CLINICAL SCHOLARSHIP
Swedish and South African Nursing Students’ Descriptions of Family Christen Erlingsson, PhD1 & Petra Brysiewicz, PhD2 1 Tau Omega, Associate Professor, Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden 2 Tau Lambda, Professor, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
Key words Cultural factors, family, family nursing, nursing students Correspondence Dr. Christen Erlingsson, Department of Health and Caring Sciences, Linnaeus University, 391 82 Kalmar, Sweden. E-mail: [email protected] Accepted: February 2, 2015 doi: 10.1111/jnu.12133
Abstract Purpose: The purpose of this study was to compare and contrast descriptions of “family” amongst Swedish and South African university nursing students. Design and Methods: This qualitative inquiry, using convenience sampling, explored how 232 undergraduate and postgraduate nursing students responded to a two-query, open-response questionnaire designed to elicit a definition of family and a description of who students considered to be members of their own families. Free-text responses were analyzed using manifest and qualitative content analysis. Findings: Five categories emerged from the data: Ties of Kinship, Ties of Love, Ties of Influence, Ties of Everyday Life, and Tied by Slipknots. Analysis clarified that students’ responses from both countries were addressing the same issues and as such were in general very similar. Contrasting Swedish and South African responses, a noticeable difference in proportions of responses coded into each category was evident. Three conceptualizations of family are offered: for the total sample, Swedish sample, and South African sample. Conclusions: The study provides data on students’ conceptualization of family usable in family research, nursing education, and practice as a basis for comparison, and as a starting point for discussions on the nursing of families, not only in South Africa and Sweden, but also in broader international contexts. Clinical Relevance: Because understanding family is important for healthcare providers in their everyday work, awareness about what is meant by family can assist nurses through increasing understanding of the complexities surrounding this issue and encouraging cultural sensitivity and openness to patients’ and families’ views about who is a family member.
In recent decades significant demographic changes have occurred globally in almost all aspects of society, and the concept of family is evolving with them (Cherlin, 2010; Child Trends, 2013). Family is considered a core social institution (Child Trends, 2013). Yet when considering the voluminous literature on the subject of family, it becomes clear that even after typologies have been catalogued, characteristics classified, and family member constellations sorted, we still have no consensus on how to define “family.” The evolving and open nature of family has resulted in a wide variety of definitions on a 228
continuum from very explicit to inexplicit definitions. Murdock’s (1949) classic definition of the nuclear family explicates family as “a social group characterized by common residence, economic cooperation, and reproduction. It includes adults of both sexes, at least two of whom maintain a socially approved sexual relationship, and one or more children, or adopted, of the sexually cohabiting adults” (p. 1). This can be compared to a more recent definition of family as “two or more individuals who depend on one another for emotional, physical, and economical support. The members of the family are Journal of Nursing Scholarship, 2015; 47:3, 228–236. C 2015 Sigma Theta Tau International
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self-defined” (Hanson, Gedaly-Duff, & Kaakinen, 2005, p. 7). Perhaps the most inclusive definition, developed in the area of family nursing, is one that simply states, “family is who they say they are” (Wright & Leahey, 2005, p. 60). A reluctance to include delimiting definitions of family in scientific projects can be seen in the Organization for Economic Cooperation and Development (OECD) report The Future of Families to 2030 (2011). This report is based on a broad “interpretation of the notion of family” (p. 5) that recognizes the evolving nature of modern families (OECD, 2011). Other researchers have discussed the risk for conceptual obfuscation with overly inclusive definitions (Baxter et al., 2009; Floyd, Mikkelson, & Judd, 2006). Already a quarter of a century ago it was argued that the term was so ambiguous that it ought to be dropped altogether (Bernardes, 1986). Despite voices claiming that this is an ambiguity we can live and do research by (Peters, 1999), all-inclusive definitions are a far cry from the specific and demarcated definitions commonly requisite in academic endeavors such as university education and research. Bearing in mind the diversity of our current definitions, one sees that these are also reflecting the motives of the responsible legal entity or project group that creates or utilizes the definition (Settles, 1999). Compare, for example, definitions that allow social security agents to determine who receives benefits; census takers to specify members of a household; researchers to describe the study sample and unit under investigation; or nurses to collect information on a patient’s closest relatives and whom to contact in an emergency. Even when a group of individuals self-define themselves as belonging to the same family, professionals representing different perspectives, like in the four examples above, would most likely describe four differing constellations of individuals that they officially label as family. However, when reflecting on varying definitions, one can see that these often do share an interesting attribute, that is, they seek to define family by specifying the criteria for including an individual as a member of a family, criteria based, for example, on legal ties, shared living space, and blood relations. The complexity of defining family by legalities, cohabitation, or genetics has become increasingly daunting. Coontz (2004) has observed that never before have so many forms of family coexisted in one society. This can be illustrated in examples from Sweden and South Africa. In Sweden, divorce and remarriage rates have continued to rise, resulting in an increased number of reconstituted families (Statistics Sweden, 2014), and legal recognition and rights with common-law marriages have been strengthened (Swedish Code of Statutes, 2003). Journal of Nursing Scholarship, 2015; 47:3, 228–236. C 2015 Sigma Theta Tau International
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These trends are visible in new family terminology that has evolved to accommodate changing ideas of family. Examples include expressions such as recently coined words plastmama and plastpapa (“plastic mom” and “plastic dad”), designating new stepparents or a parent’s new partner; sambo (“together living”), designating that ¨ two persons are cohabitating but not married; and sarbo (“living together apart”) for unmarried couples in a serious relationships who still live each in their own homes. In South Africa, family structure and family life have also been undergoing great changes. For example, many households in South Africa are now reported as being headed by children or grandmothers due to the effects of HIV/AIDS. Another change in family structure is the decline in the number of marriages and increasing cohabitation. Economy is thought be one of the major reasons for this, as it is very expensive to undertake the various traditional ceremonies involved in getting married. In addition, many women are now able to provide for themselves financially and do not have to rely on a man (Moore & Govender, 2013). The struggle for democracy has also involved the struggle for women’s equality and finding ways to blend the traditional with the contemporary, that is, indigenous laws and customs (e.g., polygamy) within the “new” South Africa (Andrews, 2009). Despite the plethora of varying definitions, referring to family still seems to work and be understood in everyday communications, even to the point of recognizing family in delimiting as well as in all-inclusive definitions. Why is this so? Is it because we have an innate and natural understanding of family and “know” what family means? This might very well be the case. Weigel (2008) studied laypersons’ understanding of family, demonstrating that people have prototypes, that is, have understandings of the meanings of a concept of family that color what they think about family-related issues when making decisions and interacting with others. Weigel concluded that a better understanding of laypersons’ conceptions of family is significant in the ongoing social and policy debates. However, laypersons’ views on family have been relatively neglected (Baxter et al., 2009), a situation that applies in both Sweden and South Africa. How can we come closer to a conceptualization of family that will both facilitate nursing practice and educational endeavors and support scientific rigor in an international context? One strategy would be to explore lay conceptions among stakeholders, for example, university students in different country contexts using the same study design. The aim of this study was therefore to compare and contrast personal descriptions of family amongst Swedish and South African university nursing students. 229
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Methods This qualitative inquiry was based on similar convenience samples of university nursing students in Sweden and South Africa responding to a two-question questionnaire. This questionnaire, designed by the first author, was initially used as a didactic tool in a postgraduate seminar in family nursing. The first question, “My personal definition of family is . . . ”, was phrased with the purpose of eliciting a general and abstract definition of a family. The second question, “Who is part of my family?”, requested students to describe who they considered to be members of their own family. Fascinating results of this exercise prompted our curiosity about how students define family and how well conceptions interface between different cultural environments. The questionnaire was therefore distributed to larger samples in Sweden and South Africa and analyzed as one data set with the goal of comparing and contrasting responses. Ethical approval was granted by the research ethics committee of University of KwaZulu Natal, South Africa (protocol reference number HSS/1361/010). Formal ethical approval was not required in Sweden. Permission to conduct the research was obtained from the respective university departments. Participants were informed of their right to refuse to participate or to withdraw from the study at any time; that there was no risk that such a decision would have consequences for future studies; and that all personal data would be treated confidentially. All response content that could lead to identifying participants was deleted from the data before inclusion in the final reports.
