Required Text: Shajani, Z. & Snell, D. (2019). Wright & Leahey’s Nurses and families: a guide to family assessment and intervention. (7th ed). Philadelphia: F.A. Davis.
THE FOLLOWING ARE INCLUDED IN THIS POSTING:
***DETAILS OF THE ASSIGNMENT
***RUBRICS
****ARTICLES posted by the professor
***SAMPLE final paper (mine also need to follow the SAMPLE)
*** CHAPTERS 1, 3, 4, 7, 8, 9, 10, and 11 of the above book

Note, you are to use a “well” family for this paper. Be sure to use your textbook as a guide for the information to be included, and use some questions from the chapters.

DETAILS OF THE ASSIGNMENT
This clinical assignment focuses on the family system and all the subsystems that affect the family, how the family unit copes, and how the nurse can help the family maintain a state of equilibrium. In your text is an outline of the Calgary Model and how it helps in the interviewing and assessment of the family. Using this model as a guideline choose a family you know to help you complete this assignment; these should not be your own family. Be sure the family is well in that they are not dealing with a newly diagnosed chronic or acute illness. Families with long-standing chronic illnesses, such as controlled hypertension or diabetes, are acceptable. Do not choose a family with acute problems including acute psychiatric illnesses.
Contact the family and explain the project you need to complete and if they are willing to participate. Set up a meeting time to speak with family members who would be most helpful with this project. Have questions prepared concerning all of the subsystems that affect families including ethnic backgrounds, working status of family members, education, etc. You may need to meet with the family more than once. Using the family assessment summary in your text, complete a family assessment.
This assessment must include content on all of the subsystems discussed in class (Neumann’s Family Systems Theory, genogram, The Calgary Model, Family Relationships and Roles, Stages of Development, Stressors, Culture-Race and Ethnicity, Religious Influences, Health and Wellness, Employment, Finances, Education, Social Class, Community), a list of family diagnoses including strengths and problems (stressors) related to each diagnoses. Students will need to summarize their project by explaining how the family members and the family unit cope with any problems that may arise; are they able to maintain a state of equilibrium or are they having difficulty maintaining a functional system? What could be done to improve or help with coping of the identified problems? Could some of the coping mechanisms of one family help another family if similar problems exist? Evaluate the Family and Formulate Diagnoses from a Nurse Practitioner’s Perspective; Interventions; Assessing Outcomes; Family Assessments in Practice
Beyond the textbook, students should search for additional resources to help explain the subsystems of the families; for example, their response to illness may be based on cultural background or religious beliefs. Find resources to support this and explain fully.
An example of a family assessment paper is posted at the bottom of these pages.
This project should have a minimum of 10 resources in addition to the course textbook.
This project should be written in narrative format with appropriate headings to identify each required section.

RUBRICS
Family Assessment Paper

Content

Points

Background about the family chosen (include how did you come to choose this family)
5
Comprehensive utilization of the Calgary family assessment model: structural, developmental and functional categories including all of their subcategories
50
Genogram
10
Family diagnoses including strengths and problems (stressors) related to each diagnoses
5
Summary (see assignment 4 in the syllabus for relevant questions to be addressed)
10
Conclusion: include what you have learned and how this knowledge could help in nursing practice
5
Find a minimum of 10 resources in addition to the course textbook to write the paper
5
Writing: correct grammar, punctuation, clear and logical organization, APA format, appropriate use of headings, reference page, minimum 5-6 pages in length
10

Rubric for Analytic Scoring of Writing
Score A
Purpose & Audience B
Organization C
Development D
Language
4 Addresses purpose Focuses consistently Explores ideas Employs words with
effectively, uses assignment to explore topic’s intrinsic interest, shows full understanding of issues, engages audience, establishes credibility, uses headings, format, and citations (where relevant) effectively. on clearly expressed central idea, uses paragraph structure and transitions to guide reader effectively. vigorously, supports points fully using an appropriate balance of subjective and objective evidence, reasons effectively making useful distinctions. fluency, develops concise standard English sentences, balances a variety of sentence structures effectively.
3 Adheres to purpose, fulfills Central idea is clear, Supports most ideas Word forms are
assignment, shows adequate understanding of key issues, style is appropriate to intended audience, presentation is readable, format is correct. paragraph structure is adequate, some problems with consistency, logic, or transitions. with effective examples and details, finds suitable balance between references to personal and external evidence, makes key distinctions. correct, sentence structure is effective, applies standard English grammar & mechanics, presence of a few errors is not distracting.
2 Wavers in purpose, Loose focus on Presents ideas in Word forms &
incompletely addresses assigned topic or directions, shows need for more study of issues, style varies, visual presentation ragged. central idea contains some repetition & digression, structure needs work. general terms, support for ideas is inconsistent or unsuitably personal or distant, some distinctions need clarification, reasoning unclear. sentence structures are adequate to convey basic meaning. Errors cause noticeable distraction.
1 Purpose unclear, No central idea, no Most ideas Word use unclear,
failure to address topic or clear logic or focus, unsupported, sentence structures
directions, weak grasp of issues, inappropriate style, and careless or messy visual presentation. many repetitions or digressions, lack of structure. confusion between personal and external evidence, unclear use of distinctions or levels of generality, reasoning flawed. inadequate for clarity, errors seriously distracting.

ARTICLE TITLES POSTED BY THE PROFESSOR. (I did not include the articles because they are lengthy but professor wants the articles used however if you would like me to email them to you, please specify and send your email address, thank you).

1. Child Well-Being Scales (CWBS) in the assessment of families and children in home-care intervention: an empirical study Sara Serbati, Monica Pivetti and Gianmaria Gioga
2. Application of the Calgary Family Assessment and Intervention Models: Reflections on the Reciprocity Between the Personal and the Professional Maureen Leahey, and Lorraine M. Wright.
3. Stressors in five client populations: Neuman systems model-based literature review. Carole Ann Skalski, Louisa DiGerolamo, Eileen Gigliotti.
4. Commitment to Family Roles: Effects on Managers’ Attitudes and Performance Laura M. Graves, Patricia J. Ohlott and Marian N. Ruderman.
5. A Framework for Teaching Family Development for the Changing Family. Jack M. Richman and Patricia G. Cook.
6. Adult attachment styles and stressor severity as moderators of the coping sequence. DIANE HOLMBERG, CHRISTINE D. LOMORE, TRISTA A. TAKACS, and E. LISA PRICE. Personal Relationships, 18 (2011), 502–517. Printed in the United States of America. Copyright © 2010 IARR; DOI: 10.1111/j.1475-6811.2010.01318.x
7. Turning stressors into something productive: an empirical study revealing nonlinear influences of role stressors on self-efficacy. Erik Lindberg, Joakim Wincent, Daniel Örtqvist. Journal of Applied Social Psychology 2013, 43, pp. 263–274. doi: 10.1111/j.1559-1816.2012.00995.x
8. Journal of Family Psychology 2001, Vol. 15, No. 4. 646-651 Copyright 2001 by the American Psychological Association, Inc. 0893-32OO/O1/S5.O0 DOI: 10.1037//0893-3200.15.4.646 Varieties of Religion-Family Linkages. John R. Snarey and David C. Dollahite.
9. Many Forms of Culture Adam B. Cohen. American Psychological Association.
10. CATHERINE E, ROSS, JOHN MIKOWSKY, AND KAREN GOLDSTEEN. The Impact of the Family on Health: The Decade in Review.
11. Journal of Latinos and Education, 11: 94–106, 2012 Copyright © Taylor & Francis Group, LLC ISSN: 1534-8431 print / 1532-771X online DOI: 10.1080/15348431.2012.659563. Mexican Immigrant Families Crossing the Education Border: A Phenomenological Study. Sandra Ixa Plata-Potter and Maria Rosario T. de Guzman.
12. WHAT’S THE MATTER WITH SOCIAL CLASS? TOM NESBIT
13. Therapeutic Assessment of Families in Healthcare Settings: A Case Presentation of the Model’s Application. JUSTIN D. SMITH, STEPHEN E. FINN, NICOLE F. SWAIN, LEONARD HANDLER. Families, Systems, & Health © 2010 American Psychological Association 2010, Vol. 28, No. 4, 369 –386 1091-7527/10/$12.00 DOI: 10.1037/a0021978.
14. Developing complex interventions for nursing: a critical review of key guidelines. Margarita Corry, Mike Clarke, Alison E While and Joan Lalor. Journal of Clinical Nursing.
15. Measuring Family Outcomes in Early Intervention: Findings From a Large-Scale Assessment. MELISSA RASPA, DONALD B. BAILEY, JR., MURREY G. OLMSTED, ROBIN NELSON, NYLE ROBINSON, MARY ELLEN SIMPSON, CHELSEA GUILLEN, RENATE HOUTS. Vol. 76. No. 4. pp. 496-510. ©2010 Council for Exceptional Children.

Family Assessment
This week we will examine the family assessment from a sociological perspective and the use of family theory upon which to base our assessment.
It is helpful to think about family theory as having three levels. At the most general level, some family theorists have advocated the development of an all-purpose general family framework (Hill) and have devoted attention to theory building and broad integration. This type of framework has met with limited success mainly because this theory needs to encompass perspectives from a wide variety of disciplines, such as sociology, psychology, biology, anthropology, psychiatry, nursing, communications, and social work. The next level includes theories that may be grouped in terms of families of theories or paradigms (world views). These paradigms include specific theories that are related in terms of general worldviews and assumptions about the nature of human interaction and family functioning. The greatest amount of research is guided by theories that are more specific. Holman and Burr view that the social sciences would be most effectively advanced by attention to the theories of the middle range (many nursing theories are in this range) that are modest in scope and generality and easily tested and reviewed.
Theoretical debates often center on issues concerning the best level at which research should be conducted. In general, the theories that are most useful serve as guides to assessing families in research and in clinical practice where they can explain the assessment. The literature points to theorists such as Burr, Hill, Nye, Reiss, Carter and McGoldrick, Gotttman, Hill and Mattessich, Holman and Burr, Jacob, and Thomas and Wilcox whose work explains family assessment theory in more detail.
Psychological Theories
Psychological approaches to the study of family have mainly been concerned with understanding the socialization of children. Because of this focus of the impact of the family on the child, using a unidirectional parent to child approach, this was considered a social theory. More recently, transactional and systems thinking began to influence the research of theorists and the social orientation could be noted in psychoanalytic, behavioral, and cognitive-developmental perspectives.
There has, in the past 40 years, been a change in theoretical and methodological approaches taken by psychologists interested in family socialization. Theorists such as Bell and Harper began discussing the reciprocal effects of children on their parents. Initial attempts at moving beyond the social model included studying the effects of parents on children, direct effects of children on their parents and indirect effects of third parties on dyadic interaction.
Current psychological conceptualizations of the family have been moving into one of three directions: object relations theory, the close relationships theory, or family systems theory. Object relations theory states as individuals participate in relationships, they develop mental representations of those relationships that serve as prototypes for future relationships. The close relationships framework has emerged from an integration of social, developmental and clinical psychology. This framework has been formed by an understanding of interactions between two people requires knowledge of their physical environment, their social environment, their separate personalities, their previous and present relationships and the interplay among these variables. The third perspective is family systems theory, which we have discussed in the past and will be discussed later in this content file.
Sociological Theories
Sociological theorizing about the family has evolved over the past 40 years. The progression in emphasis is traced by examining the work of Hill and Hansen, who identified five influential conceptual frameworks that have been used in family research; symbolic interaction, structure-function, situational, institutional and developmental. Over time the use of these frameworks was changed and theories became more complex and detailed and varied depending on the sociologists who were working on them.
There are some similarities between psychological and sociological views of family assessment including; the family constructs a sense of self through social processes and human development in the formation, maintenance and dissolution of relationships are regulated by cost and reward.
Systems Approaches
Systems views of family assessment have become more widely accepted over time. In general, systems perspective has been appealing because it attempts to deal conceptually with the complexity of dynamics within families at a higher level of analysis that that of the individual or group. The systems perspective has become closely identified with clinical work. It is beginning to permeate all fields of study and is especially useful for investigators interested in relationship phenomenon such as attachment, individuation and autonomy. I believe you all know systems theory since it is used by many nursing theorists.
Linking Theory and Assessment
Assessment is the process of gathering information used in either research or clinical work. In research, assessment typically involves the operationalization of theoretical constructs for purposes of hypothesis testing or exploration. In clinical practice, assessment involves the collection of information necessary to diagnose and treat presenting problems and evaluate the success of the intervention. Assessment potentially encompasses a wide variety of techniques, including observation, self-report through interviews for example, task, etc. In general, however, assessment involves a process of sampling data from the domains of affect, behavior and cognition. Theories should provide the guide for separating elements that are useful and those that are not.
Theory should specify the domain of family functioning that is being investigated so that the full relevant domain can be assessed. One of the potential pitfalls of family assessment is that we obtain an incomplete view of the family’s functioning. Measures vary widely in how to assess the family. Fisher developed four general categories of constructs:

1. Structure; how the family is organized, roles, and patterns that provide a framework within which the family functions.
2. Process; actions and activities within the family, including control, regulatory and communication functions.
3. Affect; expression of emotion.
4. Orientation; the family’s attitudes about itself, especially in terms of its relations with the world outside the family.
   These constructs are helpful for researchers and clinicians to understand how much of the family they are “viewing” and how what they view may be part of a bigger family picture.
   Theory should lead to clear definitions of constructs and variables. For example, the construct of expressiveness is defined in a number of different ways by different researchers. Clear theoretical underpinnings and shared meanings by researchers and clinicians should help advance the field of family assessment.
   Theory should drive decisions about assessment strategies. It is important there be an adequate conceptualization before selecting assessment strategies. Assessment based on inadequate thinking about clinical or research problems concerning the family can become unclear.
   As different theories about the family center around different aspects of family functioning, it is understood that differences in theory can lead to differences in family assessment. For example, a systems theory approach to the family would more likely focus on the relational patterns that connect the members of the family rather than on any one individual’s behavior.
   Theory should provide guidance for levels of analysis. Both researchers and clinicians interested in understanding individuals and families must find an appropriate entry point for their work. It is useful to study an attribute of an individual, some aspect of the person’s dyadic interaction or relationship with one other person, an aspect of the whole family’s functioning or how the family interacts in a larger context. If assessments are made at all of these levels how can the assessment be integrated? Some psychologists have proposed a multi-system, multi-method approach to family assessment that would gather information at multiple levels such as that of the individual, the family and the marital levels.
   An interactive relation should be established between theory and assessment. Theory should not be invented in the abstract but should be developed by researchers and clinicians in order to explain data.
   Although you are using the guidelines in your text to do your family assessments, I (the professor) want to list a number of questions that were developed by family psychology that address how to frame relevant questions of the family in order to complete an assessment. They may be helpful to you when completing your projects.
5. How does the family adapt over time while retaining its identity?
6. How do differences among families come about?
7. How is the development of a family constrained by the community and culture, and vice versa?
8. How does the need for the family to develop affect individual development and vice versa?
9. How do families create, recruit and indoctrinate new members?
10. How do families mediate between the community (or society at large) and their individual members?
11. How do families act through their individual members’ encounters with the world?
12. How does an individual bring about changes in other individual members and in the family as a whole?
13. How does the individual mind internalize the workings of a whole family system?
14. How do families equip their members for participation in other systems (such as education)?
    Note some of these questions focus on issues involving the study of the family as a unit while others involve the interface between the individual and the family, and others involve the interface between the family and the larger context (such as community). So, assessment within a family psychology framework needs to facilitate the simultaneous, integrated consideration of the individual, the family, and the larger world. Please keep this in mind when conducting your family assessments. Try to get the “big picture” of the family within their world and use this assessment to draw diagnoses of the individuals and the family unit as a whole.
    If a family member suffers from depression then state this as the diagnosis. But, also remember to diagnose the effect of this individual’s depression on the family; for example, it may cause the family to become more isolated from extended family and friends. If this is the case diagnose the family as isolated.
    Any questions about assessment and diagnoses, ask before the projects are due.
    I have posted one article on family assessment. It is a case study that examines the effects of a child’s illness on the family. Please note many of the published articles on family assessment tend to focus on one family member’s problem and how it affects the family unit.

