure their own tasks are done thoroughly. Despite the challenges, Sue and her husband make an effort to support each other (show family cohesion). They also endeavor to be devoted to raising their children. During the daytime, working hours, Sue’s parents are taking care of the children. One day, Sue’s parents had to unexpectedly attend a funeral in a distant location. As a result, Sue’s parents could not nurture the children for two to three days. Sue hastily took a leave of absence from work to become the primary caretaker for her children during this period (exhibit family coping capacity). However, her husband, not recognizing Sue’s extra efforts, continued his usual level of participation upon returning home from work, and did not consider allocating additional time to help care for the children (don’t Show family engagement).
2) Related case
A related case is an example which lacks some of the defining attributes. It is like the concept but varies when examined in detail. In this study, related case is about ‘family resilience’.
David and his wife Karen are in their 50s and live together. A few years ago, Karen was diagnosed with liver cirrhosis but did not manage properly. Recently, she was admitted to the hospital due to rapid breathing caused by ascites and was told that there was no treatment other than liver transplantation and that her life expectancy was not long. Since they have no children, they lack a family member to donate a liver. Moreover, they were informed that they would have to wait a long time for a liver transplant as their status on the Deceased Donor Liver Transplantation (DDLT) list was not high priority. Initially, the couple was disheartened, but firmly believed there would be an alternative and began to take action for the next steps. They checked if there were any surviving relatives around Karen, and David explored the possibility of becoming a donor himself. Karen started to follow the medical instructions properly to prevent further deterioration. By chance, David was found to be a suitable donor, but due to his overweight condition and poor health, immediate donation was deemed impossible. However, David did not give up and started losing his weight for the transplantation. They never give up and have hope of getting better.
3) Contrary case
Chris lives with his parents, yet they all remain indifferent to each other’s affairs (don’t have family cohesion). Chris was accused of theft at his high school and referred to a disciplinary committee review. Despite proclaiming his innocence, the school staff did not believe him, prompting them to summon his parents. However, Chris’s parents deferred the responsibility of visiting the school to each other (don’t show family engagement), and in the end, none of them showed up at the disciplinary committee meeting. Consequently, Chris was unjustly suspended from high school (cannot exhibit family coping capacity).
5. Antecedents and Consequences
Antecedents are the incidents that must precede the occurrence of the concept, while consequences are the events that follow the emergence of the concept. These are inevitable for grasping the social contexts and the typical applications of the concept, so they must be explored [13]. In this study, there are both three antecedents and consequences.
1) Antecedents
(1) Positive communication
Positive communication could be defined as open, clear, and respectful exchanges between family members that foster understanding, trust, and emotional connection [21]. It encourages the sharing of thoughts, feelings, and experiences, promotes problem-solving, and helps to prevent misunderstandings or conflicts. Positive communication is essential for listening and building a trusting relationship where families feel comfortable sharing their viewpoints and accepting professional advice without fear of being marginalized. Consistently maintaining positive communication was crucial so ‘everyone stays informed’ and they would have ‘help if needed’. With positive communication, family members can have cohesion, make the most coping ability and engage family’s affairs based on fully understanding of the current situation.
(2) Common goals and values among families
To possess family strength, family must share common goals and values among family members. Common goals and values can foster a sense of unity and purpose within a family, fostering a shared understanding and collective focus. This can not only boost family cohesion and cooperation for family affairs but also provide a common framework for decision making and problem-solving, which represent family coping capacity.
(3) Resources: economic, spiritual, social, educational
These various types of resources can certainly contribute to family strength by enhancing the family’s coping capacity, provide opportunity to engagement or cohesion and decrease some cost for cohesion. They provide the necessary infrastructure for a family to thrive and cope with the challenges of life effectively.
Economic resources provide a family with the means to meet their basic needs and more, allowing them to focus on building strong relationships and engaging in meaningful activities together rather than constantly struggling for survival [22]. Spiritual resources such as religious faith can also contribute to family strength to supportive communities and a shared framework for understanding the world and strengthen the family’s capacity to cope with adversity. Social resources, such as supportive relationships with friends, neighbors, and community members, can also enhance family strength. Those social connections can offer practical aid, emotional support, and sense of inclusion, all of which can enhance the family’s strength, resilience and well-being. Educational resources are important as well. The level of education among family members can influence their problem-solving abilities, their understanding of health and other critical issues, and how to use such resources.