Setting and Sample Researchers recruited participants among undergraduate and postgraduate nursing students, either via online access (Sweden) or face to face (South Africa). In Sweden, the study was conducted at the School of Health and Caring Sciences, Linnaeus University (LNU), Kalmar. Basic nursing at LNU is a six-semester bachelor of nursing degree program. Postgraduate studies include certificates in advanced practice, as well as master’s and PhD degree programs. Swedish students generally have very good computer skills, and the great majority of Swedish university students own their own computer, tablet, or smartphone. At LNU, 149 students responded: 99 undergraduate students and 50 postgraduate students. In South Africa, a matching sample of undergraduate bachelor of nursing students (eight-semester program) and postgraduate students participated at the Discipline of Nursing, University of KwaZulu Natal (UKZN),
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Durban. UKZN offers a variety of nursing programs ranging from certificates in nursing, undergraduate degrees, master’s, and PhD programs. Computer literacy among South African students varies greatly, and many students do not own their own computer. At UKZN, 105 nursing students responded: 63 undergraduate bachelor of nursing students and 42 postgraduate students.
Data Collection Participants in Sweden and South Africa were requested to provide demographic data (sex, age, and educational program) and responses to the two queries. C (http://www.textalk. In Sweden, Textalk WebSurvey se/websurvey/), an online program, was used to disseminate the questionnaire by sending an e-mail containing a link to Textalk to registered student addresses connected to the School of Health and Caring Sciences. A reminder e-mail was sent after 2 weeks. Students were in no way obligated to answer the survey, and no identifying data were input into the system when responses were automatically saved in the online web survey program. Responding to the survey could be done only once, but there was no time limit on how long participants could take to fill in responses nor was there a limit on response length. In South Africa, the questionnaire, printed on one side of a sheet of paper, was distributed by the second author to students currently attending classes. Questionnaires were disseminated after being granted permission to do so by the teacher as well as the students. The students were given as much time as they needed to complete the questionnaire, which was collected at the end of classroom sessions. Data were collected at LNU and UKZN over 3 months, from September to November 2011.
Data Analysis Responses were analyzed conjunctly by both researchers in face-to-face meetings in South Africa in 2012. First, an electronic database of participants’ demographic information and questionnaire responses was saved on a computer and protected by a password, known only to the researchers. During the process of uploading data, it was noted that responses from 9 Swedish and 2 South African undergraduates and 8 Swedish and 3 South African postgraduates lacked definitions of family. Therefore, continued data analysis was based on responses from 232 students: 132 Swedish and 100 South African (Table 1). Analysis was conducted using content analysis. The analysis procedure was inductive, and a blend of quantitative and qualitative elements exploring both manifest
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Table 1. Age and Sex of Sample Included in Data Analysis Age (years)
Total sample (N = 232) Swedish (Sw) group (n = 132) Sw undergraduates (n = 90) Sw postgraduates (n = 42) South Africa (SA) group (n = 100) SA undergraduates (n = 61) SA postgraduates (n = 39)
Range
Type value
Mean (median)
Female
Male
17–55 20–54 20–48 22–54 17–55 17–35 25–55
20 20 20 39 20 20 33
29 (27) 30 (29) 26 (23) 37 (36) 27.5 (23) 21.5 (21) 37.5 (37)
85% 89% 93% 81% 80% 77% 85%
15% 11% 7% 19% 20% 23% 15%
content (i.e., visible in the text and countable) and latent content (i.e., the meaning conveyed by the text; Berg ¨ 2008). Initially, responses & Lune, 2014; Elo & Kyngas, from the total student sample were read and reread in order to discern general patterns in the whole data set and identify meaning units in the individual responses. Two patterns were immediately recognizable. One pattern was that, rather than eliciting first an abstract definition (query 1) then a personal description (query 2), students instead were describing their own families in responses to both queries. A typical response to query 1 was composed of text with descriptive adjectives and adverbs. Query 2 was typically lists of family members. Based on this observation, each student’s answers to queries 1 and 2 were therefore combined. A second, noticeable pattern was that responses were typically very short and concise. Therefore, the process often suggested in content analysis descriptions of condensation, that is, shortening a meaning unit while retaining the core meaning (Graneheim & Lundman, 2004), was very limited. Condensation was utilized solely when expedient for coding longer responses. The next step was coding meaning units based on manifest content. Following this was an interpretative reading of the latent meaning conveyed by the coded data that enabled grouping codes into categories (Berg & Lune, 2014; Table 2). In a final analysis move, country level data were compared and contrasted. At this point it was also determined whether it would be meaningful to compare additional subgroups within the data set considering, for example, educational level, age, or sex. However, analysis showed that the Swedish and South African samples were very similar (see Table 2). Postgraduate participants in particular were comparable in age as well as proportion of female and male participants. In the total sample (N = 232) there were 34 males (15%). This relatively small number of male participants and similar response patterns for female and male participants inhibited the meaningfulness
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Sex
of comparing response patterns based on sex. Analysis of demographic data showed that besides country-level data, the only other data comparison that would support study validity was analysis of subgroups formed by undergraduates (Swedish undergraduates [Sw-UG] and South African undergraduates [SA-UG]) and postgraduates (Swedish postgraduates [Sw-PG] and South African postgraduates [SA-PG]).