Article on Family Assessment

Families, Systems, & Health 2010, Vol. 28, No. 4, 369 –386
© 2010 American Psychological Association 1091-7527/10/$12.00 DOI: 10.1037/a0021978
Therapeutic Assessment of Families in Healthcare Settings: A Case Presentation of the Model’s Application BY
JUSTIN D. SMITH,
STEPHEN E. FINN,
NICOLE F. SWAIN,
LEONARD HANDLER
In this article, we present a case study of a Therapeutic Assessment (TA) with an 11- year-old boy who had two unexplained behavioral episodes suggesting neurological impairment, which led to two emergency department visits at a children’s hospital. TA is a semi-structured approach that blends the extensive conceptualizing benefits of psychological assessment with the principles and techniques of evidence-based child and family interventions. We use this case to illustrate how TA is an adaptive and flexible approach to child-centered family assessment that can meet the goals of psychologists working in pediatric and general medical hospitals, primary care clinics, family medicine practices, and other health care settings. With the current case, the clinician was able to use the procedures of TA to clarify for the family their son’s unexplained behaviors, while also providing them with a therapeutic experience. In addition to addressing the family’s concerns, the clinician also addressed a number of specific questions provided by the referring neurologist that informed ongoing care of the child. This case illustrates the potential utility and effectiveness of the TA model with children and families referred to a typical psychology service in a health care setting. This case is one of the first applications of the TA model with this population and its success suggests further research in this area is warranted. Keywords: case study, family assessment, health care psychology, psychological evaluation, Therapeutic Assessment
Health care settings pose a wide array of unique challenges to psychological evaluation and assessment of children and families, which requires both the psychologist and the chosen approach to be pragmatic, flexible, and adaptive (Roberts, Mitchell, & McNeal, 2003; Rozensky, Sweet, & Tovian, 1997). The importance of using a systemic approach that assesses the child within the greater context of the family is undeniable (e.g., Dishion & Stormshak, 2007; Landreth & Bratton, 2006). Recently, some experts in assessment psychology have embraced a systemic emphasis, which has resulted in a paradigm shift in the way child assessments are conducted (Finn, 2007; Handler, 2006; Tharinger, Finn, Austin, et al., 2008). The shift in assessment psychology has coincided with the growing prominence of collaborative care between members of the health care team and mental health professionals (e.g., Connor et al., 2006; McDaniel, 1995; McDaniel & Campbell, 1996; Rozensky et al., 1997; Sweet, Tovian, & Suchy, 2003) and a growing recognition of familial factors in children’s medical issues (e.g., Alderfer & Kazak, 2006; Drotar, 2005; McDaniel, 2005; Rozensky et al., 1997). The role of the family encompasses both familial influences on children (e.g., Fiese, 2005) and the effect of the child’s medical condition on the family (e.g., Alderfer et al., 2008). In this article, we present a case study using an innovative, flexible approach to child-centered family assessment: the Therapeutic Assessment (TA) model (e.g., Finn, 2007; Hamilton et al., 2009; Smith & Handler, 2009; Smith, Wolf, Handler, & Nash, 2009; Tharinger, Finn, Wilkinson, & Schaber, 2007). We believe the TA model provides pediatric, health, and primary care psychologists with a flexible approach for addressing commonly encountered referral issues, collaborating with medical professionals, and facilitating familial changes by empowering family members to take active steps in addressing the problem alongside the health care team.
THE FUNCTION OF PSYCHOLOGICAL ASSESSMENT IN HEALTH CARE SETTINGS
Psychological assessments in health care settings often stem from a referral for consultation by the health care team that wishes to better understand the role of psychological factors related to medical concerns, such as disease management and compliance with a prescribed course of treatment. At other times physicians may be unable to identify a medical cause or explanation for a child’s symptoms, which may lead the physician to suspect an etiological role for psychological factors. Psychologists are sometimes asked to assess the family’s role in the identified patient’s presenting medical or psychological issue. Assessments can also provide an opportunity to identify long-term psychological and interpersonal problems that first appear in medical units independent of a medical condition (e.g., McDaniel & LeRoux, 2007; Rozensky et al., 1997), or are presented as secondary to, or concomitant with, a medical complaint (e.g., Roberts et al., 2003; Sweet et al., 2003). Regardless of the way in which patients reach psychologists for assessment, it seems clear that the complex diagnostic and etiologic presentation of psychological and medical conditions depicted within the biopsychosocial model (Engel, 1977) necessitates an effective multidisciplinary approach (e.g., Bradfield, 2006; Porcelli & McGrath, 2007; Rozensky et al., 1997; Sweet et al., 2003). We believe the core values, structure, and techniques of the TA model can meet psychologists’ assessment needs in health care settings, while also addressing systemic aspects of a child’s medical difficulties.
THE TA MODEL WITH CHILDREN AND FAMILIES: CORE VALUES, GOALS, AND DEFINING CHARACTERISTICS:
Therapeutic Assessment (TA) is a semi structured form of collaborative psychological assessment, developed by Stephen Finn and his colleagues at the Center for Therapeutic Assessment in Austin, TX (Finn, 2007; Finn & Tonsager, 1997). In traditional psychological assessment, psychological testing is primarily used to aid in diagnosis, case conceptualization, and treatment planning. In TA, psychological testing serves these same traditional purposes, while at the same time forming the centerpiece of a brief psychological intervention. As they undergo a TA, patients are enlisted as collaborators in all aspects of the assessment: setting goals, gathering background information, interpreting their own test performance, discussing scores and hypotheses derived from the testing, and reviewing written reports at the end of the assessment (Finn, 2007). This is in contrast to traditional psychological assessment, where patients are viewed more as passive objects of study (Finn & Tonsager, 1997). Not only are the techniques, procedures, and goals of TA compatible with pediatric and primary care psychology, but the core values of TA are highly compatible with the collaborative care model (CCM; e.g., McDaniel, 1995; McDaniel & Campbell, 1996) being currently adopted by many psychologists in medical settings. According to Finn (2009) the underlying values of TA, which inform all its procedures, are collaboration, respect, humility, compassion, openness, and curiosity. It is believed that clinicians manifesting these values in interactions with patients create an environment in which healing and growth is greatly facilitated. With children and adolescents, another major therapeutic element of TA is believed to be its ability to help families develop a more coherent, accurate, compassionate, and useful understanding of the nature of a child’s difficulties (Finn, 2007). This is accomplished by involving the parents in their child’s assessment in several major ways. In health care situations, TA can assist families in understanding the way in which psychological factors are related to the symptom presentation and the ongoing medical care of the child. In contrast to the traditional assessment paradigm, TA is intended to result in therapeutic changes in the family system, beyond simply gaining a comprehensive understanding of the child (Tharinger et al., 2007). With children and adolescents, TA is best thought of as a family systems intervention that addresses child problems and family concerns, and attempts to change parents’ understanding of and responses to their children’s behavioral and emotional problems (e.g., Smith, 2010; Smith, Handler, & Nash, 2010; Tharinger et al., 2009). Finn and his colleagues describe the principles, specific techniques, and procedures that define the TA model and differentiate it from the traditional assessment paradigm and other child-centered family interventions (Tharinger, Finn, Austin, et al., 2008; Tharinger, Finn, Hersh, et al., 2008; Tharinger, Finn, Wilkinson, et al., 2008; Tharinger et al., 2007; Tharinger, Krumholz, Austin, & Matson, in press). The effectiveness of TA with children and adolescents has been demonstrated by a number of recent empirical studies: Ougrin, Ng, & Low, 2008; Smith et al., 2009; Smith, Handler, & Nash, 2010; Smith, Nicholas, Handler, & Nash, in press; Tharinger et al., 2009. The evidence indicates that after a TA, families often improve their cohesion and communication, while also experiencing decreases in family conflict and the child’s and parents’ emotional and behavioral symptoms (Smith et al., 2010; Tharinger et al., 2009). In addition to empirical studies, there exists a number of published clinical case studies of successful child and adolescent TA: Michel, 2002; Hamilton et al., 2009; Smith & Handler, 2009; Tharinger et al., 2007; Tharinger, Gentry, & Finn, in press; Tharinger, Krumholz et al., in press; Tharinger, Matson, & Christopher, in press. The study by Ougrin et al. (2008) is notable for our work in that it occurred in a hospital emergency room setting, and studied adolescents who were admitted because of serious self harm. Compared to adolescents receiving assessment as usual, those participating in a brief TA at the time of their admission showed better compliance with treatment recommendations and an increased chance of being involved with a mental health professional 17 weeks after their self-harm incident. An article by Smith (2010) reviews the current evidence base of the TA model with children and families.
CASE PRESENTATION
Background Medical Information and Referral Roughly 10 months prior to the current referral, Georgie , an 11-year-old Caucasian male was in the dentist’s office when he had overheard a root canal procedure being described, at which point he fainted. After fainting, he complained of a headache and feeling sick to his stomach. Shortly after these symptoms arose, George’s parents, Mike and Ann, drove him to the Emergency Department (ED) of the local children’s hospital for examination. In the ED, George’s parents and the physicians described him as acting confused and “goofy,” and he displayed immature speech and thought processes, altered gait, and profound memory loss (e.g., he could not remember the alphabet or the sequence of numbers). After a computed tomography (CT) scan was found to be normal, the ED contacted Dr. M, a neurologist, who examined George and ordered magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and electroencephalography (EEG) scans, results of which were normal. Dr. M diagnosed George with common migraines (ICD-10 Code 346.10; World Health Organization, 1992). (ii) During the time in which the testing was performed, George’s symptoms began to remit. Mike and Ann reported that he returned to normal within 36 hours of fainting. Mike described his son’s return to normal like the process of “rebooting a computer – It took a while to get him back up to speed.” George had no similar symptoms over the following 10-month period. Then he unexpectedly returned to the ED. The second episode was similar to the first. However, George’s symptoms were more severe and lasted longer. Prior to this visit to the ED, and a second referral to Dr. M, George had complained of a “fuzzy” feeling on the left side of his head that he could feel move across his brain to the right side, at which time his symptoms would begin. He described this sensation as “feeling like water flowing across my brain.” George’s symptoms included odd, immature behaviors (repetitive, atypical movements) and regressed language skills (slow and pressured speech, mispronunciation of common words). However, no memory loss was reported during this episode. George’s symptoms were intermittent for the next 8 days, in which he went “in and out of the episode,” as reported by his parents. Continuing the metaphor, George reported that his symptoms would cease when “the dam builders were able to stop the flow of water across my brain.” Again, the neurologist’s examination yielded no medical explanation. Dr. M reported that he was “at a loss for how to proceed” and he suggested to George’s parents that psychological factors might be playing a role in his difficulties. Dr. M described Mike and Ann as reluctant to explore psychological testing until all medical assessment was exhausted. Once Dr. M assured them that he had done all he could, George was referred to the psychology service. When Dr. M contacted psychology, he reported that he believed George’s symptoms might be related to stress and anxiety. He had shared this perspective with the parents prior to the referral and reported that they were initially reluctant to consider psychological explanations. Given the parents’ hesitations about a psychological cause, the clinician felt the transparency and collaborative emphasis of the TA model might facilitate acceptance of any findings that indicated George’s symptoms were related to psychological factors. Dr. M’s referral also indicated that Mike and Anne might benefit from a brief psychological intervention, further suggesting that the use of the TA model with this family was appropriate. (iii) The TA model also attempts to include other appropriate key players involved in the child’s care, such as the referring physician, other members of the health care team (e.g., nurses, social work, etc.), teachers, and other mental health providers. Thus, Dr. M was asked to provide questions about George and his family that he hoped could be answered by the TA. The process of specifically addressing questions from the referral party serves to show that the referral was completed and also ensures that findings are disseminated to the health care team in order to inform subsequent care of the child. Dr. M’s questions were: 1) Is there any evidence of a neurological/neuropsychological problem?; 2) Are there any psychological explanations for George’s symptoms and presentation?; and 3) What can I do if I see George and his family again in the future? We present our answers to Dr. M’s questions at the end of the case presentation. Additional Background Information George was Mike and Ann’s first biological child; they also had a daughter, age 9, about whom they expressed no concerns. George was described as having no serious medical, emotional, or behavioral difficulties prior to the recent medical episodes. George was in the 5th grade at a public elementary school, where he was doing well academically and reportedly managed his homework well with little parental assistance. He was active in athletics, participating in baseball, basketball, football and golf. Mike and Ann were both high school teachers and coaches, and Mike had previously coached George in basketball. Mike and Ann reported that they had been happily married for nearly 15 years and that this was their first marriage. The Therapeutic Assessment TA Progression and Session Procedures George and his parents completed the TA in seven 1–2 hour sessions (11 total hours) over a 28-day period, which included each of the components of the comprehensive TA model (see Smith et al., 2009; Tharinger et al., 2007; Tharinger, Krumholz, et al., in press). TA contains many of the procedures common to any assessment, such as an initial interview, test administration, and feedback to the family. Each of these procedures in guided by Specific collaborative techniques, such as the gathering of assessment questions during the initial meeting and the extended exploration of test findings that occurs after administration of test instruments according to their standardized procedures. Unique components are typically included as well, such as family intervention sessions (Tharinger, Finn, Austin, et al., 2008) and a session in which the child is presented with feedback in the form of a personalized story or fable (Tharinger, Finn, Wilkinson, et al., 2008). Each session is conducted in a manner consistent with TA’s core values, goals, and defining characteristics, as described previously. Previous case examples of the child TA model have utilized video link technology, allowing parents to observe the testing of the child in a different room (e.g., Hamilton et al., 2009; Smith et al., 2009). (In contrast, in traditional child assessment, parents typically sit in the waiting room while their children are being assessed.) It is believed that this test observation element of TA allows parents to gain empathy for their children and to have more confidence in the eventual findings of the assessment. In the Tharinger et al. (2009) study of child TA, the parents reported that the ability to observe and collaboratively discuss their child’s testing was one of the most impactful parts of the TA. The setting in which this case was conducted, like most health care facilities, was not equipped with this technology, so parents observed the testing of the child in the same room, an arrangement which the second author has used in his independent practice setting. Parent observation may not be feasible with all families, but in this case it was viable and seemed appropriate to the clinician. Mike and Ann’s presence did not appear to inhibit George or otherwise influence the test results. Inviting parents to observe testing sessions is not always desired though, and clinicians need to judge the advantages and disadvantages of this practice with each family. In this case, the clinician’s perception was that observing the testing sessions facilitated the parents’ curiosity about George and his problems and seemed to assist them in gradually shifting their understanding as the evidence was presented. At the beginning of most sessions, the clinician met with the parents to prepare them. At the end, the clinician and parents discussed what had occurred. The child played in the waiting area during these mini consultations. The initial meeting, family intervention (Tharinger, Finn, Austin, et al., 2008), summary/discussion (Tharinger, Finn, Hersh, et al., 2008) and fable sessions (Tharinger, Finn, Wilkinson, et al., 2008), which are described below, included either the entire family or just the parents and clinician.
Initial Contact and Meeting With George and His Parents
The clinician, Justin D. Smith, contacted Ann on the telephone to schedule the initial meeting. Ann seemed eager to get the evaluation underway. She reported that these two incidents with George had been frightening and stressful, and that she and her husband wanted to understand what was happening to George. Given Ann’s curiosity, and desire to identify any psychological factors that might explain George’s problems, the clinician felt further convinced that the family might benefit from TA. The clinician described the TA model and emailed an information sheet about TA describing some common questions, such as the goals, timeframe, and level of parental involvement. (IV) Ann and Mike were instructed to develop questions they hoped the TA might be able to answer. George, Mike, and Ann arrived for the first session with assessment questions in hand, which seemed to reflect some openness to psychological explanations and willingness to participate in the TA. Their questions were: 1. How can a psychological issue translate into a neurological problem? 2. How does our son handle stress, conflict and control issues? 3. Does our son suppress his emotions and have they turned into a psychological issue? 4. Does the fact that his parents are coaches and teachers put extra pressure on him that he can’t handle? Do we expect too much of him? 5. Does his competitive nature cause problems handling achievement at different levels other than the top level? Regarding question 3, Mike and Ann said that George seemed to hold in his emotional reactions to events. Mike believed his son suppressed these feelings, ruminated about them, and then discussed them with his parents only long after the event. Mike reported that he was often surprised when George would report having been bothered by an earlier experience, as he had given no indication of being upset at the time. Regarding questions 4 and 5, Mike and Ann explained that George’s competitiveness and desire to do well in sports and academics sometimes led to his being disappointed in himself when he fell short. Mike and Ann speculated that their positions as teachers and coaches might add to the pressure George felt to succeed. Kazak (1997) suggested framing pediatric referral questions within a contextual, family systems perspective, which this family was able to accomplish from the outset. We felt that questions 4 and 5 were systemic in nature and suggested that Mike and Ann had noticed some ways in which their interactions with their son may be related to his current symptoms. It was also the clinician’s impression that Mike and Ann were emotionally invested in their son’s achievement and might be subtly communicating to him that they needed him to succeed, suggesting the potential that George indeed felt the pressure and anxiety reflected in this assessment question. Mike and Ann were very curious about their son’s recent episodes and seemed eager to find an answer to why they had occurred. They and George shared how frightening the episodes had been for the entire family. George appeared to become increasingly anxious as this topic was discussed, as evidenced by his fidgetiness and averted gaze. Mike and Ann’s assessment questions were curious, psychologically minded, and thoughtful. The clinician concluded that this was clearly a high-functioning and predominantly healthy family, which made the recent ED visits even more unexpected.
Results of the Test Administration Sessions
The selection of assessment instruments to be used in a TA is very similar to other psychological testing situations. TA allows clinicians the flexibility to use tests that are indicated by the history of the presenting problem, behavioral reports and observations during the initial meeting, referral questions from another professional (if applicable), and ongoing test findings. Since extensive knowledge of testing instruments is important to the specific therapeutic techniques of TA, clinicians tend to select tests with which they have sufficient training and experience. Although the use of performance-based measures, formerly known as “projectives”, such as the Rorschach (Exner, 2003) and Roberts Apperception Test (Roberts & Gruber, 2005), is commonplace in TA with children, it is by no means mandatory.1 The goals of TA can certainly be achieved using varied assessment instruments. In this case, we selected some assessment instruments, such as the House-Tree-Person Technique (HTP; Buck, 1966), in order to develop hypotheses to be tested by other valid and reliable measures, provide a playful experience for the child, and provide a stimulus from which the child can tell a story for his observing parents to hear. The use of storytelling and drawing tasks might be selected for this purpose particularly in cases where parents are observing the assessment. It is also within the parameters of TA to rely only on tests with strong evidence of validity and reliability. To gain a broad picture of any behavioral or familial problems, George, his parents, and his teacher completed the Behavior Assessment System for Children, Version 2 (BASC-2; Reynolds & Kamphaus, 2004), a set of rating scales about children’s behavioral and emotional problems and their adaptive strengths. Mike, Ann, and George also completed the Family Assessment Measure, Version 3 (FAM-III; Skinner, Steinhauer, & Santa-Barbara, 1995), in which family members rate each other on a number of dimensions of family functioning. The results of the BASC-2 were interesting and informative. First, George’s teacher rated him as having no significant emotional and behavioral problems and above-average strengths, with the exception of his self-esteem, which she rated as just slightly below average for children his age. Mike’s and Ann’s ratings of George were largely within normal limits, although there was a tendency for Mike to see George as having more significant problems and less strengths than did Ann. The only elevated scale on Ann’s BASC-2 was on Anxiety (T score 61), while Mike rated George in the borderline clinical range on Anxiety (67T), Somatization (60T) Atypicality (63T), Withdrawal (63T), and Internalizing Problems (60T). In fact, the absence of any significant scores on Ann’s BASC-2 is noteworthy, and suggested that she had a strong need to see George as having no psychological problems. Similar to Ann, George rated himself as having no significant difficulties and good adaptive strengths, with the exception of a slight elevation on the BASC-2 Attitude to School (63T) scale. Given the lack of other elevations, this suggested to the assessor that George had noteworthy negative feelings about school. The slight elevations on the Anxiety subscale provided evidence for the clinician to focus on test instruments that might illuminate the processes by which George manages stress and worry. The results of the FAM-III indicated that the family saw themselves as well functioning across all domains. Again there was one noteworthy exception. George’s rating of his father on the Control subscale of the Dyadic Relationship form was elevated (72T), indicating that he experienced Mike as sometimes being intrusive and overcontrolling. Although Dr. M reported in his referral that he did not suspect neuropsychological problems, given the referral picture the clinician felt it was necessary to obtain a broad cognitive ability score to understand George’s strengths and limitations. He was administered the Wechsler Intelligence Scales for Children, Version 4 (WISC-IV; Wechsler, 2003) and the Bender VisualMotor Gestalt Test, Second Edition (Brannigan & Decker, 2003). These two measures were used as a gross screening process for possible neuropsychological problems. Other tests certainly could have been used to assess cognitive functioning (e.g., CA Verbal Learning Test for Children) and neuropsychological deficits (e.g., Test of Memory and Learning, Wide Range Assessment of Memory and Learning). These tests were selected because of the breadth and depth of information provided and the clinician’s training on these instruments. George’s Full Scale IQ was 106, in the average range, and his performance was also average on Perceptual Reasoning (106), and Working Memory (102). His scores on Verbal Comprehension (112) were high average, suggesting that he generally was able to understand and express himself verbally quite well. Although within the average range, George’s score of 91 on Processing Speed revealed a personal weakness in his ability to work quickly and efficiently. Sometimes children with deficits in this area feel a great deal of pressure about completing homework and other school assignments in a timely fashion. Results of the Bender were within developmental limits and were not suggestive of a visual-motor integration problem or other neuropsychological deficit. Since neither of these tests suggested any significant deficits in cognition, processing, or visual motor integration (although admittedly, this did not qualify as a neuropsychological evaluation), further neuropsychological assessment was not sought. The focus of the assessment then shifted to George’s psychological functioning, specifically the management of stress and anxiety. Given the lack of significant findings on the self-report measures, the clinician administered the Rorschach inkblots (Exner, 2003) to better understand the underlying emotional aspects of George’s functioning. At this point in the assessment, the clinician felt as though there was insufficient evidence to adequately answer the parents’ assessment question regarding the origins of these two episodes and the role stress, anxiety, and pressure might have played. The clinician thought the Rorschach would provide a different lens through which to view this child and his problems. The HTP (Buck, 1966) was selected to develop hypotheses and stimulate expression of George’s experiences and emotions to his parents as they observed the administration and listened to stories he told about his drawings. It also provided a more playful exercise, which contrasted with the often-emotionally laden experience of being administered the Rorschach. The results of George’s Rorschach, scored using the 5th Edition of the Comprehensive System and compared to the normative data for 12-year-old respondents (Exner, 2003), indicated a detached style and a preference for clearly defined structure and expectations (Weiner, 2003). There were no signs of severe thought disorder or a psychotic disturbance. However, there was evidence that George was experiencing substantial situational stress and that he was struggling with feelings of powerlessness and anxiety, which he had inadequate resources for managing. In particular, he was neither able to reflect on and “mentalize” about his difficulties, nor very capable of verbalizing his emotional experiences. Furthermore, there was evidence that George tended to “back away” from emotionally arousing situations because he was so easily overwhelmed by them. Despite evidence of a generally positive view of interpersonal relationships and signs of a good early attachment, George did not appear to see significant others as sources of reliable support and comfort and tended to try and manage difficulties on his own, a strategy that was destined to failure given his own limited resources. Stories George told about his HTP drawings illuminated the potential source of his distress that was evident in the Rorschach results: In describing both his male and female figure drawings, he emphasized achievement. He said the male figure was “. . . a very good boy. He’s very good at comprehension in reading . . . he plays football, basketball, baseball, and golf.” When describing his female figure, he said, “She doesn’t make really good grades. She had an ‘F’ in Physics on her report card and her teacher doesn’t like her.” Finally, his description of his tree drawing appeared to dovetail with his Rorschach scores, in suggesting that he did not feel well supported: “Well it lives out in the open with not many trees around it. It doesn’t get very much sun or water. It’s a dying tree . . . it’s not a very healthy tree and doesn’t have enough water. It lives on dirt and there’s no grass.” Overall, George’s Rorschach scores suggested he had the potential for disorganization and temporary psychological incapacitation when coping demands exceed his capacities (Weiner, 2003). Even though these findings could not rule out the presence of a medical or organic problem, evidence suggested that these psychological factors could have led to George’s odd behaviors that precipitated his two visits to the ED. Therefore, a family intervention session (Tharinger, Finn, Austin, et al., 2008) was designed to further explore these findings and test the emerging hypothesis that George’s inability to manage affect and tendency to avoid turning to others for emotional support contributed to the two episodes. A second hypothesis of the family intervention session was that Mike and Ann played an important role in George’s current difficulty managing emotions. The clinician hoped the family intervention task could reveal the way in which this process occurs between George and his parents.
The Family Intervention
Session Two of the main goals of a family intervention session are to test hypotheses derived from the assessment results while providing the family with a transformative experience that might initiate changes in the family system (Tharinger, Finn, Austin, et al., 2008). The clinician’s developing conceptualization of George’s problems centered on his ineffective coping strategies for managing negative affect and inability to make use of others for emotional support. George seemed to stringently constrict and overcontrol his affective experiences, perhaps because his parents did not know how to help him with them, which led to the two unexplained episodes that were frightening to him and his parents. Secondarily, the clinician hoped to elicit the way in which George’s parents’ approach to his emotions was related to his episodes. As a minor goal, it seemed that the parents’ viewing George as strong and somewhat impervious to emotionality was uncomfortable for Mike and Ann, who preferred to downplay his emotional experiences and take a problem-solving approach to his expressed distress. With consultation from the second author, the clinician planned a family intervention session aimed at evoking the family’s strategies for identifying, managing, and discussing feelings. Rolland and Walsh (2006) identified open emotional expression as a key process in family resilience to illness, which we hoped to promote during this session. In TA, clinicians often modify assessment instruments to meet specific goals for a particular family (Finn, 2007; Tharinger, Finn, Austin, et al., 2008). In this case, the clinician used a modified version of the Early Memories Procedure (Bruhn, 1992) in which the prompts were changed to focus on different emotional experiences. For example, the family was asked to think together about their earliest memory of a time when someone in the family felt sad, angry, and so forth The clinician intentionally ordered the sequence of prompts to begin with simple emotions (e.g., sad, mad) and then progress to more nuanced affects, such as shame and embarrassment. George was able to recall memories from an early age for the simple emotions but began to have difficulty with those that were more specific. At one point, George confused embarrassment with nervousness and anxiety. Mike pointed out this misconception and explained the differences by providing relatable examples and straightforward definitions. Based on the process of this exercise and the family’s responses to the modified early memory stems, it was the impression of the clinician that the family rarely spoke about their emotions and reactions to events. George in particular showed significant difficulty identifying his more complex emotions. Despite the observed difficulty, Mike had shown his ability to discuss emotions with his son, which seemed to instill a sense of mastery for him in the session. Ann also appeared comfortable with this discussion and added some examples based on George’s recent experiences in school and athletics. At the end of this exercise, as the family and clinician discussed what had occurred, Mike asked George about why it had been difficult for him to remember events from his early childhood that corresponded to the emotions named in the task. George’s reply was striking to the clinician and his parents. He said, “I don’t really connect any feelings to my memories. I can remember stuff, but they don’t really have any feeling in them.” This statement appeared to illustrate how George attempted to manage his emotions. That is, he tended to discount or minimize his feelings because they were either too dangerous, or he was unable to identify what it is he felt, and thus had no way of symbolizing and retaining the affect. Given the evidence thus far, Mike and Ann may have inadvertently reinforced the process of George keeping his emotions to himself and attempting to modulate them without parental assistance. It was not evident to the clinician that they had noticed this process, so a second exercise was employed. The second task of the family session involved a consensus storytelling exercise using the Roberts Apperception Test, Second Edition (Roberts & Gruber, 2005). The clinician asked the family to construct one story to three emotionally laden pictures. George again had difficulty accurately and effectively identifying and processing the emotional content. While generating a story to the picture depicting a young man with a chair over his head, George was able to identify that the young man likely felt “mad” about something. However, when his father asked what had made the young man mad, George’s proposed source of the anger was incongruent with the intensity of the affect being expressed in the picture. Mike and Ann engaged their son in a discussion about this response and assisted George in identifying an event that might precipitate this level of anger. It appeared to the clinician that there was a clear disconnect between events in George’s life and the emotional experiences they evoked. This point was picked up on by George’s parents as well and discussed in detail in the following session.
Summary/Discussion Session With the Parents
In TA, assessment findings are discussed collaboratively with parents during a “summary/discussion session.” Findings are presented in the order of their level of accessibility to the parents (Finn, 2007; Tharinger, Finn, Hersh, et al., 2008). Tharinger, Finn, Hersh et al. (2008) provide detailed guidelines for this collaborative assessment feedback process. One advantage of conducting a TA with parents observing and being involved throughout the assessment is that they have witnessed and experienced the findings firsthand prior to the often anxiety-provoking “feedback” session. In a successful TA, this session serves to merely organize and clarify what has already been witnessed, discussed and experienced. Since this session is organized around the family’s assessment questions, one good strategy is to ask the parents if they can answer their questions themselves, after having been through the TA. Mike and Ann were able to clearly conceptualize George’s problems based on the assessment findings and their observations. For example, Mike and Ann spoke about the process of the family intervention session and how George seemed to have a very basic understanding of emotions and experiences. They had also experienced George’s difficulty asking for their assistance in processing and managing this affect. Although this observation was accurate, it was difficult for them to describe what might have led to George’s difficulty in this area. The clinician shared findings from the Rorschach that suggested George was easily overwhelmed by his affect, which prompted Mike and Ann to posit that their son might not connect feelings with events because of the potential for becoming more upset than he could handle. The clinician inquired about how the family handled George’s problems. Mike and Ann reported that they typically approached George’s concerns by attempting to “fix” the problem. The clinician felt this strategy might leave George feeling unsupported about his feelings, even if this approach led to a resolution of the problem. The clinician assisted Mike and Ann in identifying that this approach, although effective in some ways, also provided George with little room to identify and explore what he was feeling and may have contributed to his feeling unsupported. Mike and Ann reported that it was sometimes difficult or uncomfortable for them to manage George’s negative feelings, and it became clear that their positive feelings about themselves and the family were somewhat contingent upon their son’s achievement and positive feelings. The clinician helped Mike and Ann practice validating and discussing George’s emotional experiences, prior to helping him come to a solution. This session appeared to meet the goal of such meetings (Finn, 2007). George’s parents were beginning to think more psychologically and systemically, and also to connect the assessment findings to their real life experiences. Mike and Ann had also been able to acknowledge that they were sometimes uncomfortable with George’s expression of emotion, which seemed to be the key to fostering lasting changes in this family.
Fable Session
In TA, feedback to the child is generally provided via an individualized story or fable. These stories are written in a developmentally appropriate manner and describe the seminal findings of the assessment. This form of feedback is much less threatening to a child than direct feedback (Tharinger, Finn, Wilkinson, et al., 2008). The story written for George was about a medieval warrior whom everyone saw as very strong and capable. The warrior could also be fragile though, which the family discovered after he experienced two unexplained episodes of weakness. After consulting a knowledgeable expert, the warrior and his family discovered that he needed to learn about his feelings in order to stay strong and resilient, since this was a major source of his strength. It was also explained that the warrior’s parents had learned some secrets about how they could help him learn about feelings. This detail seemed important in instilling a sense of hopefulness for the future for George and the family. George and his family reported that they liked the story about the warrior and that it was very accurate.
Written Feedback to Parents
In contrast to the typical psychological evaluation, which is often intended for use by other professionals, in TA, parents are provided with a letter that summarizes the findings and answers their assessment questions in everyday language. (For examples of parent letters see Hamilton et al., 2009; Smith & Handler, 2009; Tharinger et al., 2007)
Follow-Up
The follow-up session occurred about 8 weeks after the fable session. The purpose of this meeting is to check in regarding progress and reassess recommendations (Finn, 2007). The clinician asked George and his parents if anything had changed in the family as a result of the TA. They reported that the TA had been a very worthwhile experience: George was becoming aware of feeling overwhelmed and was also showing progress in verbally expressing his emotions. The family reported that they had learned invaluable information about George’s functioning, the role of the family in the presenting problems, and also felt that the potential explanation for his episodes had helped ease their anxiety. Results of a second BASC-2 administration showed a few changes on scales that were previously elevated; Mike’s rating of George on Atypicality dropped from T63 to T49 and Ann’s report of her son’s Anxiety dropped from a score of (T61 to T54). Although the reported changes may seem small, the short time period between assessments suggests these findings may reflect important substantive changes in George and also the way in which Mike and Ann understand his problems. Perhaps most importantly, George had not experienced any of the symptoms that had led to his ED visits. The clinician again contacted the family via telephone 6 months after the completion of the TA to monitor their progress. Mike and Ann reported that George had no recurrent symptoms. Perhaps more importantly, they reported that he appeared to be managing his distress more effectively, as evidenced by his willingness and ability to talk with his parents when he felt stressed or upset. Mike and Ann also reported that as a result of what they learned during the TA, they felt confident in their ability to provide their son with the support he needed in these situations, which they felt ill equipped to do prior to the TA.
Dissemination of Findings to the Physician and Health Care Team
Similar to the letter provided to George’s parents, Dr. M was provided with a brief, one-page summary answering his referral questions about George in nontechnical language. We believe it is important to demonstrate to referral sources that psychology has addressed their concerns and reasons for the referral. Rozensky et al. (1997) and Sweet et al. (2003) emphasized the importance of communication and collaboration between the psychologist and medical professionals. We also feel that communication in useful, digestible language is integral for continued collaboration, particularly in multidisciplinary settings in which professionals from different backgrounds often have varied knowledge of psychological terms and tests. Here is the letter provided to Dr. M: Dr. M, I wanted to follow-up with your referral of George to psychology. George and his parents completed a comprehensive child focused family Therapeutic Assessment, which included a wide array of psychological test instruments. Here is feedback to your questions: 1. Is there any evidence of a neurological/neuropsychological problem? We found no evidence of impairment in this area at this time using a limited battery to assess cognitive functioning and visual-motor skills. 2. Are there any psychological explanations for George’s symptoms and presentation? Test results indicate that George’s capacity to manage his emotional life is often insufficient to handle periods of amplified stress. I believe it is not a coincidence that the two episodes that led to hospitalization occurred early in the school year. The structure of school and sports provides some containment, but there is an inevitable build-up followed by a breaking point. In times of increased stress, George seems to be able to get by for a while but then he becomes overwhelmed. These two episodes show that he can become incapacitated by emotional stress, leading to disintegration and behavioral regression. There is a familial component to these problems also, in that George’s parents have tended to take a more “problem-solving” approach to George’s emotions, instead of helping George tolerate and manage stressful feelings. 3. What can I do if I see George and his family again in the future? Although we cannot completely rule out an organic cause or trigger, our test results suggest that the current episodes were related to George’s coping difficulties. If he is to ever return, it may be beneficial to discuss recent stressors in George’s life, such as feeling pressure to achieve in sports, academics, and so forth and if he has been able to discuss these feelings with his mother and father. George’s parents appear committed in assisting his self expression and coming to a more mature understanding of his emotions, so this line of questioning would likely not seem inappropriate. However, if his symptoms are different, or of increased severity, we defer to your medical expertise in regards to conducting another thorough neurological examination or referring for a complete neuropsychological evaluation. Thank you again for your referral and willingness to be involved in the assessment process. If you have any additional questions or concerns feel free to contact us. Sincerely, Justin D. Smith (Nicole Swain, supervisor).
TA and Systemic Change
Although it is impossible to draw firm conclusions from a single case study, it seems useful to reflect on the processes that may have led to improvement in George and his family. Fulmer, Cohen, and Monaco (1985) listed a number of goals of structural family therapy that can be accomplished through a psychological assessment, including altering proximity, detriangulation, and reinforcing hierarchy. In this case, many of the important shifts seemed to occur from the reframing of George’s difficulties from medically based to emotionally based. As Mike and Ann witnessed George’s deficits in emotional awareness and expression, they appeared to change the way they reacted to him, which seemed to result in his feeling more understood and emotionally supported. This was accompanied by a decrease in his somatic symptomatology. We believe that shifts would have been difficult to achieve without Mike and Ann taking an active role throughout George’s assessment. If this is true, this case calls into question the common practice of assessing children and adolescents with minimal involvement of their families. As Tharinger, Finn, Austin, et al. (2008) have noted, in the vast majority of child and adolescent assessments, parents do little more than fill out behavior rating scales, give background information, and comment on feedback at the end of the assessment. We feel strongly that such an approach flies in the face of systemic conceptualizations of children’s problems and fails to harness an important therapeutic opportunity.