2) Consequences
(1) Growths and self-actualization of family members
Family strength fosters personal growth and development. When family members feel supported and encouraged, they are more likely to reach their full potential and achieve self-actualization. This could manifest in many aspects of life, including educational attainment, a successful career, personal satisfaction, and more.
(2) Overcome crises easily
Strong families are often characterized by resilience and effective coping strategies. They can adapt to changes and manage stress or crisis situations more effectively. They are also better at finding solutions to problems and navigating challenges, thanks to their established network of support and robust coping mechanisms.
(3) Reduce risk for family dissolution and dysfunction`
Families retaining strength are also often able to establish a supportive atmosphere that fosters mental well-being for all members, which in turn can prevent dysfunction due to family cohesion. For example, the risk of issues such as domestic violence, child neglect, divorce, or psychological disorders can be significantly reduced. This can include anything from avoiding problematic substance use to being more mindful about participating in family decision-making processes willingly. Similarly, family strength can indeed serve as a protective factor against various challenges that families might face, thereby reducing the risk of family dissolution and dysfunction.
6. Empirical Referents
The empirical referents for the attributes are classes or categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept [13]. Empirical referents show actual phenomena about concept can be observed. In this study, the concept of family strength, can be expressed in some phenomena such as spending time together or commitment. These empirical referents cannot be said to represent all attributes exactly, but they show the phenomena about family strength effectively.
The time spent together’ can be considered as good empirical referent of the family strength. When a family frequently spends quality time together, members have opportunity to share activities can range from casual everyday activities to more significant occasions such as family trips or celebrations. These shared experiences often foster mutual understanding, emotional bonds among family members. Also, ‘the time spent together’ can lead to better interpersonal relationships and cooperation and participation among family members, and it can provide opportunities for families to develop collective coping strategies. Therefore, the frequency and quality of the time family members spend together can be used as an empirical referent that is a concrete and observable for the abstract concept of family strength.
‘Displaying a commitment to family’ also can be empirical referents for family strength. In the context of ‘family strength’, commitment to family can be seen as an important indicator. This is because the commitment reflects the willingness of family members to invest time, resources, and emotional effort into maintaining and enhancing family bonds, functions, and overall well-being. It can exhibit engagement and cohesion. And based commitment, family can cope well some incidents using family coping capacity. So, the observation of expression about family commitment can provide direct, tangible evidence of the family strength.
7. Final Definition of Family Strength
As a result of analysis of ‘family strength’, antecedents, consequences, and attributes of family strengths are confirmed (Figure 2). Based this result, the final definition of family strength is as follows:
The definition of ‘family strength’ is the ability to engage in family matters and exert coping capacity, based on strong and resilient cohesion among family members.
DISCUSSION
Family strength is defined as an inherent, unique positive ability which can manifest regardless of the family’s structure. The family, as the most foundational social group, can exert various influences such as good or bad on the individual. Thus, understanding the characteristics of a family can play a vital role in managing the physical and mental health of its members, necessitating a clear understanding and utilization of the concept of family strength.
Reviewing the literature, although family strength is defined and used differently across various fields, its essence appears to be the equal. Based on these findings, this study identified and presented the antecedents, attributes, and consequences of family strength (Figure 2). Family strength is a positive characteristic of the family that emerges when there is positive communication among family members, shared common values and goals among family members, and utilization of resources. Furthermore, when family strength is manifested, it can foster growth and self-actualization from an individual perspective and reduce the risk for family dissolution and dysfunction from a family-wide perspective. This family strength consists of attributes such as family cohesion, family coping capacity, and family engagement. Observable phenomena associated with family strength included ‘spending time together’ and ‘displaying a commitment to the family’. By clearly defining these attributes of family strength, this study provides a basis for promoting the growth of families or family members and enhancing their ability to navigate through crises effectively. This study also provides several new perspectives compared to previous research. Previous studies have primarily focused on the outcomes resulting from family strength and developed tools to measure its aspects [10-12]. However, this research aims to deepen the understanding of family strength by clearly defining and analyzing the attributes of family strength, which are extensively utilized not only in medicine, nursing, and psychology but also in educational contexts.