Findings There were 485 meaning units (Sw-UG 167; Sw-PG 79; SA-UG 157; SA-PG 82) located in the data. Analysis resulted in 18 codes that were sorted into five categories: r Ties of Kinship (codes: lineage, legal connection) r Ties of Love (codes: caring, shared resources, personal support, shared special moments, constancy of family, trust and security, and being close) r Ties of Influence (codes: shared ideology & beliefs, grew up together, importance of place, duty, and people who have made a difference) r Ties of Everyday Life (codes: shared shelter and shared day-to-day living) r Tied by Slipknots (codes: family can fluctuate and family is a personal choice) Analysis procedure clarified that Swedish and South African nursing students were addressing the same issues and as such were very similar. Noteworthy, though, are the differing proportions of meaning units coded into each category in the Swedish and South African groups (Figure 1) and on subgroup levels (Figure 2). Results from male and female participants showed comparable proportions of meaning units coded into four of five categories. That said, analysis did reveal one finding that “stood out” concerning male responses that will be noted under the subheading “Tied by Slipknots.” Based on similarities and differences in the findings, three conceptualizations of family are proposed: for the total sample, for the Swedish sample, and for the South African sample (see Figure 1).
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Table 2. Example of Content Analysis Coding and Categorization Questionnaire response
Meaning units
Code
Category
“A person’s family is more than just sharing genetics and a name. Your family is the people who are closest to you. They are the people who will support you in your time of need. They will also be there for you in good times and bad times. I have many relatives. However, the people I would actually call my family are my mother, father, brother, grandmother, grandfather and uncle. These are the people I grew up with and live with.” (South Africa undergraduate)
Family is sharing genetics and a name.
Lineage
Ties of Kinship
Family is people who are closest to you. Family is people who will support you in your time of need. Family is people who will . . . be there for you in good times and bad times. I have many relatives. However I specify the people I would actually call my family. Family is the people I grew up with. Family is the people I . . . live with.
Being close
Ties of Love
Personal support
Ties of Love
Constancy of family
Ties of Love
Family is a personal choice
Tied by Slipknots
Grew up together
Ties of Influence
Shared shelter
Ties of Everyday Life
Ties of Kinship In this category, participants were describing the family as united based on shared genes and/or inclusion into a family through legal or other formal ties. “A small group that I have a biological connection to or intentions to create a new biological connection with” (SwUG, male). Comparing the Swedish and South African student groups, South African responses were addressing Ties of Kinship much more often than the Swedish responses (see Figure 1). Although Swedish and South African responses were very similar concerning type of content, South African responses often described family through kinship ties, sharing the same surname and thus having ancestral connections. It is a big line of people who are coming from the same ancestors . . . and may or may not be living in the same territory. For me, family is all people who share parental blood from ancestors to the ones who exist today. (SA-UG, female) Importance of surname and ancestral connections as part of describing “family” were totally lacking in Swedish responses.
Ties of Love This category predominated in the findings both in the total sample and in the Swedish and South African groups (see Figure 1). Ties of Love describes the definitional elements of emotional involvement, caring, trust, and personal support: “a shoulder to lean on” (SA-UG, male). 232
“A family is a support structure that shares your personal experiences, good/bad. A family are people that are there for you when you need them” (SA-UG, female). Many described sharing special moments, and the constancy of family that is always there for you. Family is those one feels secure with, can be oneself with. Trust and ‘being there’ for them. Also that they always are there for me. . . . We have many fun memories together and will always care and want what is best for each other. One loves one’s family with one’s whole heart. (Sw-UG, female) Family members were described as “close,” and the unconditional nature of love was an integral element. Descriptions of how families are “built on bonds of love” (SA-UG, female) sometimes revealed very fervent convictions about families, for example, as one participant expressed, “Those persons who truly would die so I could live . . . even killing someone . . . sacrifice others’ lives so that one may live” (Sw-UG, female).
Ties of Influence This category describes how families share values, an ideology, religion, or beliefs that are perhaps unique to one’s particular family. Family was also connected to people one has been influenced by, grew up with, or was raised by, that is, people who have made a difference in one’s life. “Family for me is those one grew up with. . . . Or it can be people one has frequent contact with especially during youth who become like family” (Sw-PG, female). “Family is a group of people . . . sharing Journal of Nursing Scholarship, 2015; 47:3, 228–236. C 2015 Sigma Theta Tau International
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Figure 1. Percentages of meaning units coded into each of the five categories resulting from content analysis, and conceptualizations of family based on findings from the total data set, Swedish student group and South African student group.
[the] same . . . ethics, religion and beliefs. They have similar way of doing things—a way that makes them one thing” (SA-UG, female).
Ties of Everyday Life Ties of everyday life describes family as those who share the same shelter. “Those one lives together with, with whom one shares a home” (Sw-UG, female). Family is also those who share interactions, activities, and resources of everyday life. South African data contained proportionately more responses about sharing resources, especially economic resources. “To me, a family sleeps under the same roof. They provide for each other and see the family as a priority in daily life” (SA-UG, female). Journal of Nursing Scholarship, 2015; 47:3, 228–236. C 2015 Sigma Theta Tau International
Tied by Slipknots Tied by slipknots describes the fluidity of the concept of family and how families are experienced as being in flux and not static or rigid structures. This category illustrates how defining family can also be an individualistic move, that is, the individual has the prerogative to define his or her own family. Students described how family composition may change over time and that defining family can be based on an individual’s perspective where the individual actively chooses from circumstance to circumstance who is included and who they exclude from their family. One finding that “stood out” is that this seemed to be an issue almost exclusively for the Swedish group; especially for males in the Sw-PG subgroup (see Figure 2). 233
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Figure 2. Proportion of meaning units in the total sample and in each category contributed by the subgroups; Swedish undergraduate (Sw-UG), Swedish postgraduate (Sw-PG), South African undergraduate (SA-UG), and South African postgraduate (SA-PG).