Limitations and Future Directions
This case presents preliminary evidence of the utility and applicability of the TA model in health care settings. However, further evidence regarding the efficacy of this approach with various populations is needed in order to determine its suitability for specific diagnoses encountered in health care settings. Previous research findings (e.g., Smith, Handler, & Nash, 2010; Smith et al., 2009; Smith, et al., in press; Tharinger et al., 2009) and published clinical case studies (e.g., Hamilton et al., 2009; Smith & Handler, 2009; Tharinger et al., 2007), suggest that TA is likely to be effective for a broad range of childhood and adolescent psychological problems appearing in health care settings, both independent of, and concomitant with medical concerns. Although the child TA model focuses on shifting the family’s understanding of the child, measures of family process, parent– child communication, and systemic functioning were not used to evaluate improvement in this case. Therefore, we can only speculate that familial factors contributed to the observed and reported improvements in the child’s symptoms. Future research efforts need to assess improvements in both the child’s symptoms and family functioning. We would also like to mention that our clinical experience suggests that TA may not be particularly appropriate for the assessment of involuntary populations, such as forensic evaluations. Perhaps more poignant for families likely to appear in health care settings, we recommend proceeding very cautiously when using the TA model with families who have experienced a recent traumatic event (e.g., domestic violence, child abuse, or neglect), due to the potential of retraumatization to the child or the parents. In general, clinicians will need to carefully consider when and with whom to employ the full TA model, or a modified version of TA, which may also be suitable. One potential hurdle to the application of TA in health, pediatric, family medicine, and primary care psychology is the time required to conduct a comprehensive TA, as was done in this case. Finn (2007) estimated that a comprehensive TA takes about 20% more time than a traditional psychological assessment. Although, the comprehensive TA model may be valuable when a full child/family assessment and intervention seems warranted, and there is ample time (6 –12 hours) to conduct each of the model’s components as described. Also, TA may be particularly warranted when other psychological interventions have been tried and have not proved successful. Lastly, since TA has also been found to lead to changes, it may be a desired approach as a brief intervention instead of an assessment and subsequent referral for a separate individual or family treatment.
CONCLUSIONS AND CLINICAL IMPLICATIONS
Psychologists practicing in health care settings are experts on the interface of medical and psychological conditions and they are often called upon to assist medical professionals with thorny and complicated health situations. The case we summarized represents a common referral question encountered by a psychologist in a health care setting, which is to identify possible psychological correlates and points of intervention for a medical issue involving a child and family. We have attempted to illustrate how a relatively new assessment paradigm, TA, can help untangle the web of psychosocial, familial, and intrapsychic issues involved in such referrals, while involving children and parents in a transformative process. George’s physical symptoms appear to have been at least in part related to psychological factors, but TA can also be useful in situations in which psychological issues exist alongside a diagnosed medical condition. In both types of referrals, TA works by helping to illuminate children’s unvoiced needs and experiences, and then helping parents to understand these needs and respond appropriately. As this case illustrated, when this process works, even a relatively brief intervention can result in longstanding shifts in the family’s approach to, and understanding of, the child. This case also demonstrates how the TA model is able to facilitate collaboration between members of the health care team and psychologists in medical-psychological consultations, such as those in consultation-liaison psychiatry. Dr. M specifically reported that the letter was a useful means of obtaining feedback from psychology. We believe successful cases, such as the one presented here, often result in a strengthening of the working alliance between the health care team and psychologists, and that children’s medical care benefits from such collaboration. Overall, the case presented illustrates the utility and applicability of the TA model in the contemporary role psychology often serves in health care settings. The collaborative and systemic emphases of TA align with the CCM and with pediatric, health, and primary care psychology’s current emphasis on the role of familial factors in a child’s physical health. The collaborative nature of TA may also engage parents and families who are otherwise not receptive to psychological services or to looking at psychological factors influencing their children’s medical conditions. For example, we believe that George’s parents were able to make the shifts they did in part because they were allowed to observe and participate in George’s assessment. By the time the assessment had ended, Mike and Ann themselves understood some of George’s psychological limitations and what he needed from them to overcome such difficulties, with only minor input from the clinician. Again, this illustrates a central feature of the CCM, that when patients understand and are actively engaged in constructing their own case formulations they are more likely to follow through on treatment recommendations. In comparison to the traditional assessment paradigm, TA has been found to lead to longstanding familial changes for a variety of children’s psychological problems (e.g., Smith, Handler, & Nash, 2010; Smith et al., 2009; Tharinger et al., 2009). This evidence suggests TA is an intervention in and of itself, not simply a method for gathering information to aid conceptualization and treatment recommendations. In sum, we believe that child-centered family TA is a useful tool for psychologists practicing in health care settings, and we recommend that training in this method be made available.vi We also encourage research on the utility and acceptability of TA with children and families coping with puzzling and complex medical conditions.
Further information about TA and opportunities for training are listed on the TA website: www.therapeuticassessment.com.

SAMPLE FORMAT OF FAMILY ASSESSMENT PAPER

Family Assessment
Casey Schuler
Bemidji State University

 
Family Description
The family discussed in this paper is a blended family. Included is a stepfather (SK), age 50, a mother (LS), age 48, and three children (TS, MS, LS), whose ages are 26, 21 and 18 respectively. The mother is the biological parent of all three children from a previous marriage which ended in divorce from alcoholism in her spouse. The spouse and biological father (GS) has a distant relationship with the children and does not live close. The stepfather also has a child from a previous marriage who was adopted by his uncle and aunt. SK’s previous wife (PK) and youngest child (JK) from that marriage are deceased after an automobile accident. The K family combined 8 years ago when SK and LS had met on an online dating site and fell in love.
The stepfather SK is a business owner who runs an automotive repair shop. He is the primary breadwinner for the family. The mother LK is retired from her previous job due to disability, but works part time for the public school system preparing food for the lunch programs at various schools. She also helps at the automotive shop doing customer service work when needed.
The children are all about 4 years apart and have only loose bonds due to the age differences. The oldest son TS no longer lives at home and works construction and is not married. The youngest has also moved away from the home due to indifferences with the step father. Her relationship with the family is somewhat strained and she does not live close by either. The middle child, MS has recently moved back into the home and has also just given birth to her first son JS. MS had no complications during the pregnancy. JS is a healthy child and is 6 months old. ED is the child’s father; he is helping to support the child but not living in the home.
In general, the family is described as more focused on their individual lives and careers than on family activities. LK states, “I would like to see us get together for family meals, but it is so difficult when everyone has their own thing going on”. SK stays busy with running the business and accounting as well as upkeep around their home, which consists of 20 acres in a rural area. TS jokes, “He really loves his yard.” He has been performing auto repair work for over 30 years and has made a good living from it. LK likes to spend time in the large family garden as well as managing the household duties like laundry and cleaning. LK keeps the family unit organized, as well as helping to care the newly arrived grandson in the home. She works part-time as a way to generate extra money for home repairs and spending money.
Extended family outside of the basic family unit is spread out across the state and visits with them are only a couple times a year. The strongest bonds are between the grandmother LK, the daughter MS, and the new grandchild relationship. MS works at a large online retailer as a customer support specialist. She is very busy taking care of her son. She is learning how to fulfill her new role as a young mother.
Family Assessment
The Calgary Family Assessment Model (CFAM) is a recognized template for nurses to use to help conceptualize and organize data gathered from working with families. It can be used to both compile data from a family assessment, but also may be useful when helping a family address a specific health issue. The CFAM can be seen as a branching diagram with three main categories: structural, developmental, and functional levels (Wright and Leahey 2009, Chapter 3).
Structural Assessment
The structural assessment can be broken down into the internal structure which describes the relationship between the family members, the external structure of the family and its relationships with family and systems, and the context or environment in which the family functions (Wright and Leahey 2009, p. 49-50).
Internal Structure. The family composition of the nuclear family unit consists of a mother and father in a monogamous marriage with three children, one grandchild, two dogs and a cat. The father is the step-father of the three children and the relationship to them is mixed. The father and mother act as the family’s head and decision makers.
Two of the children have moved from the home and are no longer supported by the stepfather and mother. The eldest daughter lives in the home and is currently dependent on the mother and father for direction and assistance in caring for and raising the newborn. The father of the newborn is not in a relationship with the biological mother. He also helps to care for the child through joint custody and financial support. The son is the oldest child and is active in his own life and career but assists the family regularly by helping maintain his family’s home and property or at the step father’s business. He is not married. The youngest daughter has distanced herself and maintains minimal contact with the family. She is said to be less accepting of the new marriage of her mother to her stepfather. She maintains a monogamous homosexual relationship with her partner.
Two dogs and a cat also live with the family. The dogs are large outdoor dogs which require little care and attention but consume large amounts of food on a monthly basis. It can at times be difficult to afford large quantities of food for them which is often afforded by the mother’s part-time earnings. The cat lives indoors and is approaching eleven years of age. There is a strong emotional attachment to the animals and they are considered family members in the household.
The genogram below (Figure 1) provides a visual model of the family and the relationships to each other on a multi-generational spectrum. Dates of death are noted above the individual for those whom are deceased. The family unit of this assessment is contained within the green dotted boundary line.