In this study, ‘family cohesion’ emphasizes the emotional bonds and mutual support among family members, which are crucial for fostering stability and psychological well-being within the family members [18,19]. Previous research addressing aspects of family cohesion has used various terms such as ‘strong marriage’, ‘family bonding’, ‘family organization’, and ‘maintaining family cohesion’, ‘being in relation with others’ [A2,A5,A9,A31] (Table 1). However, these elements all highlight the attribute of families being closely knit through emotional bonds. Thus, the significance of this study lies in identifying and consolidating these elements into a single, common attribute.
‘Family engagement’ indicates the active participation of family members in family decision-making and activities, which enhances family functionality and strengthens family bonds, ultimately contributing to the formation of a strong family. Previous definitions have described this concept as having ‘the greatest protective effect for youth living in adversity,’ ‘good functioning including marital strengths,’ and recognizing that ‘individuals in a family are a part of one another’ [A9,A19,A22] (Table 1). These definitions imply a commitment to functioning well together within the family system.
Finally, ‘family coping capacity’ is the ability of a family to effectively respond and adapt to crises [A4,A19,A27] (Table 1). Previous research has shown this concept to be critical for family resilience, functioning as a key factor in enhancing resilience [23]. This attribute, closely related to the concept of family resilience, can significantly enhance the overall strength and adaptability of the families [A16] (Table 1).
This study aims to establish a clear and precise definition of family attributes, thereby presenting a foundation for promoting the growth of families and individual family members and enhancing their ability to navigate crises effectively. By integratively analyzing these attributes, the research elucidates the core elements of family strength and explains how each attribute contributes to the overall health and well-being of the family. This approach can significantly aid researchers and practitioners in evaluating and strengthening family health, helping them develop specific strategies to enhance family wellbeing. Consequently, it offers a critical theoretical foundation for developing and implementing various intervention strategies based on family strengths.
In fact, this study seems to be able to exert influence in various aspects. First, in nursing educational and practical aspects, it provides a foundation for incorporating family nursing education and services. Holistic nursing care providers should consider the overall health of the family as a resource that can influence the patient. Educating nurses and nursing students on methods to enhance the three attributes of family strength-family cohesion, family coping capacigy, and family engagement-will be fundamental to promoting family strength. Developing and implementing such educational programs could gradually increase the number of strong families. This approach will help not only nurses but also nursing students understand the role and importance of families both theoretically and practically.
In terms of research and practical application, this study encourages the development of new tools to measure the three identified attributes of family strength more accurately. These tools can serve as benchmarks for providing nursing programs. Additionally, this research supports the collaboration with the patient’s family in planning and executing treatment. Individual crises often require family coping capacity, which plays a crucial role in patient recovery. Therefore, it is essential to develop programs that enhance family coping abilities to respond effectively to crises. Ensuring the continuous participation of family members in the patient’s treatment process can also maximize treatment effectiveness.
And from a policy perspective, developing support policies to strengthen family capabilities can significantly enhance family strength and well-being. Improving family-centered nursing services can effectively provide various supports needed by different families. By addressing these aspects, this study provides a theoretical foundation for developing and applying various intervention strategies based on family strengths, ultimately contributing to the improvement of family health and well-being.
In this study, while efforts were made to include as many academic fields as possible in the process of concept analysis, it cannot be definitively stated that all fields were covered due to the skewed selection of databases towards the medical fields. Also, the inability to eliminate the subjective judgement of the researcher during the analysis can be considered a limitation of this study. However, given the current active research on family strength across various academic fields, there is merit in recognizing its importance and clarifying its concept.
CONCLUSION
This research preformed a concept analysis of family strength using the Walker & Avant method. The attributes of family strength were identified as family cohesion, family coping capacity, and family engagement. Through finding these attributes of family strength, it is possible to facilitate individuals’ growth and establish a foundation for developing strategies to navigate crises effectively. It is suggested that future research should focus on developing and validating assessment tools for measuring the identified attributes in this study.
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