My definition of the concept of family is that each individual owns their own definition of who is part of their family without taking into consideration blood or legal ties. The individual’s definition is not constant, and can change over time. (Sw-PG, male)
Discussion Although nursing students from Sweden and those from South Africa emphasized different aspects and perspectives, they provided very similar and comparable descriptions of family. Similarities in findings from Swedish and South African participants indicate that there are basic perspectives in conceptualizations of family common on a global level. Koerner and Fitzpatrick (2004) have suggested defining family based on three general perspectives: (a) structural (e.g., people related through blood or relationships approved by law), (b) functional (e.g., providing material and emotional support), and (c) transactional (family members generate a sense of family identity with emotional ties and experience of a history and future). This way of defining family was indeed illustrated by findings in this study. Ties of Kinship presents a structural perspective. A functional perspective can be compared to findings in Ties of Everyday Life. A transactional perspective is visible in Ties of Love, Ties of Influence, and Tied by Slipknots. When contrasting results, greatest differences between Swedish and South African responses were seen in categories Ties of Kinship, Ties of Influence, and Tied by Slipknots. Although both Swedish and South African 234
participants’ responses were similar in Ties of Kinship, there was a greater proportion of South African responses in this category. South African responses had a strong emphasis on lineage. That one may have legitimate claims to belong to a family due to sharing the same surname was only found in the South African data. In South Africa, family often refers to a much wider circle of people than generally understood by Western definitions (Siqwana-Ndulo, 1998). Cultural aspects perhaps are at the root of this difference, especially concerning the significance of sharing a surname in South Africa. In Sweden, until a law in 1982, many carried on the patronymic tradition of deriving a newborn’s surname from the first name of the father by adding the suffix of “son.” For example, if the father is Karl Svensson the newborn is given a first name, for example Lars, and the surname Karlsson (Karl’s son). In the next generation, Lars would carry on the tradition by registering his own children with the surname Larsson. There has also been the practice in Sweden of parents, each with different surnames, contributing both their surnames to their children, for example, Svensson-Larsson. A third aspect of Swedish culture is the widespread usage of first names in both informal and formal relationships (Daun, 1996). Due to these conventions, it is possible that surnames simply do not have the same importance in Swedish culture compared to other cultures. This provides clues to why conceptualization of family based on surname was absent in the Swedish data. Differences between Swedish and South African response patterns seen in the Ties of Influence category Journal of Nursing Scholarship, 2015; 47:3, 228–236. C 2015 Sigma Theta Tau International
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may also be due to cultural dissimilarities between countries. Swedish culture can be considered paradoxical in that while there is a strong emphasis on sameness and conformity, it is a society based on individualism, social autonomy, and fostering children to be self-sufficient. The individual is legally viewed as an independent unit and the terms family and kin are relatively irrelevant and comparatively vague from a legal perspective (Daun, 1996). In contrast, South African participants agreed that it was important for a family to share a common ideology and defined family members as being important resources, physically and emotionally. This could be explained by the idea of Ubuntu. Ubuntu, an Nguni word, from the aphorism Umuntu Ngumuntu Ngabantu (“a person is a person because of or through others”), entails primary values ensuring a happy and quality community life in the spirit of family. Africans are socialized from an early age to understand that difficult goals or tasks can only be achieved collectively. This spirit of solidarity permeates every aspect of African life, including that of family life (Mbigi, 1997). Ties of Influence was an integral element in conceptualizations of family provided by participants in this study. Yet the question begs to be asked how often in practice, education, or research we consider family from a Ties of Influence perspective. One must also ask if it isn’t the researchers’ personal description of family that guides recruitment procedures without reflection on whether it might not be a viable description for these particular participants. Are we as nurses, educators, and researchers focusing too narrowly on blood and legal relationship (cf. Ties of Kinship) or if persons live together (cf. Ties of Everyday Life)? If so, it may be time to broaden our views to include conceptualizations held among laypersons, for example, laypersons from within our own ranks, such as the nursing students who participated in this study. Circumstances such as evolving cultural values, changing demographics, and consequences of HIV/AIDS support a general trend toward increasing the inclusiveness of definitions and opening up delimiting definitions of family to be a better match to increasing diversity in family forms and living situations around the world. Examples of this can be found in global reports (cf. Child Trends, 2013) as well as in nursing curriculum (cf. Hanson et al., 2005). One, perhaps unexpected, result of this trend could be what Swedish students were indicating in their responses in Tied by Slipknots. Students seemed to be interpreting the inclusiveness of modern definitions such as “family is who they say they are” (Wright & Leahey, 2005, p. 60) as allowing for extremely flexible and changeable descriptions, providing opportunities for exclusion when describing one’s family. Journal of Nursing Scholarship, 2015; 47:3, 228–236. C 2015 Sigma Theta Tau International
Understanding conceptualizations of family is most likely of great importance for the unfolding of future scenarios concerning issues of global equality and inequality, stability and instability, and distribution and sharing of resources (Child Trends, 2013). Although our world is fast becoming a global community, we must ask if definitions of family are global, that is, transferable from one country to another, or if each country must seek to define family based on cultural and local parameters. Nursing education focusing on the problematics of conceptualizing family, together with increased nursing research that provides a basis for comparison between nations, seems pivotal for increasing understanding of what is meant by family in a global community. The similarity in conceptualizations of family derived from findings of the current study (see Figure 1) lends hope for increased transferability of knowledge, education, and research in nursing regarding families.
Limitations This study showed differences between Swedish and South African responses. We have made an assumption that these differences were due primarily to cultural aspects. Further studies with larger samples would be needed in order to validate this and to investigate how participants’ sex or age perhaps also influences responses. Additional demographic information regarding the participants’ marital status and if they had children of their own could also have enriched the data and should be included in future investigations with this questionnaire.
Conclusions and Recommendations Findings from this current study contribute data to facilitate conceptualization of family in nursing education and in family research, not only in South Africa and Sweden, but also in broader international contexts. Responding to the questionnaire hopefully also provides participating nursing students with an opportunity to reflect on their own assumptions about family. Understanding family is important for healthcare providers in their everyday work and perhaps especially in countries with great cultural diversity, such as South Africa. Yet it might be even more vital to be aware of variations and similarities in describing family in countries such as Sweden, where many, despite increasing cultural diversity, still perceive themselves to live in a fairly homogenous society (Daun, 1996). Awareness about what is meant by family can assist nurses in their daily work through increasing understanding of the complexities surrounding this issue and 235
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encouraging cultural sensitivity and openness to patients’ and families’ views about who is a family member. It can also be posited that other students in diverse areas of studies would also benefit from an opportunity to reflect over personal and general definitions of family. Researchers are encouraged to take results of this study under consideration when formulating descriptions of family samples and being as precise as possible when naming families as participants.