Figure 1: Family genogram
External Assessment. Externally, the family assessment falls into two main subcategories. First, the extended family, which includes generations within the family, is reviewed. Second, the CFAM recognizes larger systems such as work relations, other families, and specific agencies such as welfare, courts, or service providers with direct involvement in the family’s function (Wright and Leahey 2009, p. 50-60).
The maternal extended family includes five generations. They consist of the three generations within the nuclear unit, as well as a widowed great-grandmother and a widowed great-great-grandmother on the maternal side. There are some health concerns involved with maintaining independent living for the great-grandmother and assisted living for the great-great-grandmother. All of the third, forth, and fifth generations which includes many siblings and their kin are alive and no major health concerns are noted within the family’s line.
The mother LK’s previous marriage deteriorated from an alcoholic spouse, who is also the biological father of her three children. The relationship between the father and his children is distant. The biological mother and father do not get along well and he did not provide adequate financial support for the children. He lives many hours away and does not travel to see the children. The children do, however, maintain some contact with their fraternal grandmother. She is ninety years old, retired, and still maintains an independent lifestyle. Alcoholism is a noted condition in the biological father’s side of the family which also has affected several of his siblings.
The stepfather’s family is comprised of three generations. His mother, now 86, is still alive and lives alone. She struggles with mobility and has had both knees and both hips replaced from deteriorating joints. She no longer drives. During the interview, family members jokingly describe her as the “bionic woman.” She is widowed and requires assistance from all of her children for rides and certain tasks involving home maintenance. Her husband died at the age of 55 from heart disease. Of the children she conceived, the stepfather, SK is the youngest. His family was large with six older siblings. Three of the older siblings have died. The eldest child, a daughter, had died in her thirties. She developed mental retardation from rheumatic fever when she was young and lived in a nursing home for the remainder of her life. Two of the older siblings died in their fifties from a heart attack and a motorcycle crash.
SK’s previous marriage ended as a result of a car crash which killed his wife and youngest child. The older child was adopted by an uncle and aunt after the accident when SK was unable to provide care for him. His biological son is now nineteen years old and lives independently. The relationship is described as shifted to more of an “uncle and nephew” type of interaction after the adoption.
The family often celebrates holidays with both the stepfather’s family and the mother’s family on two separate days. The families have only united for a few occasions such as marriages, graduations, and the birth of the grandchild JS. When they do have events together with both sides of the family present, everyone gets along great.
Because of the involvement in the family’s small business, several members of the shop’s staff also have close relationships and various interpersonal interactions with the family. The business functions to provide financial income for several staff members and their families. The wife’s part-time job has less influence on the family other than that of providing supplemental income. The North Dakota Department of Human Services Child Support Enforcement division is one service the family utilizes for child support of the three children from the biological father. The local hospital has also been involved with the pregnancy, birth and welfare of the newborn grandchild and his mother.

Figure 2: Ecomap
Contextual Assessment. The context of a family is described as the “whole situation or background relevant to some event or personality.” This might include elements of race, ethnicity, social class, spirituality, and environmental factors (Wright and Leahey 2009, p. 62-70).
The family is a middle class family of Caucasian American decent. German and Norwegian lines of heritage are prevalent among all family lines along with some Swedish and Danish as well. The family Christian with several denominations which include Catholicism on the stepfather’s side and Lutheranism on the mother’s side. They do not attend church regularly but all children have been baptized and confirmed. The children attended a private Christian school for primary and secondary education.
The male members of the family, SK and the oldest son TS have attended a post-secondary educational school for technical training such as an automotive technology or architectural technology and design degrees. None of the family members have attended a 4-year institution within the primary family unit, although, several members of the extended family have completed undergraduate and graduate programs. All members, with exception to the newborn, have graduated with a high school diploma.
All living generations are native to the United States. Culturally, most traditions include those of the typical American Christian such as Christmas, Thanksgiving, and Easter celebrations. The children have been raised with “traditional Lutheran standards and values”, LK says.
As owning and operating a business is the primary source of income for the family, some instability in income occur from variations in the amount of business the automotive shop generates. SK says the winter months are the strongest months, but it costs a lot of money to heat the shop at the same time. The family does, however, remain flexible with additional income generated LK’s part-time salary. The business was purchased six years ago from the previous owner for whom SK had originally managed operations and worked as the master mechanic. The business has seen some growth over the last six years. The business is stable and the family predicts continued growth in the future. The business also serves as the primary source for retirement savings for SK and LK. TS, the eldest son states, “I don’t think I would ever take over the business when my stepdad retires, it’s just not my thing.”
Developmental Assessment
Much like Erik Erikson theorized on the stages of psychosocial development individuals progress through, the CFAM similarly asserts that families also progress through certain stages of development (Crain, 2011 and Wright & Leahey, 2009). The CFAM uses Mcgoldrick & Carter’s model of the six stages of the family life cycle (Mcgoldrick & Carter, 1999, p. 2). These stages are:

1. Leaving home: single young adults.
2. The joining of families through marriage: the new couple.
3. Families with young children.
4. Families with adolescents.
5. Launching children and moving on.
6. Families in later life.
   Each of these stages are “delineated”, CFAM points out, and “expansion, contraction and realignment” of these stages as members of the family “enter, exit, and develop” is to be expected (Wright & Leahey, 2009, p. 90).
   Stage of Development. Eight years ago when SK and LK met, the second stage of family development was begun. The couple began the Joining of Families through Marriage. Developmentally, Mcgoldrick & Carter (1999) note that the family must make a “commitment to a new system”. This includes the formation of the marrital system and the “realignment of relationships with extended family and friends to include the spouse”. In the same regard, the development also includes the children from previous relationships. Mcgoldrick & Carter (1999) indicate that the remairried family formation has several additional and unique steps in development in addition to simply joining in marriage:
7. Entering the relationship: recovery from loss of prior marriages and recommiting to marriage to form a family
8. Conceptualizing and planing the new family: accepting fears and patience in adjusting to new roles, boundaries, andaffective issues.
9. Remarriage and reconstrction: resolution of previous spouces and acepting a new family model with flexible boundaries.
   The family simultainiosly entered into the fourth and fifth stages once the commitment to a new system had been made. The children of this now blended family were 10, 14, and 18 years of age when SK and LS wed. The family at that time was a Family with Adolescents as well as Launching Children, who as the eldest son was preparing to go to college his senior year of high school. According to the emotional process of transition described by Mcgoldrick & Carter (1999), the family must increase flexability of family boundaries to include childrens independence as well as accept a multitude of entries and exits as launching children begin to reduce dependence on the family unit.
   Now that the children have grown and the youngest child was out of the home at age eighteen, the family has progressed from a Family with Adolescents to solely Launching Children. SK, the stepfather, is quoted as often stating, “I had them all out of the house for six whole months”, says TS, refering to their middle child moving back in after she had found out she was going to have a baby.
   The creation of the new family of the daughter MS has also entered into a Family With Young Children where, deveopmentaly, Mcgoldrick and Carter (1999) say they are “accepting a new member into the system”. This includes adjusting and making space for a new child as well as financial planing. The grandparents and parents are also realigning their relationships to include new roles and responsibilities (Mcgoldrick & Carter, 1999).
   The following diagram (Figure 3) illistrates the families current relationships between each indicating the level of closeness.The legend provided decribes the levels of attachment between each member of the family as decribed in the assessment.

Figure 3: Family Attachments.
Functional Assessment
The functional assessment portion of the CFAM describes the family’s current interactions with each other and how they perform as a unit. It is also described as the “here and now” portion of the assessment that includes two basic aspects of functioning: instrumental and expressive (Wright & Leahey, 2009, pp. 116-117).
Instrumental functioning. Crucial interactions amongst the family make up the instrumental functioning portion of the assessment. These include basic and routine activities of daily living such as preparing meals, house care, laundry, caring for children, and other unique activities that comprise a family’s function. These are the interactions that define the family. Tasks or roles may change due to events and challenges that the family faces or specific family members. Assessing the family’s instrumental functioning can reveal details about the families specific functioning during events such as illnesses. It is also effective in revealing the resiliencies that the family may have as well (Wright & Leahey, 2009, pp. 116-117).
In the CFAM, Wright & Leahey (2009) suggest assessing the family across the six stages of health and illness. These inclide the family efforts at (1) health promotion, (2) family appraisal of symptoms, (3) care seeking, (4) referal and obtaining care, (5) acute response to illness by client and family, and (6) adaptation to illness and recovery (Friedman, Bowden, & Jones, 2003).
The family is currently most involved in the efforts of health promotion and LK states she, “takes on most of the responsibility”. She reminds family members of things like check-ups and dental visits and coordinates care for the family as it is needed. LK also monitors the family’s health issues and everyone in the family turns to her with questions and for guidence.
The daughter MS relied on her mother for support and guidance during her first pregnancy as well as help now with the newborn in the home. As the grandparent, LK is active in making sure MS is able to care for her child as a new mother. Having three children of her own, LK is a good role model for her daughter MS.
LK used work as a government employee but was placed on disability leave after being diagnosed with a benign brain tumor in 2006. This was diagnosed after she had two seizures. While she was recovering from surgury, the family was able to effectively cover her rolesin the home as well as adapt as she entered into the recovery stage. The family has also taken steps to advance SK’s career and income through the purchace of the auto shop to make up for the lost income of LK’s original salary. The family tells me that they feel they are very close to the level of fuctioning they had before the surguries. LK says this, “It’s just one of those things that hit you and there is no choice in the matter so you just have to deal with it.” She also notes that her family was “very supportive” during her recovery.
Expressive Functioning. CFAM assesses expressive functioning with nine categories of communication: (1) emotional, (2) verbal, (3) non-verbal, (4) circular communication, (5) problem solving, (6) roles, (7) influence and power, (8) beliefs and (9) alliances and coalitions. If there are barriers in coping with any instrumental issue, communication barriers will also arise. On the other hand, Wright and Leahey add that even families with no instrumental difficulties, they may still experience a breakdown in communication and expression (Wright & Leahey, 2009, p. 117).
Emotional Communication. The family does not discuss their emotions often amongst themselves but were able, for the purpose of this assessment, able to discuss emotions that they experience between each other. TS and LK explain that they do not usually get too upset with each other. TS notes that when he and his sisters were younger there was some sibling hostility but it isn’t so bad now that they are older and, “everyone can be civil”.
Verbal Communication. Direct verbal communication generally is understood between family members. SK, the stepfather, tends to be sarcastic at times and can’t always be taken seriously. LK is said to have indirect verbal messages at times when she is annoyed but it is always understood. With kids moving away from home, they use texting on a regular basis. Actual phone calls are less often.
Nonverbal Communication. The family has various non-verbal traits and cues. The interviewees, LK and TS both made good eye contact. LK often touched TS on the shoulder when she was telling stories about him. TS tended to use his hands when he spoke. He sat comfortably, partially slouched down in a large chair. LK would often look to TS for affirmation when she was unsure of details and TS would continue her story. LK tended to do most of the narrating.
Circular Communication. There seemed to be some patterns of arguments that occur from circular communication but overall, communication is strong. Often, LK states that she has to confront SK with issues or bills and he might get irritated and avoid her and the issue, but he eventually takes care of the issue. The following diagram (Figure 2) describes this circular communication between the couple.

Figure 2. Circular communication diagram.
Problem Solving. The family denies any issues with problem solving. Usually, the family uses a team approach and discusses issues amongst everyone in the family. There are disagreements from time to time but debates rarely get heated.
Roles. Roles within the family are well defined. The primary financial decision maker is LK, even though SK is the primary source for income in the family. She generally makes the decisions related to projects and major purchases that the family makes, where as SK makes the decisions for his automotive business. The role of parent is also primarily LK, as SK provides more of a role model type lead in children’s lives rather than parent. TS, the oldest sibling is also a role model to his two younger sisters.
Influence and Power. SK does hold final say over all decisions in the household but he is generally passive on most issues, says LK, “We all get along pretty well.”
Beliefs. The family lives by Christian values and bases their decisions of strong moral values. They agree that they should all try to treat others as they would like to be treated.
Alliances and Coalitions. While everyone gets along, it appears as though the siblings are not extremely close and do not visit with each other independently. Rather, they gather as a family together with the parents. Most alliances revolve around friends outside of the family.
Strength/Problems List
Table 1. Strength / Problem List
Subsystem Strengths Problems
Marital-Parental Subsystem • Parents are aware of children’s independence as adults but are understanding of failures and provide encouragement.
• Roles are considered equally important and are well established.
• Tasks are performed based upon talents and strengths. • Trouble with coping with SK’s role as new head of household among youngest child LS.
• SK stays busy with running the business and does not have much time for family affairs.
Parent-Child Subsystem • All children are equally valued within the home.
• Grand-parents are actively involved in raising the grandchild JS
• Son is given more independence that the daughters as a male child.
• “The youngest always got the most attention.”
Sibling Subsystem • All children get along.
• TS serves as a role model for his younger sisters. • Large age differences in the siblings affect relationships.
Individual Systems • SK enjoys running his business and supporting the family.
• LK enjoys her part-time job as well as coordinator for the family.
• TS has gained independence from his parents and has successfully launched from the home. • SK stays busy running his business and it is stressful at times.
• MS is stressed with birth of new child in a non-married setting.

Family Summary
The K family is a structurally diverse, blended family which is the product of two past marriages. The children belong to the mother biologically. The older siblings get along with the stepfather but the youngest does not. They have several new sub-families that branch off from the main unit as children have grown into young adults and are now launching from the home. The eldest daughter has recently begun a family of her own but still lives in the home. The grand child’s father is welcome in the home and provides support in raising the child.
Individuals effectively perform their roles within the family boundaries and the family continues to thrive. The Stepfather SK is the primary wage earner for the household by running his business and LK provides her support in managing the home and day to day issues. They are flexible and adapt to change effectively as demonstrated by their ability to cope with LK’s diagnosis and recovery from a brain tumor in 2006.
Assessment Summary
The family is a growing family of five with one child now bearing a child of her own. They are a non-traditional, blended family. They are all Caucasian of American descent and practice Christianity of the Lutheran denomination. The father’s previous marriage ended when that wife and youngest child were killed in an automobile accident. The mother’s previous marriage ended in divorce due to alcoholism in her previous spouse. The mother is the biological parent of all three children and the stepfather’s remaining child has been raised by this brother and his wife. They live in a rural area and enjoy the quiet country life at home.
The father owns his own automotive repair business and in heavily involved in running the business. He works six days a week managing the operation and works late some nights totaling sales for the day and working on payroll. The business generates the primary income for the family to pay for their mortgage and utilities. The mother is disabled and works part-time serving food for the public school system. She uses the money for home repairs and groceries. The parents help each other where they can and are actively involved with one another’s lives. The mother is the primary parental figure and the stepfather acts as a positive role model for the children more than as a parental figure.
The mother was diagnosed with a benign brain tumor six years ago after experiencing two seizures. This was a vulnerable time for the family who is otherwise free from any serious health problems. She was forced to retire from her employment position as well as her role as contributing financial provider. The family was very supportive in her rehabilitation. The stepfather has since expanded his career to better support the family and relieve stresses for his wife. Since having the tumor removed, she has made a strong recovery and has been able to resume her role as the primary parental figure and has also resumed part-time employment to support the family with supplemental income.
There are two daughters and an older son, ages 19, 22 and 26, respectively. They get along but do not generally maintain a close friendship due to differences in age. Two of the children have moved out from the home and have successfully launched; they support themselves financially.
The 22 year old daughter has moved back into the home six months after learning she was pregnant. She has now had that child and is busy caring for the infant. She plans to continue to raise the child in the grandparents’ home until she is financially and emotionally able to function as a single parent in her own home. The child is shared jointly with the biological father and he maintains a positive relationship with the mother and her family.
This family spends most holidays together. The family generally is in agreement with each other except for the youngest daughter who did not cope will with her parents’ new marriage. She does not get along with the stepfather well but does, however, make it to most holiday meals.
The family is generally healthy with no chronic illnesses. The mother has taken steps to lose weight and shows a positive example to the children to eat healthy and exercise. Most meals while the children were in the house were home cooked. The parents have always tried to urge their children not to eat too much fast food or unhealthy meals. They are aware of many health maintenance issues such as smoking. The mother reports quitting smoking eight years ago for her children but the stepfather still smokes. This is a concern for the mother who recognizes that her spouse, the stepfather, has lost his father and one brother to heart disease when they were both in their mid-fifties. Neither parent drinks alcohol regularly and the children, all in early adulthood seem to use alcohol responsibly most of the time.
Family Nursing Diagnoses and Intervention
The Calgary Family Intervention Model (CFIM) is a complementary companion to the Calgary Family Assessment Model. The CFIM examines interventions for family functioning across three domains: cognitive, affective and behavioral. Wright & Leahey (2009) expalin that “interventions can be designed to promote, improve, or sustain family functioning in any or all three domains, but a change in one area can affect the other domains.” They further assert that interventions can only be offered to the family, but “should not instruct, direct, demand, or insist” on a particular change or way of functioning. A families openness to intervention will greatly be determined by thier historical functioning (Wright & Leahey, 2009, p. 144).
Diagnosis.
The first and most important diagnosis directly relates to the families health promotion. The wife demonstrates a readiness for enhanced knowledge: smoking cessation related to interest in improving health as evidenced by verbalized statements of interest in smoking cessation programs for her husband.
Second, I recognized ineffective health maintenance related to denial of the effects of smoking as evidenced by continued smoking of one pack per day by the stepfather.
Lastly, there was apparent ineffective family communication related to discord between stepfather and stepdaughter as evidenced by strained family relationships.
Intervention.
For the first diagnosis, LK demonstrated readiness for enhanced knowledge with helping her husband with smoking cessation. Interventions for this diagnosis include sharing with her websites where she can access information related to smoking and smoking cessation.
The Centers for Disease Control and Prevention website contains a great fact sheet which details information about nicotine dependence, the health benefits of cessation, methods to help users quit, as well as a list of helpful resources for the family to use.
The second diagnosis also related closely with the first diagnosis. Ineffective health maintenance is observed due to the stepfather’s continued smoking and inability to permanently quit. The CDC website is also useful for providing information about this to the stepfather. Because the stepfather was not present during the interview, it was not possible to assess his readiness to accept tobacco cessation information. By providing the family with informational resources, they can learn and discuss matters as they see fit without pressure to accept the information immediately.
Due to discord between the stepfather and youngest step-daughter, I was interested in providing the family with information aimed at improving the ineffective family communication.
Interventions I provided included directing them to The National Stepfamily Resource Center website. The resource center is a dedicated program that can link families to support groups as well as provide information backed by research, as well as helpful links for further informational resources.
I also encouraged the family to be open with each other. I noted a lack of emotional openness between the individuals which can possibly create barriers to understanding each other’s feelings.
Circular Questioning
Wright & Leahey (2009) deferentiate between two types of questions used in assessment to help investigate problems. First, linear questions are used to investigate a problem. Linear questions are often used to begin an assessment and gather information. Circular questioning is then used to explore topics and promote conversation. Circular questions are meant to effect change (Wright & Leahey, 2009, p. 146).
Circular questioning was used to begin dialog about the family issue about the new grandchild in the family. The discussion was directed toward the older brother TS.
Q: [Me] “Were you excited to become an uncle?
A: [TS] “Honestly, I wasn’t. I didn’t really know what to expect.”
Q: [Me] “What were some of your concerns with becoming an uncle?”
A: [TS] “I’m not very experienced with children. I didn’t even know how to hold him when he was born.”
Q: [Me] “Do you feel more comfortable with him now?”
A: [TS] “Definitely. It came pretty quickly.”
Q: [Me] “How do you think you sister (MS) is doing as a single parent?”
A: [TS] “I think she is doing just fine. Our mother has been a great role model for her and she is always there to help answer her questions.”
Desired Outcomes
As this family is already a healthy functioning family, the desired outcomes would be to continue the promotion of health maintenance and effective functioning to support family relationships. Diagnoses made for this family aim to improve function and aim to promote further health prevention as well as to improve the communication between members of this blended stepfamily. This family has demonstrated resiliency and flexibility with issues and external events and efforts were made to further strengthen these abilities.
Family Health Resource List
The National Stepfamily Resource Center and Centers for Disease Control and Prevention websites were used as tools to provide knowledge and resources to the family as a means of promoting optimum family functioning.
• http://www.stepfamilies.info
• http://www.cdc.gov/tobacco/osh/index.htm
GenoPro® 2011 software was used for the creation of diagrams and illustrations to conceptualize data gathered during the family assessment. 