Clinical Resources
r r
Organization for Economic Cooperation and Development. The future of families to 2030. http://dx.doi.org/10.1787/9789264168367-en Child Trends. World family map 2013: Mapping family change and child well-being outcomes. http://worldfamilymap.org/2013/
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¨ H. (2008). The qualitative content analysis Elo, S., & Kyngas, process. Journal of Advanced Nursing, 62(1), 107– 115. Floyd, K., Mikkelson, A. C., & Judd, J. (2006). Defining the family through relationships. In L.H. Turner & R. West (Eds.), The family communication sourcebook (pp. 21–39). Thousand Oaks, CA: Sage. Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures, and measures to achieve trustworthiness. Nurse Education Today, 24, 105–112. Hanson, S., Gedaly-Duff V., & Kaakinen J. R. (2005). Family health care nursing. Theory, practice & research (3rd ed.). Philadelphia, PA: F.A. Davis. Koerner, A. F., & Fitzpatrick, M. A. (2004). Communication in intact families. In A. L. Vangelisti (Ed.), Handbook of family communication (pp. 177–195). Mahwah, NJ: Lawrence Erlbaum Associates. Mbigi, L. (1997). Ubuntu: The African dream in management. Randburg, South Africa: Knowledge Resources. Moore, E., & Govender, R. (2013). Marriage and cohabitation in South Africa: An enriching explanation? Journal of Comparative Family Studies, 44(5), 623–639. Murdock, G. P. (1949). Social structure. New York, NY: Macmillan. Organization for Economic Cooperation and Development (OECD). (2011). The future of families to 2030. Projections, policy challenges and policy options; a synthesis report. International Futures Program. Peters, J. (1999). Redefining western families. Marriage and Family Review, 28(3/4), 55–66. Settles, B. H. (1999). Definitions of the family: Professional and personal issues. Marriage and Family Review, 28(3/4), 209–224. Siqwana-Ndulo, N. (1998). Rural African family structure in the Eastern Cape Province, South Africa. Journal of Comparative Family Studies, 29(2), 407–417. Statistics Sweden. (2014). Statistical database: Population. ˚ Retrieved from Stockholm: Statistiska Centralbyran. http://www.scb.se/ Swedish Code of Statutes. (2003). Cohabitees (2003:376). Stockholm, Sweden: Ministry of Justice. Weigel, D. (2008). The concept of family: An analysis of laypeople’s views of family. Journal of Family Issues, 29(11), 1426–1447. Wright, L. M., & Leahey, M. (2005). Nurses and families: A guide to family assessment and intervention (4th ed.). Philadelphia, PA: F. A. Davis.
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Swedish and South African Nursing Students’ Descriptions of Family Christen Erlingsson, PhD1 & Petra Brysiewicz, PhD2 1 Tau Omega, Associate Professor, Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden 2 Tau Lambda, Professor, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
Key words Cultural factors, family, family nursing, nursing students Correspondence Dr. Christen Erlingsson, Department of Health and Caring Sciences, Linnaeus University, 391 82 Kalmar, Sweden. E-mail: [email protected] Accepted: February 2, 2015 doi: 10.1111/jnu.12133
Abstract Purpose: The purpose of this study was to compare and contrast descriptions of “family” amongst Swedish and South African university nursing students. Design and Methods: This qualitative inquiry, using convenience sampling, explored how 232 undergraduate and postgraduate nursing students responded to a two-query, open-response questionnaire designed to elicit a definition of family and a description of who students considered to be members of their own families. Free-text responses were analyzed using manifest and qualitative content analysis. Findings: Five categories emerged from the data: Ties of Kinship, Ties of Love, Ties of Influence, Ties of Everyday Life, and Tied by Slipknots. Analysis clarified that students’ responses from both countries were addressing the same issues and as such were in general very similar. Contrasting Swedish and South African responses, a noticeable difference in proportions of responses coded into each category was evident. Three conceptualizations of family are offered: for the total sample, Swedish sample, and South African sample. Conclusions: The study provides data on students’ conceptualization of family usable in family research, nursing education, and practice as a basis for comparison, and as a starting point for discussions on the nursing of families, not only in South Africa and Sweden, but also in broader international contexts. Clinical Relevance: Because understanding family is important for healthcare providers in their everyday work, awareness about what is meant by family can assist nurses through increasing understanding of the complexities surrounding this issue and encouraging cultural sensitivity and openness to patients’ and families’ views about who is a family member.
In recent decades significant demographic changes have occurred globally in almost all aspects of society, and the concept of family is evolving with them (Cherlin, 2010; Child Trends, 2013). Family is considered a core social institution (Child Trends, 2013). Yet when considering the voluminous literature on the subject of family, it becomes clear that even after typologies have been catalogued, characteristics classified, and family member constellations sorted, we still have no consensus on how to define “family.” The evolving and open nature of family has resulted in a wide variety of definitions on a 228
continuum from very explicit to inexplicit definitions. Murdock’s (1949) classic definition of the nuclear family explicates family as “a social group characterized by common residence, economic cooperation, and reproduction. It includes adults of both sexes, at least two of whom maintain a socially approved sexual relationship, and one or more children, or adopted, of the sexually cohabiting adults” (p. 1). This can be compared to a more recent definition of family as “two or more individuals who depend on one another for emotional, physical, and economical support. The members of the family are Journal of Nursing Scholarship, 2015; 47:3, 228–236. C 2015 Sigma Theta Tau International
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self-defined” (Hanson, Gedaly-Duff, & Kaakinen, 2005, p. 7). Perhaps the most inclusive definition, developed in the area of family nursing, is one that simply states, “family is who they say they are” (Wright & Leahey, 2005, p. 60). A reluctance to include delimiting definitions of family in scientific projects can be seen in the Organization for Economic Cooperation and Development (OECD) report The Future of Families to 2030 (2011). This report is based on a broad “interpretation of the notion of family” (p. 5) that recognizes the evolving nature of modern families (OECD, 2011). Other researchers have discussed the risk for conceptual obfuscation with overly inclusive definitions (Baxter et al., 2009; Floyd, Mikkelson, & Judd, 2006). Already a quarter of a century ago it was argued that the term was so ambiguous that it ought to be dropped altogether (Bernardes, 1986). Despite voices claiming that this is an ambiguity we can live and do research by (Peters, 1999), all-inclusive definitions are a far cry from the specific and demarcated definitions commonly requisite in academic endeavors such as university education and research. Bearing in mind the diversity of our current definitions, one sees that these are also reflecting the motives of the responsible legal entity or project group that creates or utilizes the definition (Settles, 1999). Compare, for example, definitions that allow social security agents to determine who receives benefits; census takers to specify members of a household; researchers to describe the study sample and unit under investigation; or nurses to collect information on a patient’s closest relatives and whom to contact in an emergency. Even when a group of individuals self-define themselves as belonging to the same family, professionals representing different perspectives, like in the four examples above, would most likely describe four differing constellations of individuals that they officially label as family. However, when reflecting on varying definitions, one can see that these often do share an interesting attribute, that is, they seek to define family by specifying the criteria for including an individual as a member of a family, criteria based, for example, on legal ties, shared living space, and blood relations. The complexity of defining family by legalities, cohabitation, or genetics has become increasingly daunting. Coontz (2004) has observed that never before have so many forms of family coexisted in one society. This can be illustrated in examples from Sweden and South Africa. In Sweden, divorce and remarriage rates have continued to rise, resulting in an increased number of reconstituted families (Statistics Sweden, 2014), and legal recognition and rights with common-law marriages have been strengthened (Swedish Code of Statutes, 2003). Journal of Nursing Scholarship, 2015; 47:3, 228–236. C 2015 Sigma Theta Tau International