References
Crain, W. (2011). Theories of Development: Concepts and Applications (6th ed.). Upper Saddle River, NJ: Pearson Education, Inc.
Friedman, M. R., Bowden, V. R., & Jones, E. (2003). Family Nursing: Research, Theory, and Practice (5th ed.). Upper Saddle River, NJ: Prentice Hall.
Mcgoldrick, M., & Carter, B. (1999). The Expanded Family Life Cycle: Individual, Family, and Social Perspectives (3rd ed.). Boston, MA: Allyn and Bacon.
Wright, L. M., & Leahey, M. (2009). Nurse and Families: A Guide to Family Assessment and Intervention (5th ed.). Philadelphia, PA: F. A. Davis Company.

Required Text: Shajani, Z. & Snell, D. (2019). Wright & Leahey’s Nurses and families: a guide to family assessment and intervention. (7th ed). Philadelphia: F.A. Davis.

Chapter 1
Family Assessment and Intervention: An Overview
Learning Objectives
• Understand the evolution of family nursing.
• Identify the difference between nursing interventions and family nursing interventions.
• Describe the indications and contraindications for a family assessment and interventions.
• Identify the Calgary Family Assessment Model (CFAM) and the Calgary Family Intervention Model (CFIM) as frameworks for family systems nursing.
Key Concepts
Calgary Family Assessment Model (CFAM)
Calgary Family Intervention Model (CFIM)
Family nursing interventions
Family systems nursing
Nursing interventions
Nurses have an ethical and moral obligation to involve families in their health-care practice. Family has a significant impact on the health and well-being of individual members. Family-centered care is achieved responsibly and respectfully by relational practices consisting of collaborative nurse-family relationships together with sound family assessment and intervention knowledge and skills.
As nurses theorize about, conduct research on, and involve families more in health care, they modify their usual patterns of clinical practice. The implication for this change in practice is that nurses must become competent in assessing and intervening with families through collaborative nurse-family relationships. Nurses who embrace the belief that illness needs to be treated as a family affair can more efficiently learn the knowledge and clinical skills required to conduct family interviews (Wright & Bell, 2009). This belief invites nurses to think interactionally, or reciprocally, about families. The dominant focus of family nursing assessment and intervention must be the reciprocity between health and illness and the family. Providing nurses with a framework for family assessment and the interventions for treating families can facilitate the transition from thinking in an individualistic manner toward thinking interactionally and, thus, thinking “family.”
It is most helpful and enlightening for nurses to assess the impact of illness on the family and the influence of family interaction on the cause, course, and cure of illness. Additionally, the reciprocal relationship between nurses and families is also a significant component of both easing suffering and enhancing healing.
Family systems nursing integrates nursing, systems, cybernetics, change, and family therapy theories (Bell, 2009; Wright & Leahey, 1990). It requires familiarity with an extensive body of knowledge: family dynamics, family systems theory, family assessment, family intervention, and family research. It also requires accompanying competence in family interviewing skills. Family systems nursing focuses simultaneously on the family and individual systems (Bell, 2009; Wright & Leahey, 1990). All nurses should be knowledgeable about and competent in involving families in health care across all domains of nursing practice.
KEY CONCEPT DEFINED
Family Systems Nursing
A framework that integrates nursing, systems, cybernetics, change, and family therapy theories and focuses interventions simultaneously on the family and the individual systems.
The language of family nursing has been growing and evolving over the course of many years. Table 1-1 summarizes the terms that name, describe, and communicate aspects of family-centered care and identifies the authors and sources of these vital additions to nursing practice.
EVOLUTION OF THE NURSING OF FAMILIES
Throughout nursing’s history, family involvement has always been part of health care, but it has not always been labeled as such. Because nursing originated in patients’ homes, family involvement and family-centered care were natural occurrences. With the transition of nursing practice from homes to hospitals during the Great Depression and World War II, families became excluded not only from involvement in caring for ill members but also from major family events such as birth and death. After having undergone all these developmental changes, the practice of nursing has now come full circle, with an obligation to invite families once again to participate in their own health care. However, this invitation is being made with much more knowledge, research evidence, respect, and collaboration than at any other time in nursing history.
TABLE 1-1 Common Terms Used in Family-Centered Care and Their Sources
TERMS SOURCE
Family interviewing Wright and Leahey, 2013
Family health promotion nursing Bomar, 2004
Family health-care nursing Hanson, 2001; Hanson and Boyd, 1996; Kaakinen, Coehlo, Steele, Tabacco, and Hanson, 2018
Family nursing Bell, Watson, and Wright, 1990; Friedman, Bowden, and Jones, 2003; Gilliss, 1991; Gilliss, Highly, Roberts, and Martinson, 1989; Svavarsdottir and Jonsdottir, 2011; Wegner and Alexander, 1993; Wright and Leahey, 1990
Family nursing practice Family systems nursing Bell, 2009; Wright and Leahey, 1990; Wright, Watson, and Bell, 1990
Nursing of families Feetham, Meister, Bell, and Gilliss, 1993
Family nursing as relational inquiry Doane and Varcoe, 2005
The history, evolution, and theory development of the nursing of families in North America have been discussed in depth in the literature (Anderson, 2000; Doane, 2003; Duhamel, 2015; Feetham, Meister, Bell & Gilliss, 1993; Ford-Gilboe, 2002; Friedman, Bowden, & Jones, 2003; Gilliss, 1991; Gilliss, Highly, Roberts, & Martinson, 1989; Hartrick, 2000; Kaakinen, Coehlo, Steele, Tabacco, & Hanson, 2018; Kobayashi, 2011). These authors have made significant contributions to the advancement of family nursing knowledge. Table 1-2 summarizes the evolution of family nursing.
The evolution, development, and practice of family nursing are well established and are being documented in many countries outside North America (see Table 1-3).
TABLE 1-2 Timeline of the Evolution of Family Nursing
YEAR EVOLUTION OF FAMILY NURSING
1970–Present Institute for the Family, Family Therapy Services, Department of Psychiatry, University of Rochester, Rochester, New York, is begun.
1973–Present Calgary Family Therapy Centre, Calgary, AB, Canada, is begun.
1982–2007 Family Nursing Unit, University of Calgary, Calgary, AB, Canada, is opened.
1984 First edition of Nurses and Families is published (Wright & Leahey).
1985–2010 Family Therapy Training Program, Calgary, AB, Canada, is begun.
1988 First International Family Nursing Conference, Calgary, AB, Canada, was held.
1990–1998 Family Nursing Center, University of Wisconsin–Eau Claire, is in operation.
1991–Present Chicago Center for Family Health, affiliate of the University of Chicago, Chicago, Illinois, is opened.
1993–2017 Denise Latourelle Family Nursing Unit, University of Montreal, Quebec, Canada, is opened.
1995 Journal of Family Nursing is started.
2000 Family Health Nurse—Context, Conceptual Framework and Curriculum (World Health Organization, 2000) is developed.
2001 World Health Organization Family Health Nurse Multinational study begins.
2001 International Council of Nurses (ICN) document entitled “The Family Nurse: Frameworks for Practice” is published.
2001-Present Family Stress and Illness Program, Behavioral Health Center, the Children’s Hospital of Philadelphia, Pennsylvania, is opened.
2002 International Council of Nurses (ICN) Nurses Day theme: Family Nursing Nine Star Family Nursing is identified.
2007–2011 Landspitali University Hospital Family Nursing Implementation Project is operational.
2008 Glen Taylor Nursing Institute for Family and Society, Minnesota State University, Mankato, Minnesota, is established.
2009 International Family Nursing Association (IFNA) is established.
2013 International Family Nursing Association (IFNA) “IFNA Position Statement on Pre-Licensure Family Nursing Education” is published.
2015 International Family Nursing Association (IFNA) “IFNA Position Statement on Generalist Competencies for Family Nursing Practice” is published
2017 International Family Nursing Association (IFNA) “IFNA Position Statement on Advanced Practice Competencies for Family Nursing” is published.
TABLE 1-3 Documented Family Nursing Research and Practice Outside of North America
COUNTRY AUTHORS
Brazil Angelo, 2008
Denmark Voltelen, Konradsen, and Østergaard, 2016
Finland Astedt-Kurki, 2010; Astedt-Kurki and Kaunonen, 2011
Hong Kong Simpson et al, 2006
Iceland Svavarsdottir, 2008; Svavarsdottir and Sigurdardottir, 2011
Japan Bell, 1999; Moriyama, 2008; Sugishita, 1999
Nigeria Irinoye, Ogunfowokan, and Olaogun, 2006
Nordic countries Svavarsdottir, 2006
Scotland O’Sullivan Buchard, Claveirole, Mitchell, Walford, and Whyte, 2004
Sweden Saveman, 2010; Saveman and Benzein, 2001
Thailand Wacharasin and Theinpichet, 2008
Numerous disciplines have attempted to define and conceptualize the concept of family. Each discipline has its own point of view or frame of reference for viewing the family, and all have an ever-increasing appreciation of diversity issues, for example:
• Economists are concerned with how the family works together to meet material needs.
• Sociologists are concerned with the family as a specific group in society.
• Psychologists are concerned with the emotional ties within a family.
It is helpful for nurses to be aware of the many models offered by various disciplines and the distinct variables emphasized in each model because no one assessment model explains all family phenomena. In any clinical practice setting, nurses benefit from adopting a clear conceptual framework, or map, of the family. This framework encourages the synthesis of data so that family strengths and problems can be identified and a useful nursing plan devised. When no conceptual framework exists, it is extremely difficult for the nurse to group disparate data or to examine the relationships among the multiple variables that affect the family. Use of a family assessment framework helps to organize this massive amount of seemingly different information. It also provides a focus for intervention.
NURSING PRACTICE LEVELS WITH FAMILIES: GENERALIST AND SPECIALIST
Schober and Affara (2001) emphasize that nursing practice with families is directed by whether the concept of the family is defined as family as context or family as client. One way to alleviate potential confusion of practice levels is to clearly distinguish two levels of expertise in nursing with regard to clinical work with families: generalists and specialists. Typically, generalists are nurses at the baccalaureate level who predominantly use the concept of the family as context (Wright & Leahey, 1990), although upper-level baccalaureate students begin to conceptualize the family as the unit of care. Specialists, on the other hand, are nurses at the graduate (master’s or doctoral) level who predominantly use the concept of family as the unit of care. This requires specialization in family systems nursing (Wright & Leahey, 1990). Family systems nursing specialization requires that “the focus is always on interaction and reciprocity. It is not ‘either/or’ but rather ‘both/and’” (Wright & Leahey, 1990, p. 149). However, these boundaries can become blurred, with upper-level baccalaureate students recognizing the importance of focusing on interaction and reciprocity. These students often develop nursing competence and are able to deal with individual and family systems simultaneously.
CALGARY FAMILY ASSESSMENT MODEL: AN INTEGRATED FRAMEWORK
The Calgary Family Assessment Model (CFAM) is a multidimensional framework consisting of three major categories: structural, developmental, and functional (see Chapter 3). The model is based on a theory foundation involving systems, cybernetics, communication, and change. It was adapted from Tomm and Sanders’s (1983) family assessment model and has been substantially embellished since the first edition of Nurses and Families in 1984. The model is also embedded within larger worldviews of postmodernism, feminism, and the biology of cognition. Diversity issues are also emphasized and appreciated within this model.
KEY CONCEPT DEFINED
Calgary Family Assessment Model (CFAM)
A multidimensional framework consisting of three major categories—structural, developmental, and functional—based on a theory foundation involving systems, cybernetics, communication, and change.
Of course, any model is useful only if it can be comprehended by nurses and then transferred into their generalist practice with families. There has been recent research conducted to validate the usefulness of the CFAM/Calgary Family Intervention Model (CFIM) such as the following:
• Perceived level of knowledge and difficulty in applying family assessment among senior undergraduate nursing students (Lee, Leung, Chan, & Chung, 2010)
• Psychometric development of the Iceland-Family Perceived Support Questionnaire (ICE-FPSQ; Sveinbjarnardottir, Svavarsdottir, & Hrafnkelsson, 2012a)
• Psychometric development of the Iceland-Expressive Family Functioning Questionnaire (ICE-EFFQ; Sveinbjarnardottir, Svavarsdottir, & Hrafnkelsson, 2012b)
INDICATIONS AND CONTRAINDICATIONS FOR A FAMILY ASSESSMENT
It is important to identify guidelines for determining which families will automatically be considered for family assessment. Because families now tend to have increased health-care awareness and knowledge, nurses are encountering families who present themselves as a unit for assistance with family health and illness issues. Frequently, however, families believe the illness involves only one family member. Therefore, with each illness situation, a judgment must be made about whether that particular illness or problem should be approached within a family context. Box 1-1 lists the indications for family assessment.
Conducting and completing a family assessment does not absolve nurses from assessing serious risks, such as suicide and homicide, or serious illnesses in individual family members. Family assessment is neither a panacea nor a substitute for an individual assessment. Contraindications for family assessment are shown in Box 1-2.
During the engagement process, nurses must explicitly present the rationale for a family assessment. (Refer to Chapters 6 and 7.) A nurse’s decision to conduct a family assessment should be guided by sound clinical principles and judgment. The nurse can take advantage of opportunities to consult with peers and supervisors if questions exist about the suitability of such an assessment.
After completing the family assessment, the nurse must decide whether to intervene with the family. In the next section, general ideas about intervention are discussed. Specific ideas for nurses to consider when making clinical decisions about interventions with particular families are presented in Chapters 4, 8, and 9.
Box 1-1 Indications for Family Assessment
• A family is experiencing emotional, physical, or spiritual suffering or disruption caused by a family crisis (e.g., acute or chronic illness, injury, or death).
• A family is experiencing emotional, physical, or spiritual suffering or disruption caused by a developmental milestone (e.g., birth, marriage, youngest child leaving home).
• A family defines an illness or problem as a family issue, and a motivation for family assessment is present.
• A child or adolescent is identified by the family as having difficulties (e.g., cyberbullying, fear of cancer treatment).
• The family is experiencing issues that jeopardize family relationships (e.g., end-of-life illness, addictions).
• An adult family member is being admitted to the hospital.
• A child is being admitted to the hospital.
KEY CONCEPT DEFINED
Calgary Family Intervention Model (CFIM)
An organizing framework conceptualizing the intersection between a particular domain—cognitive, affective, or behavioral—of family functioning and a specific intervention offered by health-care professionals; a companion to the CFAM.
Box 1-2 Contraindications for Family Assessment
• Family assessment compromises the individuation of a family member (e.g., if a young adult has recently left home, a family interview may not be desirable).
• The context of a family situation permits little or no leverage (e.g., the family might have a constraining belief that the nurse is working as an agent of some other institution, such as the court).
CALGARY FAMILY INTERVENTION MODEL: AN ORGANIZING FRAMEWORK
The Calgary Family Intervention Model (CFIM) is an organizing framework for conceptualizing the relationship between families and nurses that helps change to occur and healing to begin. Specifically, the model highlights the family-nurse relationship by focusing on the intersection between family member functioning and interventions offered by nurses (see Chapter 4). It is at this intersection that healing can take place. The CFIM is a resilience- and strength-based, collaborative, nonhierarchical model that recognizes the expertise of family members experiencing illness and the expertise of nurses in managing illness and promoting health. The model is rooted in notions from postmodernism and the biology of cognition. It can be applied and used with patients and families from diverse cultures because it emphasizes the “fit” of particular interventions from a particular cultural viewpoint. To the best of our knowledge, it remains the only family nursing intervention model that is currently documented.
NURSING INTERVENTIONS: A GENERAL DISCUSSION
Numerous terms are used to distinguish and label the treatment portion of nursing practice, including intervention, treatment, therapeutics, action, activity, moves, and micromoves (Bell & Wright, 2011; Bulechek & McCloskey, 1992). This textbook prefers the designation intervention. The most rigorous effort to standardize the language for nursing interventions is the work of McCloskey and Bulechek (1992) and their colleagues at the University of Iowa who developed the Nursing Interventions Classification (NIC), which is a comprehensive, research-based, standardized classification of nursing interventions on nurses’ reports of their practices (Butcher, Bulechek, McCloskey, Dochterman, & Wagner, 2018).
KEY CONCEPT DEFINED
Nursing Interventions
Any action or response of the nurse, including the clinician’s overt therapeutic actions and internal cognitive-affective responses, that occurs in the context of a nurse-client relationship; actions offered to effect and enhance individual, family, or community functioning for which the clinician is accountable.
Family nursing practice differs in that a list of strengths and problems is generated rather than diagnoses. We conceptualize the list as one observer’s perspective, not as the “truth” about a family. The list presents problems or concerns that nurses can address. It has been our experience that nursing diagnoses have become too rigid and do not include enough consideration of the determinants of health. We prefer to identify the strengths of a family and list them alongside the problems. The advantage of this type of listing is that it gives a balanced view of a family. It also asks the nurse not to be blinded by a family’s problems or diagnosis but to realize that every family has strengths and resources, even in the face of potential or actual health problems.
Definition of a Nursing Intervention
Butcher et al (2018) define nursing interventions as “any treatment based upon clinical judgment that a nurse performs to enhance patient/client outcomes” (p. 2). Nursing interventions include both direct and indirect care aimed at individuals, families, and the community. These interventions include physiological and psychological approaches, illness treatment and prevention, and health promotion (Butcher et al, 2018, p. 2). Wright and Bell (2009) offer an alternate definition: “any action or response of the clinician, which includes the clinician’s overt therapeutic actions and internal cognitive-affective responses, that occurs in the context of a clinician-client relationship offered to effect individual, family, or community functioning for which the clinician is accountable” (p. 140). Wright and Bell (2009) expand on their definition of intervention by suggesting that clinical interventions are actualized only in a relationship between the clinician and the family members” (p. 140). Interventions are normally purposeful and conscious and usually involve observable behaviors of the nurse.
Context of a Nursing Intervention
Nursing interventions should focus on the nurse’s behavior and the family’s response followed by the nurse’s response to the family and so forth. We believe that nurse behaviors and client behaviors are contextualized in the nurse-client relationship and are therefore interactional. This differs from nursing diagnoses and nursing outcomes, which focus on client behavior and are not usually interactional in nature (Butcher et al, 2018). An interactional phenomenon occurs whereby the responses of a nurse (interventions) are invited by the responses of clients/family members (outcome) that are, in turn, invited by the responses of a nurse. To focus on only client behaviors or nurse behaviors does not take into account the relationship between nurses and clients. All of our nursing interventions are interactional—that is, not doing to or for the patient but with the patient. Nursing interventions are actualized only in a relationship.
However, some nurses do find the classification of nursing interventions to be helpful in providing a language to describe and conceptualize specific treatment efforts (Butcher et al, 2018).
Intent of Nursing Interventions
The intent or aim of any nursing intervention is to effect change, whether to decrease a high temperature of a patient or improve family functioning when caring for a young boy with chronic illness and his family. Therefore, effective nursing interventions are those to which clients and families respond because of the “fit,” or meshing between the intervention offered by the nurse and the biopsychosocial-spiritual structure of family members. In relational practice with families, there is no predetermined, standardized intervention to use across a number of families. Rather, the nurse, in collaboration with a specific family, determines what interventions are most useful for a family experiencing a particular illness.
NURSING INTERVENTIONS FOR FAMILIES: A SPECIFIC DISCUSSION
Nurses can intervene with families in numerous ways, depending on the compassion, competence, skills, and even imagination of each nurse and, most importantly, depending on the nurse’s relationship with each family (Bell, 2011).
Wright and Leahey (2013) identified factors that contribute to the slower pace of developing nursing interventions with families, which have negatively influenced the implementation of family nursing (Leahey & Harper-Jaques, 2010):
• Lack of appreciation for the interactional aspect of families and illness
• Shortage of nurse educators who are also skilled family clinicians
• Shortage of administrative support for implementation of family nursing
• Minimal ongoing educational support of family interventions in clinical settings
Because interventions related to the family are independent nursing actions for which nurses are accountable, nurse educators and researchers need to name, specify, explore, understand, and test interventions related to the family. There are encouraging signs, with more literature being published not only in nursing journals but a wide variety of multidisciplinary journals. In addition, discussions of family interventions are being presented at conferences worldwide. More nurses are committed to increasing knowledge of family nursing interventions through describing and examining their effectiveness in actual clinical practice and through quantitative and qualitative studies; however, we believe that nurses’ contributions must increase in order for family nursing interventions to be implemented in clinical settings. “There is a critical need for more research methods and research evidence about how to best move family nursing knowledge into action” (Duhamel, 2017, p. 461). Nurses in direct clinical contact with families perceive family interventions differently than nurses who predominantly conduct research or engage in theory development. Nurse educators and researchers need to understand more about the challenges, successes, and difficulties of implementing family nursing in practice settings.
KEY CONCEPT DEFINED
Family Nursing Interventions
Actions based on clinical judgment and knowledge that are used when nurses work with families; they focus on changing the cognitive, affective, or behavioral domains of family functioning.
For example, Duhamel, Dupuis, and Wright (2009) implemented a clinical project in which nurses were found to have difficulty integrating the theoretical aspects of family systems nursing into their practice and therefore desired to acquire additional clinical skills. Specifically, the nurses stated their most pressing need was to develop their abilities to deal with relational issues such as conflict between families and health professionals and family-communication problems. However, they frequently labeled families as “demanding” or “complaining,” which was perceived as separate from the relational aspect of care. One of the conclusions was that nurses’ beliefs about families often led them to label families’ responses to illness as being “dysfunctional” or members being in “denial” rather than more benevolent responses such as family members suffering, being under stress, or experiencing anxiety. This project led these nursing educators to further study three methods of training in family systems nursing (FSN) for successful knowledge transfer into practice (Duhamel, et al, 2009). This study called attention to the need for more educational support in the clinical setting to promote utilization of FSN knowledge in addition to the provision of administrative support. These various studies make clear that a circular, interactional process between education, research, and practice needs to be adhered to and respected (Duhamel & Dupuis, 2011).
More recently, Eggenberger and Sanders (2016) conducted a pilot project to examine the influence of educational interventions on nurses’ attitudes toward and confidence in providing family care. Findings indicated that educational interventions increased nurses’ understanding of family illness experiences and related knowledge and skills (p. 221). Svavarsdottir et al (2015) reinforce the idea of providing meaningful clinical family nursing education to support nurses in applying family systems nursing in clinical practice.
In a participatory action designed study by Duhamel and Talbot (2004), nurses indicated that they gained a better understanding of the illness’s impact on the family members’ relationships, acquired an appreciation of the importance of active listening, practiced a humanistic and personalized approach that centered on family members’ specific concerns and helped to reduce their anxiety, and integrated new family systems nursing interventions into their practice.
Interventions With Families
Notions about reality gleaned from postmodernism and social constructionism are helpful when conceptualizing ideas about interventions. It is unwise to attempt to ascertain what is “really” going on with a particular family or what the “real” problem or suffering is. Rather, nurses should recognize that what is “real” to them as nurses is always a consequence of the nurse’s construction of the world. Maturana (1988) presents an intriguing notion of reality by submitting that individuals (living systems) bring forth reality—they do not construct it, and it does not exist independent of them. This concept has implications for nurses’ clinical work with families—specifically, what nurses perceive about particular situations with families is influenced by how nurses behave (i.e., their interventions), and how they behave depends on what they perceive. (Refer to Chapter 2 for more understanding of Maturana’s biology of cognition.)
Therefore, one way to change the “reality” that family members have constructed is to assist them with developing new ways of interacting in the family. The interventions that we use in this endeavor focus on changing the cognitive, affective, or behavioral domains of family functioning. As family members’ perceptions or beliefs about each other and the illness in their family change, so do their behaviors.
Nurses need to keep the element of time in mind with regard to interventions. Interventions are an integral part of family interviewing, spanning engagement to termination. Normally, interventions used during family interviews are influenced by the nurse’s and family’s experiences of dealing with problems or illnesses or other forms of suffering.
If engagement and assessment have been adequate, the interventions are generally more effective. For example, if a nurse working with a family perpetually addresses certain family members first, the family may disengage, and the opportunity to further intervene may be eliminated. The nurse must possess family interviewing skills and must be sensitive to family function before embarking on specific goal-oriented interventions.
Family nurse clinicians are grounded in the everyday complexities and uniqueness of each family they serve. Although clinicians may benefit from the research literature that offers a description of family responses in health and illness, they are intimately involved in doing intervention and consequently find themselves wanting to know about the specific practices offered to families. We have found it encouraging to learn about the increased examples of intervention programs to assist families.
Family Interactions
There is research being conducted to uncover family interventions with families experiencing physical illness, particularly regarding the usefulness of family interventions that target family interactions and examine the influence of each family member’s illness experiences on other family members (Duhamel & Dupuis, 2004; Duhamel & Talbot, 2004; E.g., Frederiksen, Vamosi, & Lorentzen, 2017; Noiseux & Duhamel, 2003; O’Farrell, Murray, & Hotz, 2000). Chesla (2010) reviewed a meta-analysis of randomized control trials of family intervention research and found that family interventions improve health in persons with chronic illness and their family members across the life span. Her results were encouraging in that the review of family intervention studies with adults indicated there were beneficial effects for family member health and for patient mental health. There was also reasonable evidence that a family-centered approach for children with type 1 diabetes was helpful. Nurses were involved in one-quarter to one-third of the research studies that were reviewed.
Home Visits
Crossman, Warfield, Kotelchuck, Hauser-Cram, and Parish (2018) conducted a study to examine the relationship between the importance of home visitation in early intervention and positive family relationships for parenting a child with a developmental disability. Early intervention home visits provided the opportunity to identify mothers who were challenged, thus providing the development of family strength-based partnerships to foster competency and resiliency.
An example of nurses taking the initiative to promote family health with children with attention deficit-hyperactivity disorder (ADHD) is an in-home intervention called Parents and Children Together (PACT; Kendall & Tabacco, 2011). Recognizing that families with children with ADHD have more interpersonal conflict and negativity in their family and social lives, a program was designed to provide both assessment and resources. This is an impressive effort to empower families, particularly mothers, in the daily management of their children.
Therapeutic Conversations
There is an abundant amount of literature discussing the significance and outcomes of therapeutic conversations as intervention (Bell, Moules & Wright, 2009; Gisladottir & Svavarsdottir 2017; Limacher & Wright, 2006; Marklund, Eriksson, Lindh & Saveman, 2018; McLeod & Wright, 2008; Moules, 2009; Ragnarsdóttir & Svavarsdottir, 2014; Robinson & Wright, 1995; Sveinbjarnardottir, Svavarsdottir, & Wright, 2013; Voltelen, Konradsen & Ostergaard, 2016; Wright, 2015). One example is the work of Gisladottir, Treasure, and Svavarsdottir (2017), who evaluated the effectiveness of therapeutic conversation interventions in group and caregiver sessions on the supporting role of caregivers of people with eating disorders using the CFAM and CFIM as theoretical frameworks. Therapeutic conversations as a family intervention with caregivers in both group and private sessions were found to be beneficial.
Psychosocial/Psychoeducational Interventions
Hirschman and Hodgson (2018) conducted a review of the literature on interventions targeting transitions in care for persons living with dementia and their caregivers. Results identified that “successful interventions were those that included five key elements: (a) educating the individual and caregiver about likely transitions in care and ways to delay or avoid the transition; (b) providing timely communication of information among everyone involved, including the individual, caregiver and care team; (c) involving the individual and caregiver in establishing goals of care (person-centered); (d) comprising a strong collaborative interprofessional team; and (e) implementing evidence-based models of practice” (p. s135).
Konradsdottir and Svavarsdottir (2011) conducted a quasi-experimental study of families with adolescents who had diabetes. Following their educational and support intervention with these families utilizing CFAM and CFIM, there was a significant improvement in the parents’ coping patterns compared with before the intervention.
Web-Based Interventions
Increasing use of Web-based interventions because of their low cost, flexibility, time requirements, and accessibility for families is revealed in recent literature (Kaltenbaugh et al., 2015; Wasilewski, Stinson & Cameron, 2017). Blanton, Dunbar, and Clark (2018) evaluated a caregiver-focused Web-based intervention to improve stroke survivor physical function and reduce caregiver negative outcomes. Results supported content validity and user satisfaction of the Web-based intervention and identified this as an important beginning step towards testing the efficacy of the intervention in a large clinical trial.
Barbabella et al (2016) conducted a Web-based psychosocial intervention for family caregivers of older adults in three European countries. The findings indicated that the intervention improved family caregivers’ awareness, efficacy, and empowerment, which led to better recognition of their own needs and improved efforts for developing and accessing coping resources.
Another innovative intervention program promoting family health is a Web-based asthma education project (Garwick, Seppelt, & Belew, 2011). This program addresses the cultural and literacy backgrounds of families and involved family members in the actual needs’ assessment and in the development of the Web site.
Family Health Promotion
Efforts to develop and identify intervention strategies for family health promotion are also being made, although little documentation of their effectiveness is evident. We believe this to be due to the fact that researchers are focused on family interventions as treatment rather than as health promotion. Family health promotion is an area of family nursing in which there are tremendous opportunities for the development and testing of family interventions.
Family Responses to Interventions
The previous discussion of interventions in family nursing practice primarily focused on the nurse’s behaviors. However, interventions are actualized only in a relationship. Therefore, it is equally important to ascertain the responses of family members to interventions that are offered. Bell and Wright (2007) challenge the predominant belief within “good science” that before intervention research can be designed and conducted, there first must be a thorough understanding of the phenomena (i.e., an in-depth knowledge of what the variables are that mediate families’ response to health and illness). They offer an alternate view that in daily nursing practice, nurses encounter families suffering in a variety of clinical settings that require immediate care and intervention. Therefore, family nursing practice as it occurs in the daily life of nurses needs to be described, explored, and evaluated to gain an understanding of what is working in the moment. What are nurses actually doing and saying that is helpful to families in their experience of illness?
Robinson and Wright (1995) identified what nurses do that makes a positive difference to families. They found that families who experienced difficulty managing a member’s chronic condition and sought assistance in an outpatient nursing clinic could readily identify interventions that alleviated or eased their suffering. The nursing interventions that made a difference for these families fell within two stages of the therapeutic change process:
• Creating circumstances for change
• Bringing the family together to engage in new and different conversations
• Establishing a therapeutic relationship between the nurse and family, particularly in the areas of providing comfort and demonstrating trust
• Moving beyond and overcoming problems
• Inviting meaningful conversation
• Noticing and distinguishing family and individual strengths and resources
• Paying careful attention to and exploring concerns
• Putting illness problems in their place
Families are increasingly expressing the importance of having opportunities to examine with nurses the influence of each family member’s illness experiences on other family members, noting that these interventions are significant for them (Benzein, Olin & Persson, 2015; Eggenberger & Sanders, 2016; O’Farrell, Murray, & Hotz, 2000; Svavardottir et al, 2015). Literature unpacking the interventions of therapeutic conversations (Benzies, 2016; Ostlund, Backstrom, Saveman, Lindh, & Sundin, 2016), commendations (Benzies, 2016; Houger Limacher & Wright, 2003, 2006), and therapeutic letters (Moules, 2002, 2003, 2009) have enhanced our understanding of how, when, and why these interventions are healing for families. Duhamel and Talbot (2004) also identify that family members described the “humanistic attitude of the nurse, constructing a genogram, interventive questioning, offering educational information, normalization, and exploring the illness experience in the presence of other family members” as the most useful interventions (p. 21).
INDICATIONS AND CONTRAINDICATIONS FOR FAMILY INTERVENTIONS
After a family assessment, a nurse must decide whether to intervene with a family. Considerations should include the family’s level of functioning, the nurse’s own skill level, and the resources available. Indications for family interventions are described in Box 1-3.
After the nurse and family have decided that intervention is indicated, they must then collaboratively decide on the duration and intensity of the family sessions. If sessions occur too frequently, the family may have insufficient time to recalibrate and process the change. The optimal number of days, weeks, or months between sessions is difficult to state categorically. We recommend that nurses ask family members when they would like to have another meeting, particularly if the family meetings are occurring on an outpatient basis. Families are much better judges than nurses of how frequently they need to be seen to resolve a particular problem.
Furthermore, nurses should be aware that the duration and intensity of sessions depend on the context in which the family is seen. For example, if a hospital nurse is working with a family, the nurse may have the opportunity for only one or two meetings before the patient is discharged, whereas a community health nurse may be able to schedule a series of meetings. The context in which the nurse encounters a family commonly dictates the frequency and number of family meetings. Additionally, whether a nurse has 1 or 10 meetings with a family for assessment or intervention, there are important considerations for terminating with a family. An in-depth discussion of termination is provided in Chapter 12.
Family intervention is not always required, and contraindications for family intervention exist. These contraindications are generally evident to the nurse immediately after the family assessment. Sometimes during the course of intervention, however, families indicate a desire to stop treatment (see Chapter 12). Box 1-4 lists possible contraindications for family interventions.
Nurses working with patients and families in a variety of health-care settings need to have a good understanding of when family involvement is indicated and when it is contraindicated. Not only for their own benefit but also for each family’s benefit, nurses should distinguish between family assessment and family intervention. Families are often willing to come for an assessment when they can see the nurse face-to-face and make their own assessment of the nurse’s competence. When a nurse does a careful, credible assessment, the nurse has an easier time initiating family intervention.
Box 1-3 Indications for Family Interventions
A family member presents with an illness that has an obvious detrimental impact on other family members.
• A grandfather’s Alzheimer disease may cause his grandchildren to be afraid of him.
• A young child’s cyberbullying behavior may be related to his mother’s deterioration from multiple sclerosis.
A family member contributes to another family member’s symptoms or problems.
• Lack of visitation from adult children exacerbates physical or psychological symptoms in an elderly parent.
• One family member’s improvement leads to symptoms or deterioration in another family member.
• Decreased asthma symptoms in one child correlate with increased abdominal pain in a sibling.
A child or an adolescent develops an emotional, behavioral, or physical problem in the context of a family member’s illness.
• An adolescent with diabetes suddenly requests that his mother administer his daily insulin injections even though he has been injecting himself for the past 6 months.
Illness is first diagnosed in a family member.
• If family members have no previous knowledge of or experience with a particular illness, they require information and may also require reassurance and support.
A family member’s condition deteriorates markedly.
• Whenever deterioration occurs, family patterns may need restructuring, and intervention is indicated.
A chronically ill family member moves from a hospital or rehabilitation center back into the community.
• A young adult returns home after being hospitalized for 6 months at a drug rehabilitation center.
An important individual or family developmental milestone is missed or delayed.
• An adolescent is unable to move out of the home at the anticipated time. A chronically ill patient dies.
• Although the patient’s death may be a relief, the family might feel a tremendous void when the caregiving role is lost.
Box 1-4 Contraindications for Family Interventions
• All family members state that they do not wish to pursue family meetings or treatment even though it is recommended.
• Family members state that they agree with the recommendation for family meetings or treatment but would prefer to work with another professional.
CRITICAL THINKING QUESTIONS

1. In your clinical practice, why would it be important for you to use the CFAM/CFIM?
2. Consider your own clinical practice:
   a. What family nursing interventions do you currently use? How do you know if they are effective?
   b. What family nursing interventions could you implement in your practice, and how would you know if they were effective?

Chapter 3
The Calgary Family Assessment Model
Learning Objectives
• Describe the three major categories of the Calgary Family Assessment Model (CFAM), structural, developmental, and functional, and their associated subcategories.
• Define terms used in the CFAM.
• Identify questions to ask families to obtain information and how they apply to each category of the CFAM.
Key Concepts
Circular communication
Circular pattern diagrams (CPDs)
Developmental assessment
Ecomap
Family development
Family life cycle
Functional assessment
Genogram
Structural assessment
The Calgary Family Assessment Model (CFAM) is an integrated, multidimensional framework based on the foundations of systems, cybernetics, communication, and change theory and influenced by postmodernism and the biology of cognition. This text includes a discussion of the distinction between using the CFAM to assess a family and using the CFAM as an organizing framework, or template, for working with families to help them resolve health-related problems or other issues.
The CFAM has received wide recognition since the first edition of this book in 1984. It has been adopted by many faculties, schools of nursing, and other health science disciplines. It has been referenced frequently in the literature, especially the Journal of Family Nursing. In addition, the International Council of Nurses has recognized it as one of the four leading family assessment models in the world (Schober & Affara, 2001). Originally adapted from a family assessment framework developed by Tomm and Sanders (1983), the CFAM was substantially revised in 1994, 2000, and 2005.
The CFAM consists of three major categories:

1. Structural
2. Developmental
3. Functional
   Each category contains several subcategories. It is important for each nurse to decide which subcategories are relevant and appropriate to explore and assess with each family at each point in time. That is, not all subcategories need to be assessed at the first meeting with a family, and some subcategories need never be assessed. If too many subcategories are used, the nurse may become overwhelmed by all the data. If the nurse and the family discuss too few subcategories, each may have a distorted view of the family’s strengths or problems and the family situation.
   It is useful to conceptualize these three assessment categories and their many subcategories as a branching diagram (Figure 3-1). As the nurse uses the subcategories on the right of the branching diagram, the nurse collects more and more microscopic data. It is important for nurses to be able to move back and forth on the diagram in order to draw together all of the relevant information into an integrated assessment. This process of synthesizing data helps nurses working with complex family situations.
   It is also important for a nurse to recognize that a family assessment is based on the nurse’s personal and professional life experiences, beliefs, and relationships with those being interviewed. It is useful for nurses to determine whether they are using CFAM as a model to assess a family or as an organizing framework for clinical work with a specific family to help the family address a health issue. When learning the CFAM, students and practicing nurses new to family work will likely find the model helpful for directly assessing families. Similarly, researchers seeking to assess families will find the model useful. This use of the model involves asking the family questions about themselves for the express purpose of gaining a snapshot of the family’s structure, development, and functioning at a particular point in time.
   However, how we have used the CFAM is not in a research manner but rather in a clinical manner. Once nurses become experienced with the categories and subcategories of the CFAM, they can use the CFAM as a clinical organizing framework to help families solve problems or issues.
   For example, a single-parent family in the developmental stage of families with adolescents will have many positive experiences from earlier developmental stages to draw from in coping with the teenager’s unexpected illness. The nurse, being reminded of family developmental stages by using the CFAM, will draw forth those resiliencies. The nurse will ask questions and collaboratively develop interventions with the family to enhance their functioning during this health-care episode.