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These trends are visible in new family terminology that has evolved to accommodate changing ideas of family. Examples include expressions such as recently coined words plastmama and plastpapa (“plastic mom” and “plastic dad”), designating new stepparents or a parent’s new partner; sambo (“together living”), designating that ¨ two persons are cohabitating but not married; and sarbo (“living together apart”) for unmarried couples in a serious relationships who still live each in their own homes. In South Africa, family structure and family life have also been undergoing great changes. For example, many households in South Africa are now reported as being headed by children or grandmothers due to the effects of HIV/AIDS. Another change in family structure is the decline in the number of marriages and increasing cohabitation. Economy is thought be one of the major reasons for this, as it is very expensive to undertake the various traditional ceremonies involved in getting married. In addition, many women are now able to provide for themselves financially and do not have to rely on a man (Moore & Govender, 2013). The struggle for democracy has also involved the struggle for women’s equality and finding ways to blend the traditional with the contemporary, that is, indigenous laws and customs (e.g., polygamy) within the “new” South Africa (Andrews, 2009). Despite the plethora of varying definitions, referring to family still seems to work and be understood in everyday communications, even to the point of recognizing family in delimiting as well as in all-inclusive definitions. Why is this so? Is it because we have an innate and natural understanding of family and “know” what family means? This might very well be the case. Weigel (2008) studied laypersons’ understanding of family, demonstrating that people have prototypes, that is, have understandings of the meanings of a concept of family that color what they think about family-related issues when making decisions and interacting with others. Weigel concluded that a better understanding of laypersons’ conceptions of family is significant in the ongoing social and policy debates. However, laypersons’ views on family have been relatively neglected (Baxter et al., 2009), a situation that applies in both Sweden and South Africa. How can we come closer to a conceptualization of family that will both facilitate nursing practice and educational endeavors and support scientific rigor in an international context? One strategy would be to explore lay conceptions among stakeholders, for example, university students in different country contexts using the same study design. The aim of this study was therefore to compare and contrast personal descriptions of family amongst Swedish and South African university nursing students. 229
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Methods This qualitative inquiry was based on similar convenience samples of university nursing students in Sweden and South Africa responding to a two-question questionnaire. This questionnaire, designed by the first author, was initially used as a didactic tool in a postgraduate seminar in family nursing. The first question, “My personal definition of family is . . . ”, was phrased with the purpose of eliciting a general and abstract definition of a family. The second question, “Who is part of my family?”, requested students to describe who they considered to be members of their own family. Fascinating results of this exercise prompted our curiosity about how students define family and how well conceptions interface between different cultural environments. The questionnaire was therefore distributed to larger samples in Sweden and South Africa and analyzed as one data set with the goal of comparing and contrasting responses. Ethical approval was granted by the research ethics committee of University of KwaZulu Natal, South Africa (protocol reference number HSS/1361/010). Formal ethical approval was not required in Sweden. Permission to conduct the research was obtained from the respective university departments. Participants were informed of their right to refuse to participate or to withdraw from the study at any time; that there was no risk that such a decision would have consequences for future studies; and that all personal data would be treated confidentially. All response content that could lead to identifying participants was deleted from the data before inclusion in the final reports.
Setting and Sample Researchers recruited participants among undergraduate and postgraduate nursing students, either via online access (Sweden) or face to face (South Africa). In Sweden, the study was conducted at the School of Health and Caring Sciences, Linnaeus University (LNU), Kalmar. Basic nursing at LNU is a six-semester bachelor of nursing degree program. Postgraduate studies include certificates in advanced practice, as well as master’s and PhD degree programs. Swedish students generally have very good computer skills, and the great majority of Swedish university students own their own computer, tablet, or smartphone. At LNU, 149 students responded: 99 undergraduate students and 50 postgraduate students. In South Africa, a matching sample of undergraduate bachelor of nursing students (eight-semester program) and postgraduate students participated at the Discipline of Nursing, University of KwaZulu Natal (UKZN),
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Durban. UKZN offers a variety of nursing programs ranging from certificates in nursing, undergraduate degrees, master’s, and PhD programs. Computer literacy among South African students varies greatly, and many students do not own their own computer. At UKZN, 105 nursing students responded: 63 undergraduate bachelor of nursing students and 42 postgraduate students.
Data Collection Participants in Sweden and South Africa were requested to provide demographic data (sex, age, and educational program) and responses to the two queries. C (http://www.textalk. In Sweden, Textalk WebSurvey se/websurvey/), an online program, was used to disseminate the questionnaire by sending an e-mail containing a link to Textalk to registered student addresses connected to the School of Health and Caring Sciences. A reminder e-mail was sent after 2 weeks. Students were in no way obligated to answer the survey, and no identifying data were input into the system when responses were automatically saved in the online web survey program. Responding to the survey could be done only once, but there was no time limit on how long participants could take to fill in responses nor was there a limit on response length. In South Africa, the questionnaire, printed on one side of a sheet of paper, was distributed by the second author to students currently attending classes. Questionnaires were disseminated after being granted permission to do so by the teacher as well as the students. The students were given as much time as they needed to complete the questionnaire, which was collected at the end of classroom sessions. Data were collected at LNU and UKZN over 3 months, from September to November 2011.
Data Analysis Responses were analyzed conjunctly by both researchers in face-to-face meetings in South Africa in 2012. First, an electronic database of participants’ demographic information and questionnaire responses was saved on a computer and protected by a password, known only to the researchers. During the process of uploading data, it was noted that responses from 9 Swedish and 2 South African undergraduates and 8 Swedish and 3 South African postgraduates lacked definitions of family. Therefore, continued data analysis was based on responses from 232 students: 132 Swedish and 100 South African (Table 1). Analysis was conducted using content analysis. The analysis procedure was inductive, and a blend of quantitative and qualitative elements exploring both manifest
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Table 1. Age and Sex of Sample Included in Data Analysis Age (years)
Total sample (N = 232) Swedish (Sw) group (n = 132) Sw undergraduates (n = 90) Sw postgraduates (n = 42) South Africa (SA) group (n = 100) SA undergraduates (n = 61) SA postgraduates (n = 39)
Range
Type value
Mean (median)
Female
Male
17–55 20–54 20–48 22–54 17–55 17–35 25–55
20 20 20 39 20 20 33
29 (27) 30 (29) 26 (23) 37 (36) 27.5 (23) 21.5 (21) 37.5 (37)
85% 89% 93% 81% 80% 77% 85%
15% 11% 7% 19% 20% 23% 15%
content (i.e., visible in the text and countable) and latent content (i.e., the meaning conveyed by the text; Berg ¨ 2008). Initially, responses & Lune, 2014; Elo & Kyngas, from the total student sample were read and reread in order to discern general patterns in the whole data set and identify meaning units in the individual responses. Two patterns were immediately recognizable. One pattern was that, rather than eliciting first an abstract definition (query 1) then a personal description (query 2), students instead were describing their own families in responses to both queries. A typical response to query 1 was composed of text with descriptive adjectives and adverbs. Query 2 was typically lists of family members. Based on this observation, each student’s answers to queries 1 and 2 were therefore combined. A second, noticeable pattern was that responses were typically very short and concise. Therefore, the process often suggested in content analysis descriptions of condensation, that is, shortening a meaning unit while retaining the core meaning (Graneheim & Lundman, 2004), was very limited. Condensation was utilized solely when expedient for coding longer responses. The next step was coding meaning units based on manifest content. Following this was an interpretative reading of the latent meaning conveyed by the coded data that enabled grouping codes into categories (Berg & Lune, 2014; Table 2). In a final analysis move, country level data were compared and contrasted. At this point it was also determined whether it would be meaningful to compare additional subgroups within the data set considering, for example, educational level, age, or sex. However, analysis showed that the Swedish and South African samples were very similar (see Table 2). Postgraduate participants in particular were comparable in age as well as proportion of female and male participants. In the total sample (N = 232) there were 34 males (15%). This relatively small number of male participants and similar response patterns for female and male participants inhibited the meaningfulness
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Sex
of comparing response patterns based on sex. Analysis of demographic data showed that besides country-level data, the only other data comparison that would support study validity was analysis of subgroups formed by undergraduates (Swedish undergraduates [Sw-UG] and South African undergraduates [SA-UG]) and postgraduates (Swedish postgraduates [Sw-PG] and South African postgraduates [SA-PG]).
Findings There were 485 meaning units (Sw-UG 167; Sw-PG 79; SA-UG 157; SA-PG 82) located in the data. Analysis resulted in 18 codes that were sorted into five categories: r Ties of Kinship (codes: lineage, legal connection) r Ties of Love (codes: caring, shared resources, personal support, shared special moments, constancy of family, trust and security, and being close) r Ties of Influence (codes: shared ideology & beliefs, grew up together, importance of place, duty, and people who have made a difference) r Ties of Everyday Life (codes: shared shelter and shared day-to-day living) r Tied by Slipknots (codes: family can fluctuate and family is a personal choice) Analysis procedure clarified that Swedish and South African nursing students were addressing the same issues and as such were very similar. Noteworthy, though, are the differing proportions of meaning units coded into each category in the Swedish and South African groups (Figure 1) and on subgroup levels (Figure 2). Results from male and female participants showed comparable proportions of meaning units coded into four of five categories. That said, analysis did reveal one finding that “stood out” concerning male responses that will be noted under the subheading “Tied by Slipknots.” Based on similarities and differences in the findings, three conceptualizations of family are proposed: for the total sample, for the Swedish sample, and for the South African sample (see Figure 1).
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Table 2. Example of Content Analysis Coding and Categorization Questionnaire response
Meaning units
Code
Category
“A person’s family is more than just sharing genetics and a name. Your family is the people who are closest to you. They are the people who will support you in your time of need. They will also be there for you in good times and bad times. I have many relatives. However, the people I would actually call my family are my mother, father, brother, grandmother, grandfather and uncle. These are the people I grew up with and live with.” (South Africa undergraduate)
Family is sharing genetics and a name.
Lineage
Ties of Kinship
Family is people who are closest to you. Family is people who will support you in your time of need. Family is people who will . . . be there for you in good times and bad times. I have many relatives. However I specify the people I would actually call my family. Family is the people I grew up with. Family is the people I . . . live with.
Being close
Ties of Love
Personal support
Ties of Love
Constancy of family
Ties of Love
Family is a personal choice
Tied by Slipknots
Grew up together
Ties of Influence
Shared shelter
Ties of Everyday Life
Ties of Kinship In this category, participants were describing the family as united based on shared genes and/or inclusion into a family through legal or other formal ties. “A small group that I have a biological connection to or intentions to create a new biological connection with” (SwUG, male). Comparing the Swedish and South African student groups, South African responses were addressing Ties of Kinship much more often than the Swedish responses (see Figure 1). Although Swedish and South African responses were very similar concerning type of content, South African responses often described family through kinship ties, sharing the same surname and thus having ancestral connections. It is a big line of people who are coming from the same ancestors . . . and may or may not be living in the same territory. For me, family is all people who share parental blood from ancestors to the ones who exist today. (SA-UG, female) Importance of surname and ancestral connections as part of describing “family” were totally lacking in Swedish responses.
Ties of Love This category predominated in the findings both in the total sample and in the Swedish and South African groups (see Figure 1). Ties of Love describes the definitional elements of emotional involvement, caring, trust, and personal support: “a shoulder to lean on” (SA-UG, male). 232
“A family is a support structure that shares your personal experiences, good/bad. A family are people that are there for you when you need them” (SA-UG, female). Many described sharing special moments, and the constancy of family that is always there for you. Family is those one feels secure with, can be oneself with. Trust and ‘being there’ for them. Also that they always are there for me. . . . We have many fun memories together and will always care and want what is best for each other. One loves one’s family with one’s whole heart. (Sw-UG, female) Family members were described as “close,” and the unconditional nature of love was an integral element. Descriptions of how families are “built on bonds of love” (SA-UG, female) sometimes revealed very fervent convictions about families, for example, as one participant expressed, “Those persons who truly would die so I could live . . . even killing someone . . . sacrifice others’ lives so that one may live” (Sw-UG, female).
Ties of Influence This category describes how families share values, an ideology, religion, or beliefs that are perhaps unique to one’s particular family. Family was also connected to people one has been influenced by, grew up with, or was raised by, that is, people who have made a difference in one’s life. “Family for me is those one grew up with. . . . Or it can be people one has frequent contact with especially during youth who become like family” (Sw-PG, female). “Family is a group of people . . . sharing Journal of Nursing Scholarship, 2015; 47:3, 228–236. C 2015 Sigma Theta Tau International
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Figure 1. Percentages of meaning units coded into each of the five categories resulting from content analysis, and conceptualizations of family based on findings from the total data set, Swedish student group and South African student group.
[the] same . . . ethics, religion and beliefs. They have similar way of doing things—a way that makes them one thing” (SA-UG, female).
Ties of Everyday Life Ties of everyday life describes family as those who share the same shelter. “Those one lives together with, with whom one shares a home” (Sw-UG, female). Family is also those who share interactions, activities, and resources of everyday life. South African data contained proportionately more responses about sharing resources, especially economic resources. “To me, a family sleeps under the same roof. They provide for each other and see the family as a priority in daily life” (SA-UG, female). Journal of Nursing Scholarship, 2015; 47:3, 228–236. C 2015 Sigma Theta Tau International
Tied by Slipknots Tied by slipknots describes the fluidity of the concept of family and how families are experienced as being in flux and not static or rigid structures. This category illustrates how defining family can also be an individualistic move, that is, the individual has the prerogative to define his or her own family. Students described how family composition may change over time and that defining family can be based on an individual’s perspective where the individual actively chooses from circumstance to circumstance who is included and who they exclude from their family. One finding that “stood out” is that this seemed to be an issue almost exclusively for the Swedish group; especially for males in the Sw-PG subgroup (see Figure 2). 233
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Figure 2. Proportion of meaning units in the total sample and in each category contributed by the subgroups; Swedish undergraduate (Sw-UG), Swedish postgraduate (Sw-PG), South African undergraduate (SA-UG), and South African postgraduate (SA-PG).