Figure 3-1 Branching diagram of the CFAM.
Families do not generally present to health-care professionals to be “assessed.” Rather, they present themselves or are encountered by nurses while coping with an illness or seeking assistance to improve their quality of life. The CFAM helps guide nurses in helping families.
In this chapter, each assessment category is discussed separately. Terms are defined, and sample questions relevant to each CFAM category are proposed for the nurse to ask family members. We do not suggest that nurses ask these questions in a disembodied way. Rather, real-life clinical examples are provided in Chapters 4, 7, 8, 9, and 10 to further describe how to use the sample questions and apply the CFAM. The use of assessment and interventive questions will be discussed in Chapter 4 (The Calgary Family Intervention Model [CFIM]). We wish to emphasize that not all questions about various subcategories of the model need to be asked in the first interview, and questions about each subcategory are not appropriate for every family. Families are obviously composed of individuals, but the focus of a family assessment is less on the individual and more on the interaction among all of the individuals within the family.
STRUCTURAL ASSESSMENT
In assessing a family, the nurse needs to examine its structure—that is, who is in the family, the connections among family members vis-à-vis those outside the family, and the family’s context. Three aspects of family structure can most readily be examined: internal structure, external structure, and context. Each of these dimensions of family structural assessment is addressed separately.
KEY CONCEPT DEFINED
Structural Assessment
One of the categories of the Calgary Family Assessment Model (CFAM) that nurses use to identify who is in the family, the connections among family members in regard to those outside the family, and the family’s context.
Internal Structure
Internal structure includes six subcategories:

1. Family composition
2. Gender
3. Sexual orientation
4. Rank order
5. Subsystems
6. Boundaries
   Family Composition
   The subcategory family composition has many meanings because of the many definitions given to family. Wright and Bell (2009) define family as “a group of individuals who are bound by strong emotional ties, a sense of belonging, and a passion for being involved in one another’s lives” (p. 46).
   There are five critical attributes to the concept of family:
7. The family is a system or unit.
8. Its members may or may not be related and may or may not live together.
9. The unit may or may not contain children.
10. There are commitment and attachment among unit members that include future obligation.
11. The unit caregiving functions consist of protection, nourishment, and socialization of its members.
    Using these ideas, the nurse can include the various family forms that are prevalent in society today, such as the biological family of procreation, the nuclear family (family of origin), the sole-parent family, the stepfamily, the communal family, and the lesbian, gay, bisexual, queer, intersex, transgender, or twin-spirited (LGBQITT) couple or family. Designating a group of people with a term such as “couple,” “nuclear family,” or “single-parent family” specifies attributes of membership, but these distinctions of grouping are not more or less “families” by reason of labeling. Rather, attributes of affection, strong emotional ties, a sense of belonging, and durability of membership determine family composition.
    Nurses need to find a definition of family that moves beyond the traditional boundaries that limit membership using the criteria of blood, adoption, and marriage. We have found the following definition of family to be most useful in our clinical work: the family is who they say they are (Wright & Leahey, 2013). With this definition, nurses can honor individual family members’ ideas about which relationships are significant to them and their experiences of health and illness.
    Although we recognize the dominant North American type of separately housed nuclear families, our definition allows us to address the emotional past, present, and anticipated future relationships within the family system. It is important to note that our definition of family is based on the family’s conception of family rather than who lives in the household. Family configurations continue to evolve in society, for example, LGBQITT families, adoptive and foster families, stepfamilies, multigenerational families, and sole-parent families.
    Changes in family composition are important to note. These changes could be permanent, such as the loss of a family member or the addition of a new person into the family home, such as a new baby, a nanny, a boarder, or an elderly parent who can no longer live independently. Changes in family composition can also be transient. For example, stepfamilies commonly have different family compositions on weekends or during vacation periods when children from previous relationships cohabit. Families with a child in placement or those experiencing homelessness often temporarily live with other relatives and then move on.
    Losses tend to be more severe depending on how recently they have occurred, the younger some of the family members are when the loss occurs, the smaller the family, the greater the numerical imbalance between male and female members of the family resulting from the loss, the greater the number of losses, and the greater the number of prior losses. The circumstances surrounding the loss may be of exquisite concern for the nurse. For example, some parents of severely mentally ill children have reported that they were encouraged to give up custody of their children to foster care as a way of securing intense health-care treatment for them.
    Serious illness or death of a family member, violence or war, and natural disasters can lead to profound disruption in the family and have long-term impacts. These situations often result in aunts and uncles raising nieces and nephews, or grandparents raising grandchildren, or friends or faith-based communities raising children and are often overlooked in regard to family structural arrangement. The extent of the impact of a member’s death on the family depends on the social and cultural meaning of death, the history of previous losses, the timing of the death in the life cycle, and the nature of the death (Becvar, 2001, 2003).
    Every family touched by tragedy faces the task of making sense of what happened, why it happened, and how to adjust to the changed landscape. Families can find inspiration from many sources to cope with unprecedented tragedy.
    The position and function of the person who died in the family system and the openness of the family system must also be considered. We have found it useful to note the family’s losses and deaths during the structural assessment process, but not necessarily to make an immediate assumption that these losses are of major significance to the family. By taking this stance, we disagree with the position taken by some clinicians who assert that it is important to track patterns of adaptation to loss as a routine part of family assessment even when it is not initially presented as relevant to the chief complaints.
    In our clinical practice with families, we have found it useful to ask ourselves these questions to determine the composition of families:
    • “Who is in this family?”
    • “Who does this family consider to be ‘family’?”
    Questions to Ask the Family.
    • “Could you tell me who is in your family?”
    • “Does anyone else live with you, for example, grandparents, boarders?”
    • “Has anyone recently moved out?”
    • “Is there anyone else you think of as family who does not live with you? Anyone not related biologically?”
    Gender
    The subcategory of gender is a basic construct, a fundamental organizing principle. We believe in the constructivist “both/and” position—that is, we view gender as both a universal “reality” operational in hierarchy and power and as a reality constructed by ourselves from our particular frame of reference. We recognize gender as both a fundamental basis for all human beings and as an individual premise. Gender is important for nurses to consider because the difference in how men and women experience the world is at the heart of the therapeutic conversation. We can help families by assuming that the differences between women and men can be changed, discarding unhelpful cultural scripts for women and men, and recognizing and attending to hidden power issues. However, nurses need to consider that not all couples want to equalize the imbalance of power and that some may prefer traditional roles.
    In couple relationships, the problems described by men and women commonly include unspoken conflicts between their perceptions of gender—that is, how their family and society or culture tell them that men and women should feel, think, or behave—and their own experiences.
    We argue on behalf of the integration of male and female attributes in each person. Human development is a process of increasingly complex forms of relatedness and integration rather than a progression from attachment to separation. Gender is, in our view, a set of beliefs about or expectations of male and female behaviors and experiences. These beliefs have been developed by cultural, religious, and familial influences as well as by socioeconomic status and sexual orientation.
    It’s important to understand the difference between gender and sex. Sex is defined as the physiological difference between the male and female, whereas gender references social and cultural distinctions, such as social relationships and their symbolic meaning. Gender identity is related to how one identifies oneself as being masculine or feminine (McDowell, 2018).
    According to the World Health Organization (WHO, 2015), gender is increasingly being recognized as an important determinant of health, and issues such as gender inequality and lack of understanding of gender norms and roles can lead to poor health outcomes. Sharma, Chakrabarti, and Grover (2016) reviewed recent studies on gender difference in caregiving among families with mental illness and found that women are predominately the caregivers and, as a result, experience physical burdens and higher levels of psychological distress. The authors found that women tended to have multiple roles, such as wives, daughters, sisters, mothers, and employees, which increased pressure on them and caused role strain and conflict. These role strains and conflicts had major adverse effects on families, including fatigue and burnout, leading to emotional disturbance and depression.
    Levac, Wright, and Leahey (2002) recommend that assessment of the influence of gender in the family is especially important when societal, cultural, or family beliefs about male and female roles are creating family tension. In this situation, couples may desire to establish more equal relationships, with characteristics such as the following:
    • Partners hold equal status (e.g., equal entitlement to personal goals, needs, and wishes).
    • Accommodation in the relationship is mutual (e.g., schedules are organized equally around each partner’s needs).
    • Attention to the other in the relationship is mutual (e.g., equal displays of interest in the other’s needs and desires by both partners).
    • Enhancement of the well-being of each partner is mutual (e.g., the relationship supports the psychological health of each equally).
    In our clinical supervision with nurses doing relational family practice, we have found it useful to have them consider their own ideas about male, female, intersex, twin-spirited, and transgender persons. Bjarnadottir, Bockting, and Dowding (2017) conducted an integrative review of patient perspectives when answering questions about sexual orientation and gender identity and found that nurses need to be mindful of heteronormative assumptions. The evidence from this review also identified the patients’ willingness to answer questions about sexual orientation and their perceptions of its importance.
    Questions to Ask the Family.
    • “What effect did your parents’ ideas have on your own ideas of masculinity and femininity?”
    • “If your arguments with your male children were about how to stay connected rather than how to separate, would your arguments then be different?”
    • “If you would show the feelings you keep hidden, Harry, would your wife think more or less of you?”
    • “How did it come to be that Mom assumes more responsibility for the dialysis than Dad does?”
    Sexual Orientation
    The subcategory of sexual orientation includes sexual majority and sexual minority populations. According to the American Psychological Association (2015), sexual orientation is “a component of identity that includes a person’s sexual and emotional attraction to another person and the behavior and/or social affiliation that may result from this attraction. A person may be attracted to men, women, both, neither, or to people who are genderqueer, androgynous, or have other gender identities. Individuals may identify as lesbian, gay, heterosexual, bisexual, queer, pansexual, or asexual, among others” (p. 6).
    Nurses need to reflect critically on attitudes about sexual orientation when working with families. We believe that nurses should be able to support a patient along whatever sexual-orientation path the individual takes and that the patient’s sense of integrity and interpersonal relatedness are the most important goals of all. The United Nations (2015) further supports this in identifying that societal discrimination against lesbian, gay, bisexual, and transgender (LGBT) people is a direct threat to their health and well-being. We agree with Yingling, Cotler, and Hughes (2017) that there is a global need for nurses to develop their knowledge and skills in a culturally sensitive manner to appropriately provide care for LGBT people and their families.
    Questions to Ask the Family.
    • “Elsbeth, at what age did you first engage in sexual activity?”
    • “When LaCheir first told your mom that she was lesbian, what effect did it have on your mom’s caregiving with her?”
    • “When your brother, Lee, announced that he was gay and leaving his marriage, how did your parents respond?”
    • “What did your parents tell you, Lilah, about your ambiguous genitals?”
    Rank Order
    The subcategory rank order refers to the position of the children in the family with respect to age and gender. Birth order, gender, and distance in age between siblings are important factors to consider when doing an assessment. Toman (1993) has been a major contributor to research about sibling configuration. In his main thesis, the duplication theorem, he asserts that the more new social relationships resemble earlier intrafamilial social relationships, the more enduring and successful they are. For example, the marriage between an older brother (of a younger sister) and a younger sister (of an older brother) has good potential for success because the relationships are complementary. If the marriage is between two firstborns, a symmetrical competitive relationship might exist, with each one vying for the position of leadership.
    The following factors also influence sibling constellation: the timing of each sibling’s birth in the family history, the child’s characteristics, the family’s idealized “program” for the child, and the parental attitudes and biases regarding gender differences. Although we believe that sibling patterns are important to note, we urge nurses to also remember that different child-rearing patterns have emerged as a result of increased use of birth control, the women’s movement, the large number of women in the workforce, and the great variety of family configurations. We hold the view that sibling position is an organizing influence on the personality, but it is not a fixed influence. Each new period of life brings a re-evaluation of these influences. An individual transfers or generalizes familial experiences to social settings outside the family, such as kindergarten, schools, and clubs. Given the availability and powerful influence of the Internet, the universe of available relationships and experiences is greatly expanded. As an individual is influenced by the environment, his or her relationships with colleagues, friends, and spouses are also generally affected. With time, multiple influences in addition to sibling constellation can affect personality organization.
    Prior to meeting with a family, we encourage nurses to hypothesize about the potential influence of rank order on the reason for the family interview. For example, nurses could ask themselves, “If this child is the youngest in the family, could this be influencing the parents’ reluctance to allow him to give his own insulin injections?” Nurses could also consider the influence of birth order on motivation, achievement, and vocational choice. For example, is the firstborn child under pressure to achieve academically? If the youngest child is starting school, what influence might this have on the couple’s persistent attempts with in vitro fertilization? We urge clinicians not only to consider rank order when children are young but also its relevance when working with siblings in later life. Overlooking the fact that individuals may be influenced by old or ongoing conflicts may lead to missed opportunities for healing.
    Questions to Ask the Family.
    • “How many children do you have, Amber?”
    • “Who is the eldest? How old is he or she?”
    • “Who comes next in line?”
    • “Have there been any miscarriages or abortions?”
    • “If your older sister, Gerda, showed more softness and were less controlling of your mom, might you be willing to talk more with your mom?”
    • “Would you be willing to talk about difficult issues, such as her giving up driving because of her macular degeneration?”
    Subsystems
    Subsystems is a term used to discuss or mark the family system’s level of differentiation; a family carries out its functions through its subsystems. Dyads, such as husband-wife, wife-wife, or mother-child, can be seen as subsystems. Subsystems can be delineated by generation, gender, interest, function, or history.
    Each person in the family belongs to several different subsystems. In each subsystem, that person has a different level of power and uses different skills. A 65-year-old woman can be a grandmother, mother, wife, and daughter within the same family. An eldest boy is a member of the sibling subsystem, the male subsystem, and the parent-child subsystem. In each of the subsystems, he behaves according to his position. He has to concede the power that he exerts over his younger brothers in the sibling subsystem when he interacts with his stepmother in the parent-child subsystem. An only child living in a single-parent household has different subsystem challenges when she lives on alternate weekends with her mother, her new wife, and their new baby. The ability to adapt to the demands of different subsystem levels is a necessary skill for each family member.
    In our clinical practice, we have found it useful to consider whether clear generational boundaries are present in the family. If they are, does the family find them helpful or not? For example, we ask ourselves whether one child behaves like a parent or husband surrogate. Is the child a child, or is there a surrogate-spouse subsystem? By generating these hypotheses before and during the family meeting, we are able to connect isolated bits of data to either confirm or negate a hypothesis.
    Questions to Ask the Family.
    Some families have special subgroups—for example, those who identify that women do certain things, those who identify that men do certain things, and those who identify that children do certain things.
    • “Do different subgroups exist in your family? If so, what effect does this have on your family’s stress level?”
    • “When Mom and your sister, Nora, stay up at night and talk about Dad’s use of crack, what do the boys do?”
    • “Who in the family is most affected by Cleve’s crack problem, and how does it affect them?”
    • “Who gets together in the family to talk about Shabana’s self-mutilating behaviors?”
    Parent-child:
    • “How has your relationship with Caitylin changed since her diagnosis with severe acute respiratory syndrome?”
    Marital:
    • “How much couple time can you and Simon carve out each month without talking about the children?”
    Sibling:
    • “On a scale of 1 to 10, with 10 being the most, how scared were you when Alex developed congestive heart failure?”
    Boundaries
    The subcategory boundaries refers to the rule “defining who participates and how” (Minuchin, 1974, p. 53). Family systems and subsystems have boundaries, the function of which is to define or protect the differentiation of the system or subsystem.
    For example, the boundary of a family system is defined when a father tells his teenage daughter that her boyfriend cannot move into the household. A parent-child subsystem boundary is made explicit when a mother tells her daughter, “You are not your brother’s parent. If he is not taking his medication, I will discuss it with him.”
    Boundaries can be diffuse, rigid, or permeable. As boundaries become diffuse, the differentiation of the family system decreases. For example, family members may become emotionally close and richly cross-joined. These family members can have a heightened sense of belonging to the family and less individual autonomy. A diffuse subsystem boundary is evident when a child is “parentified,” or given adult responsibilities and power in decision making.
    When rigid boundaries are present, the subsystems tend to become disengaged. A husband who rigidly believes that only wives should visit the elderly relatives, and whose wife agrees with him, can become disengaged from or peripheral to the senior adult-child subsystem. Clear, permeable boundaries, on the other hand, allow appropriate flexibility. Under these conditions, the rules can be modified. We do not support the pathologizing of coalitions or subsystems just because they exist. In working with families from different cultures, races, and social classes or those from rural settings, we have found that fostering other central ties may be most beneficial for the family.
    Boundaries tend to change over time. Boss (2002) suggests that family boundaries become ambiguous during the process of reorganization after the acquisition or the loss of a member. This is particularly evident in families experiencing separation or divorce. As couples make the transition to parenthood, they may experience the desired child as a family member who is psychologically present but physically absent. This is particularly relevant if there is a surrogate mother or a known sperm donor involved during the pregnancy. Other variations include the ambiguity experienced by some families when a family member is in prison, or overseas fighting in a war, or living in a rehab hospital following a tour of duty or some other traumatic event, or when a family member has dementia or is undergoing gender transition. Boss (2016) uses the term ambiguous loss “to describe a situation of unclear loss that remains unverified and thus without resolution” (p. 270) and discusses how ambiguous loss leads to boundary ambiguity, that is, not knowing who is within or out of a family system.
    Boundary styles can facilitate or constrain family functioning. For example, an immigrant family that moves into a new culture may be very protective of its members until it gradually adapts to the cultural milieu. Its boundaries regarding outside systems may be quite firm and rigid at first but may gradually become more flexible.
    The closeness-caregiving dimension of boundaries is another aspect for nurses to consider. The relative sharing of territory can be assessed along aspects of contact time (time together), personal space (physical nearness, touching), emotional space (sharing of affects), informational space (information known about each other), private space (shared private conversations separate from others), and decisional space (extent to which decisions are localized within various individuals or subsystems). The closeness-caregiving dimension of a boundary may be very significant for nurses to assess when dealing with older people with chronic illnesses and their adult children.
    In our clinical supervision with nurses, we encourage them to consider how each family differentiates itself from other families in the community and in the city. The nurse considers whether there is a parental subsystem, a marital subsystem, a sibling subsystem, and so forth. The nurse should consider the following questions:
    • “Are the boundaries clear, rigid, or diffuse?”
    • “Does the boundary style facilitate or constrain the family?”
    • “If there are multiple stepfamilies, which boundary predominates?”
    Questions to Ask the Family.
    • “Is there anyone with whom you can talk to when you feel stressed by your upcoming retirement?” (The nurse can ask family members the same question.)
    • “To whom would you go if you felt happy? If you felt sad?”
    • “Would there be anyone in your family opposed to your talking with that person?”
    • “Who would be most in favor of you talking with that person?”
    • “What impact might it have on your mom’s ability to deal with your dad’s illness if she had more support from your grandparents?”
    External Structure
    External structure includes two subcategories:
12. Extended family
13. Larger systems
    Extended Family
    The subcategory of extended family includes the family of origin and the family of procreation as well as the present generation and stepfamily members. Multiple loyalty ties to extended family members can be invisible but may be very influential forces in the family structure. Special relationships and support can exist at great geographical distances. Also, conflicted and painful relationships can seem fresh and close at hand despite the extended family living far away or not being in frequent contact. How each member sees himself or herself as a separate individual yet part of the “family ego mass” (Bowen, 1978) is a critical structural area for assessment.
    Levac, Wright, and Leahey (2002) recommend assessment of the quantity and type of contact with extended family to provide information about the quality and quantity of support. The importance of social media connections cannot be overemphasized. A young man paralyzed following a sports injury may be connected with many people through Facebook, Twitter, and blogs, which is a helpful way for the family, friends, and colleagues to link to the patient and to each other. Such connective interaction “does hope,” a notion we support and find healing. In our clinical work we consider whether there are many references to the extended family. How significant is the extended family to the functioning of this particular family? Are they available for support in times of need? If so, how? By mobile or land phones, e-mail, webcam, Skype, iChat, and Internet chat groups? Are they in close physical proximity?
    Questions to Ask the Family.
    • “Where do your parents live?”
    • “How often do you have contact with them?”
    • “What about your brothers, sisters, and step-relatives?”
    • “Which family members do you never see?”
    • “Which of your relatives are you closest to?”
    • “Who phones whom? With what frequency?”
    • “Whom do you ask for help when problems arise in your family?”
    • “What kind of help do you ask for?”
    • “Would your family in Ireland be available if you needed their help?”
    • “Would you feel more comfortable contacting your family by e-mail or in a chat room?”
    Larger Systems
    The subcategory larger systems refers to the larger social agencies and personnel with whom the family has meaningful contact. Larger systems generally include work systems, and for some families, they include public welfare, child welfare, foster care, courts, and outpatient clinics. There are also larger systems designed for special populations, such as agencies mandated to provide services to the mentally or physically handicapped or the frail elderly. For many families, engagement with such larger systems is not problematic and can be life-affirming. We believe that larger professional systems can be an appreciative audience that supports families’ narratives of hope and preferred new lives. We encourage nurses to use language carefully in discussing clients with larger-system helpers so as to support family stories of courage, growth, and persistence instead of perpetuating stories of hopelessness and problems.
    Some families and larger systems, however, may develop difficult relationships that exert a toll on normative development for family members. Some health-care professionals in larger systems contribute to families being labeled “multiproblem,” “resistant,” “noncompliant,” or “uncooperative.” Health-care professionals limit their perspectives by using these labels.
    Another larger-system relationship that nurses should consider is the computer network. Electronic bulletin boards, chat rooms, text messaging, and discussion groups are increasing. The Internet can offer families valuable assistance in terms of information, validation, empathy, advice, and encouragement; however, it can also provide inaccurate and misleading information, and thus it is important for nurses to support families to access reliable information. Some have used e-mail to augment, extend, deepen, inform, enrich, and prepare for in-person psychotherapy. However, online dialogues can sometimes be more sustaining than transformative. Vigorous attention should be given to ways that professional expertise and electronic connectivity can be combined. Telenursing is one such example. Nurses need to consider how they can ensure that the voices of all family members are part of the discussion between the nurse and the family when using tele-health care. Using videoconferencing to gather all the larger-system helpers in one space with the family to discuss, plan, and evaluate care can be a solution.
    In our clinical supervision with nurses, we encourage them to discover whether the meaningful system is the family alone or the family and its larger-system helpers.
    Nurses can ask themselves questions such as the following:
    • “Who are the health-care professionals involved?”
    • “What is the relationship between the family and the larger system?”
    • “How regularly do they interact? Is their relationship symmetrical or complementary?”
    • “Are the larger systems overconcerned? Overinvolved? Underconcerned? Underinvolved?”
    • “Does the larger system blame the family for its problems?”
    • “What do the helpers desire for the family?”
    • “Is the nurse being asked to take responsibility for another system’s task?”
    • “How do the family and helpers define the problem?”
    One young woman suffering from metastases from breast cancer, when asked, “Who do you think of like family?” answered, “I have three families: my own family, my church family, and my ‘family’ at the cancer center.”
    Questions to Ask the Family.
    • “What agency professionals are involved with your family, Mr. Rajwani?”
    • “How many agencies regularly interact with you?”
    • “Has your family moved from one health-care system to another?”
    • “Who most thinks that your family needs to be involved with these systems?”
    • “Who most thinks the opposite?”
    • “Would there be agreement between your definition of the problem and the system’s definition of the problem?”
    • “How about between the definitions of the solution?”
    • “What has been the best or worst advice you have been given by professionals for this issue, Atul?”
    • “How is our working relationship going so far, Laura? If it were not going well, would you tell me?”
    Context
    Context is explained as the whole situation or background relevant to some event or personality. Each family system is itself nested within broader systems, such as neighborhood, socioeconomic status, region, and country, and is influenced by these systems. The connectivity experienced by persons using the Internet is another context to be considered. Because the context permeates and circumscribes both the individual and the family, its consequences are pervasive. Context includes but is not limited to these five subcategories:
14. Ethnicity
15. Race
16. Social class
17. Spirituality and/or religion
18. Environment
    Ethnicity
    Ethnicity refers to the concept of a family’s “peoplehood” and is derived from a combination of its history, race, social class, and religion. It describes a commonality of overt and subtle processes transmitted by the family over generations and usually reinforced by the surrounding community. Ethnicity is an important factor that influences family interaction. We believe that nurses must be aware of the great variety within as well as among ethnic groups. Some people are second-, third-, or fourth-generation immigrants, with ancestors who were born in a foreign country. Others may be from “recently arrived” immigrant families, either legally arrived or undocumented, of whom some are refugees.
    Ethnic differences in family structure and their implications for intervention have often been highlighted in a stereotypical manner. For example, some families may have strong extended family connections and loyalties, others may have flexible family boundaries, and some may include other family members in child-rearing. There may be emotionality between relatives and between generations, whereas other families may have strictly defined boundaries between generations.
    We believe our own cultural narratives help us to organize our thinking and anchor our lives, but they can also blind us to the unfamiliar and unrecognizable and can foster injustice. For example, the importance of learning their histories and experiences when caring for refugee immigrant women is invaluable because it provides context and a greater understanding of their situations.
    Nurses should sensitize themselves to differences in family beliefs and values and be willing to alter their “ethnic filters.” We believe it is important for nurses to recognize their own ethnic blind spots and adjust their interventions accordingly. We are never “expert,” “right,” or in full possession of the “truth” about a family’s ethnicity. Also, if we engage a translator to assist us with family work, we should not assume that the translator is an “expert” on this particular family’s ethnicity. Rather, both we and the translator should strive to be informed and curious about ourselves and others’ diversity as we collaborate in health care. The importance of participatory models of knowledge transfer and exchange cannot be underestimated.
    Questions that we have found useful to ask ourselves include the following:
    • “What is the family’s ethnicity?”
    • “Have the children and parents had periods of separation in their immigration experience? If so, with what impact?”
    • “Is their social network from the same ethnic group? Do they find that helpful or not?”
    • “If the available economic, educational, health, legal, and recreational services were similar to the family’s ethnic values, how would our conversation be different?”
    • “Are the assessment and testing instruments we use in our clinic relevant for this ethnic group? Do they match the values and beliefs of this particular family?”
    Questions to Ask the Family.
    • “Could you tell me about your Japanese cultural practices or traditions regarding illness?”
    • “How does being an immigrant from Afghanistan influence your beliefs about when to consult with health professionals?”
    • “What does health mean to you?”
    • “How would you know that you are healthy? How would I know that you are healthy?”
    • “As a second-generation Chilean family, how are your health-care practices similar to or different from those of your grandparents?”
    • “Which practices seem most useful to you at this point in your family’s life?”
    Race
    The subcategory of race is a basic construct and not an intermediate variable. Race influences core individual and group identification. Race intersects with mediating variables such as class, religion, and ethnicity. Racial attitudes, stereotyping, and discrimination are powerful influences on family interaction and, if left unaddressed, can be negative constraints on the relationship between the family and the nurse.
    There is a dearth of literature on potential relationship strengths in intercultural and interracial relationships. We encourage nurses to elicit strengths rather than challenges in working with these couples.
    Racial differences, whether intracultural or intercultural, are not problems as such. Rather, prejudice, discrimination, and other types of intercultural aggression based on these differences are problems. For some persons, whether of the majority or minority race, the word “race” is very distasteful because we are all members of the human race. They feel that the word itself implies harsh borders between groups of people in the human race and is therefore not very constructive in binding us together.
    It is important for nurses to understand family health beliefs and behaviors influenced by racial identity, privilege, or oppression. In our clinical work with families, we have found it very useful to critically reflect on our own ideas about our race, marginalization, invisible and visible minorities and to vigorously pursue the differences between and within various racial groups. We believe health professionals should be racially and culturally sensitive.
    Questions to Ask the Family.
    • “What differences do you notice between, for example, your relatives’ child-rearing practices and your own?”
    • “Could you help me to understand what I need to know to be most helpful to you?”
    Social Class
    Social class, or socioeconomic status, shapes educational attainment, income, and occupation. Each class, whether upper-upper, lower-upper, upper-middle, lower-middle, upper-lower, or lower-lower, has its own clustering of values, lifestyles, and behaviors that influence family interaction and health-care practices. Social class affects how family members define themselves and are defined; what they cherish; how they organize their day-to-day lives; and how they meet challenges, struggles, and crises. For example, middle-class seniors may be more likely to help their adult children, whereas working-class older adults may be more likely to receive help.
    Social class has been referred to as one of the prime molders of the family value and belief system. Much of the sociological and psychological research has been confounded by social class differences among ethnic groups. We believe that, in a racist and classist society, class and race are not inseparable.
    Just as nursing has often been presented as intercultural, it has also been presented as interclass and nonpolitical. We believe that many nurses have pursued sickness in families to the exclusion of obtaining the meaning people give to events; their day-to-day living standards; and their access to employment, income, and housing. Social class issues have often been considered to be of little consequence to the “serious talk” about illness. This viewpoint has enabled nurses to sidestep many class issues associated with inequality and injustice. However, treatment must take into account the cultural, social, and economic context of the people seeking help. From factory workers to farmers to business executives, families are trying to cope with higher health-care costs and threats of losing insurance coverage. They continually make decisions based on which health care they can afford. With higher prescription drug costs and growth in the aging population, many families are anxious about their long-term care and ability to provide for their loved ones. Economic uncertainty, conflict and war, and fears of terrorism have created increased difficulties for the working poor.
    Assessment of social class helps the nurse understand in a new way the family’s stressors and resources. Generally speaking, women move down in social class following a divorce, whereas men do not. Recognizing differences in social class beliefs between themselves and families may encourage nurses to utilize new health promotion and intervention strategies. It is important for health-care delivery that nurses be aware of such influences as the “glass ceiling” and part-time temporary work versus full-time permanent work with benefits. In our clinical work we have often asked ourselves how a family’s social class might influence their healthcare beliefs, values, utilization of services, and interaction with us. Serious illness can intensify financial problems, diminish the capacity to deal with them, and call for solutions at odds with conventional financial wisdom. We have wondered about the intrafamilial differences with respect to class and how these might help or hinder a family coping with, for example, chronic illness.
    Questions to Ask the Family.
    • “How many times have you moved within the past 5 years?”
    • “Have these moves had a positive or negative influence on your ability to deal with your son’s HIV?”
    • “How many schools has your daughter, Frances, attended?”
    • “How does your money situation influence your use of health-care resources?”
    • “What impact does Neil’s shift work have on your family’s stress level?”
    Spirituality and/or Religion
    Family members’ spiritual and religious beliefs, rituals, and practices can have a positive or negative influence on their ability to cope with or manage an illness or health concern. Therefore, nurses must explore this previously neglected area. Emotions such as fear, guilt, anger, peace, and hope can be nurtured or tempered by one’s spiritual or religious beliefs. Wright (2017) encourages distinguishing between spirituality and religion for the purposes of assessment and believes that doing so has the potential to invite more openness by family members regarding this potentially sensitive domain of inquiry. Spirituality is defined as whatever or whoever gives ultimate meaning and purpose in one’s life and invites particular ways of being in the world toward others, oneself, and the universe (Wright, 2017). Religion is defined as an affiliation or a membership in a particular faith community that shares a set of beliefs, rituals, morals, and sometimes a health code centered on a defined higher or transcendent power most frequently referred to as God (Wright, 2017).
    Levac, Wright, and Leahey (2002) recommend that assessment of the influence of religion is most critical at the time of diagnosis of a chronic or life-threatening illness. Assessment is especially important and relevant when crises have occurred that may cause extreme suffering, such as a traumatic death caused by a motor vehicle accident; sudden death due to illness, violence, or abuse; or a life-threatening diagnosis. In these situations, it is critical that the nurse ascertain what meaning the family gives to their suffering due to these tragic events and ultimately how family members make sense of their suffering (Wright, 2017). We think that beliefs, spirituality, and transcendence are keys to family resilience.
    Spirituality and religion also influence family values, size, health care, and socialization practices. For example, individualism can be intricately related to religious ideals and work ethic. Community and family support, on the other hand, can also be evident in certain religions, and this can foster intergenerational and intragenerational support. Folk-healing traditions that combine health and religious practices are quite common in some ethnic groups. In some spiritualistic practices, a medium, or counselor, helps to exorcise the spirits causing illness. Such healers, religious leaders, shamans, and clergy can be invaluable resources for families dealing with crises and with long-term needs such as caregiver support.
    Spirituality and religion are hidden and commonly underused resources in family work. We encourage nurses visiting families’ homes to note the presence of signs of religious influence in the home—for example, statues, candles, flags, and religious texts, such as the Bible, Torah, or Koran. We have been curious about dietary restrictions and habits as well as traditional or alternative health practices influenced by religious beliefs. We have been cautious, however, not to assume that strong spiritual or religious beliefs enhance marital happiness or interaction, although they may diminish the possibility of divorce.
    Our clinical work with families has taught us that the experience of suffering frequently becomes transposed to one of spirituality as family members try to find meaning in their suffering (Wright, 2017). If nurses are to be helpful, they must acknowledge that suffering, and in many cases the senselessness of it, is ultimately a spiritual issue. Therefore, in our clinical work we have asked ourselves about the influence of religion and spirituality on the family’s health-care practices.
    Questions to Ask the Family.
    • “What meaning does spirituality or religion have for you in your everyday life?”
    • “Are you involved with a mosque, temple, church, or synagogue?”
    • “Would talking with anyone in your church help you cope with Pierre’s illness?”
    • “Are your spiritual beliefs a source of support for you in coping with your illness? A source of stress for you? For other family members?”
    • “Who among your family members would most encourage your use of spiritual beliefs to cope with Perminder’s cancer?”
    • “What are your sources of hope?”
    • “Have you found that prayer or other religious practices help you cope with your son Surinder’s schizophrenia? If so, may I ask what you pray for?”
    • “Have your prayers been answered?”
    • “What does your religion say about gender roles? Ethnicity? Sexual orientation? How have these beliefs affected you, Davinderpal?”
    Environment
    The subcategory environment encompasses aspects of the larger community, the neighborhood, and the home. Environmental factors such as adequacy of space and privacy and accessibility of schools, day care, recreation, and public transportation influence family functioning. These are especially relevant for older adults, who are more likely to remain in a poor environment even if it has become dangerous to live there.
    In our clinical work with families, we have asked ourselves and the nurses with whom we work to consider whether the home is adequate for the number of people living there. Does our perception differ from the family’s perception? What health and other basic services are available within the home? Within the neighborhood? How accessible, in terms of distance, convenience, and so forth, are transportation and recreation services? How safe is the area? By asking in an open-ended way what other contextual forces may influence the family, it is possible to obtain a much broader range of responses. These can vary from “belief in politics” to “shopping at the mall” to “music.”
    Questions to Ask the Family.
    • “What community services does your family use?”
    • “Are there community services you would like to learn about but do not know how to contact?”
    • “On a scale of 1 to 10, with 10 being most comfortable, how comfortable are you in your neighborhood?”
    • “What would make you more comfortable so that you can continue to function independently at home?”
    Structural Assessment Tools
    The genogram and the ecomap are two tools that are particularly helpful in outlining a family’s internal and external structures. Each is simple to use and requires only a piece of paper and a pen. The genograph designed by Duhamel and Campagna (2000) can also be used to draw the genogram. Alternatively, some computer programs have genograms as a feature.
    KEY CONCEPT DEFINED
    Genogram
    A structural assessment tool that shows a diagram of the family constellation.
    The genogram is a diagram of the family constellation. The ecomap, on the other hand, is a diagram of the family’s contact with others outside the immediate family. It pictures the important connections between the family and the world. We are aware of the arbitrariness of the distinction for some cultural groups between a genogram and an ecomap. For example, the standard genogram may be difficult to complete with families who do not solely believe that family is strictly a biological entity. We encourage nurses to develop a fit between these tools to depict specific family compositions.
    KEY CONCEPT DEFINED
    Ecomap
    A structural assessment tool that shows a diagram of the family’s contact with others outside the immediate family and illustrates the important connections between the family and the world.
    These tools have been developed as family assessment, planning, and intervention devices. They can be used to reframe behaviors, relationships, and time connections within families, as well as to detoxify and normalize families’ perceptions of themselves. By pointing to the future as well as to the past and the present, genograms facilitate alternative interpretations of family experience. They can help both the nurse and the family see the larger picture and view problems in both a historical and current context. Genograms can also be used to foster the training of culturally competent clinicians and for nurses to increase their self-awareness.
    Darwent, McInnes, and Swanson (2016) adapted the genogram to develop an Infant Feeding Genogram to map the family structure of women who were the first in their families to breastfeed their children. This unique use of a genogram resulted in setting the context for discussions about women’s experience of breastfeeding within their family culture by helping to identify strengths and possible deficits in social supports.
    We agree with McGoldrick, Gerson, and Petry (2008) that although much can be said about expanding genograms to include issues from larger social contexts (the sexual, cultural, religious, or spiritual genogram), realistically such mapping is extremely difficult to accomplish. Gendergrams have been developed to map gender relationships over the life cycle. At best, we can probably explore only a few dimensions at a time, and we recommend that these dimensions be directly connected to the purpose of the family’s encounter with the nurse. For example, a nurse meeting with a couple in a rehabilitation treatment center for sexual addiction might reasonably explore a family’s sexual and addiction history on a genogram. This content area would likely not be appropriate for a nurse meeting with a family in an intensive care unit. McGoldrick et al (2008) have outlined important issues that are difficult to capture on genograms:
    • Family members involved in family business
    • Family members’ relationships to the health-care system
    • Cultural genogram issues
    • Family secrets
    • Particular family-relationship nuances, including power, patterns of avoidance, and so forth
    • Patterns of friendship
    • Relationships with work colleagues
    • Spiritual genograms
    • Community genograms
    • Tracking medical and psychological stressors
    Genograms don’t typically show the emotional connections among family members, present or past. The complex relationships of those who have warmed our hearts, mentored and nurtured us, aggravated us, or caused us severe trauma generally are not depicted. This is both a limitation of genograms and an asset; genograms tend to be a quick snapshot of the present.
    With the help of computers, we can make three-dimensional maps that enable us to track complex genogram patterns. Our caution for practicing nurses is to use the genogram as a clinically relevant tool, not as a map or data-collection sheet. Computerized genograms enable us to explore specific family patterns, resiliencies, and symptom constellations. Gathering, mapping, and tracking family history is much easier using a computer database. We urge nurses to ask themselves: “What is the purpose of collecting vast amounts of information about this family’s history, and how will this information be helpful for the purpose of my work with this family?” Using computers and genogram information will provide rich data for family research, but it is unknown how useful this will be for immediate family care. Of course, by using computer genogram software, there will be many more possibilities for depicting family issues at different moments in family history. Clinicians and family members will have the opportunity to choose what aspects of a genogram they want to display for a particular purpose and at the same time create a database of a family’s whole history.
    Genogram
    Genograms convey a great deal of information in the form of a visual gestalt. When one considers the number of words it would take to portray the facts thus represented, it becomes clear how simple and useful these tools are. Genograms, when placed on patients’ charts, act as constant visual reminders for nurses to “think family.” As an engagement tool, the genogram is helpful to use during the first meeting with the family. It provides rich data about relationships over time and may also include small amounts of data about health, occupation, religion, ethnicity, and migrations. The genogram can be used to elicit information helpful to both the family and the nurse about development and other areas of family functioning. It is a tool that enables clinicians to develop hypotheses for additional evaluation in a family assessment.
    The skeleton of the genogram (a blank genogram is shown in Figure 3-2) tends to follow conventional genetic and genealogic charts and depicts the internal family structure:
    • It includes at least three generations.
    • Family members are placed on horizontal rows that signify generational lines (a marriage or common-law relationship is denoted by a horizontal line).
    • Children are denoted by vertical lines.
    • Children are rank-ordered from left to right beginning with the eldest child.
    • Each individual is represented.
    Some authors differ slightly in the symbols they use to denote the details of the genogram. The symbols in Figure 3-3, however, are generally agreed on. With the increased use of computer genograms, symbols and color coding will become standardized.
    The person’s name and age should be noted inside the square or circle. Outside the symbol, significant data gathered from the family (e.g., “travels a lot,” “depressed,” “overinvolved in work”) should be noted. If a family member has died, the year of his or her death is indicated above the square or circle. When the symbol for miscarriage is used, the sex of the child should be identified if it is known. A small square is used to denote a sperm donor (McGoldrick et al, 2008). It is helpful to draw a circle around the different households. We find that when children have lived in several contexts (e.g., immediate biological family, foster family, grandparents, adoptive family), separate genograms can help to show the child’s multiple families over time.