My definition of the concept of family is that each individual owns their own definition of who is part of their family without taking into consideration blood or legal ties. The individual’s definition is not constant, and can change over time. (Sw-PG, male)
Discussion Although nursing students from Sweden and those from South Africa emphasized different aspects and perspectives, they provided very similar and comparable descriptions of family. Similarities in findings from Swedish and South African participants indicate that there are basic perspectives in conceptualizations of family common on a global level. Koerner and Fitzpatrick (2004) have suggested defining family based on three general perspectives: (a) structural (e.g., people related through blood or relationships approved by law), (b) functional (e.g., providing material and emotional support), and (c) transactional (family members generate a sense of family identity with emotional ties and experience of a history and future). This way of defining family was indeed illustrated by findings in this study. Ties of Kinship presents a structural perspective. A functional perspective can be compared to findings in Ties of Everyday Life. A transactional perspective is visible in Ties of Love, Ties of Influence, and Tied by Slipknots. When contrasting results, greatest differences between Swedish and South African responses were seen in categories Ties of Kinship, Ties of Influence, and Tied by Slipknots. Although both Swedish and South African 234
participants’ responses were similar in Ties of Kinship, there was a greater proportion of South African responses in this category. South African responses had a strong emphasis on lineage. That one may have legitimate claims to belong to a family due to sharing the same surname was only found in the South African data. In South Africa, family often refers to a much wider circle of people than generally understood by Western definitions (Siqwana-Ndulo, 1998). Cultural aspects perhaps are at the root of this difference, especially concerning the significance of sharing a surname in South Africa. In Sweden, until a law in 1982, many carried on the patronymic tradition of deriving a newborn’s surname from the first name of the father by adding the suffix of “son.” For example, if the father is Karl Svensson the newborn is given a first name, for example Lars, and the surname Karlsson (Karl’s son). In the next generation, Lars would carry on the tradition by registering his own children with the surname Larsson. There has also been the practice in Sweden of parents, each with different surnames, contributing both their surnames to their children, for example, Svensson-Larsson. A third aspect of Swedish culture is the widespread usage of first names in both informal and formal relationships (Daun, 1996). Due to these conventions, it is possible that surnames simply do not have the same importance in Swedish culture compared to other cultures. This provides clues to why conceptualization of family based on surname was absent in the Swedish data. Differences between Swedish and South African response patterns seen in the Ties of Influence category Journal of Nursing Scholarship, 2015; 47:3, 228–236. C 2015 Sigma Theta Tau International
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may also be due to cultural dissimilarities between countries. Swedish culture can be considered paradoxical in that while there is a strong emphasis on sameness and conformity, it is a society based on individualism, social autonomy, and fostering children to be self-sufficient. The individual is legally viewed as an independent unit and the terms family and kin are relatively irrelevant and comparatively vague from a legal perspective (Daun, 1996). In contrast, South African participants agreed that it was important for a family to share a common ideology and defined family members as being important resources, physically and emotionally. This could be explained by the idea of Ubuntu. Ubuntu, an Nguni word, from the aphorism Umuntu Ngumuntu Ngabantu (“a person is a person because of or through others”), entails primary values ensuring a happy and quality community life in the spirit of family. Africans are socialized from an early age to understand that difficult goals or tasks can only be achieved collectively. This spirit of solidarity permeates every aspect of African life, including that of family life (Mbigi, 1997). Ties of Influence was an integral element in conceptualizations of family provided by participants in this study. Yet the question begs to be asked how often in practice, education, or research we consider family from a Ties of Influence perspective. One must also ask if it isn’t the researchers’ personal description of family that guides recruitment procedures without reflection on whether it might not be a viable description for these particular participants. Are we as nurses, educators, and researchers focusing too narrowly on blood and legal relationship (cf. Ties of Kinship) or if persons live together (cf. Ties of Everyday Life)? If so, it may be time to broaden our views to include conceptualizations held among laypersons, for example, laypersons from within our own ranks, such as the nursing students who participated in this study. Circumstances such as evolving cultural values, changing demographics, and consequences of HIV/AIDS support a general trend toward increasing the inclusiveness of definitions and opening up delimiting definitions of family to be a better match to increasing diversity in family forms and living situations around the world. Examples of this can be found in global reports (cf. Child Trends, 2013) as well as in nursing curriculum (cf. Hanson et al., 2005). One, perhaps unexpected, result of this trend could be what Swedish students were indicating in their responses in Tied by Slipknots. Students seemed to be interpreting the inclusiveness of modern definitions such as “family is who they say they are” (Wright & Leahey, 2005, p. 60) as allowing for extremely flexible and changeable descriptions, providing opportunities for exclusion when describing one’s family. Journal of Nursing Scholarship, 2015; 47:3, 228–236. C 2015 Sigma Theta Tau International
Understanding conceptualizations of family is most likely of great importance for the unfolding of future scenarios concerning issues of global equality and inequality, stability and instability, and distribution and sharing of resources (Child Trends, 2013). Although our world is fast becoming a global community, we must ask if definitions of family are global, that is, transferable from one country to another, or if each country must seek to define family based on cultural and local parameters. Nursing education focusing on the problematics of conceptualizing family, together with increased nursing research that provides a basis for comparison between nations, seems pivotal for increasing understanding of what is meant by family in a global community. The similarity in conceptualizations of family derived from findings of the current study (see Figure 1) lends hope for increased transferability of knowledge, education, and research in nursing regarding families.
Limitations This study showed differences between Swedish and South African responses. We have made an assumption that these differences were due primarily to cultural aspects. Further studies with larger samples would be needed in order to validate this and to investigate how participants’ sex or age perhaps also influences responses. Additional demographic information regarding the participants’ marital status and if they had children of their own could also have enriched the data and should be included in future investigations with this questionnaire.
Conclusions and Recommendations Findings from this current study contribute data to facilitate conceptualization of family in nursing education and in family research, not only in South Africa and Sweden, but also in broader international contexts. Responding to the questionnaire hopefully also provides participating nursing students with an opportunity to reflect on their own assumptions about family. Understanding family is important for healthcare providers in their everyday work and perhaps especially in countries with great cultural diversity, such as South Africa. Yet it might be even more vital to be aware of variations and similarities in describing family in countries such as Sweden, where many, despite increasing cultural diversity, still perceive themselves to live in a fairly homogenous society (Daun, 1996). Awareness about what is meant by family can assist nurses in their daily work through increasing understanding of the complexities surrounding this issue and 235
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encouraging cultural sensitivity and openness to patients’ and families’ views about who is a family member. It can also be posited that other students in diverse areas of studies would also benefit from an opportunity to reflect over personal and general definitions of family. Researchers are encouraged to take results of this study under consideration when formulating descriptions of family samples and being as precise as possible when naming families as participants.
Clinical Resources
r r
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