Figure 3-2 Blank genogram.
The following is an example of a nuclear and extended family genogram (Figure 3-4):
The Lamensa Family
• Raffaele, age 47, married to Silvana, age 35, since 2000, lived common-law for 2 years prior to their marriage.
• There are two children: Gemma, age 14, in grade 8, and Antonio, age 7, repeating grade 1.
• Raffaele is employed as a machinist; Silvana refers to him as “an alcoholic.”
• Silvana is a homemaker and states that she has been “depressed” for several years.
• Both of Raffaele’s parents are deceased; his father died in 2010, and his mother died in 2008 of a stroke.
• Raffaele’s older brother Antonio also has a drinking problem; Antonio was named for his grandfather.
• Silvana’s mother, Nunziata, age 54, has arthritis and is getting progressively worse since her husband died in 2007.
• Silvana has two older sisters and a brother.

Figure 3-3 Symbols used in genograms.
The following is an example of a family genogram for a lesbian couple with a child born to one of them (Figure 3-5):
Jennifer and Amanda
• Jennifer (age 30) and Amanda (age 28) have lived as a couple since 2016 and have been married since 2018.
• Jennifer’s biological son, Griffin (age 8), was conceived by artificial insemination (the unknown sperm donor is depicted as a small square).
• Jennifer’s mother, Adrienne, a retired nurse (age 65), divorced Jennifer’s father in 1991; remarried in 1993; had another daughter, Mitzi, by her second husband; and became a widow when he died in 1999.
• Mitzi (age 24) is considering transgender surgery.
• Amanda’s parents are separated, and her father is living common-law with Dan, his business partner.
• Amanda has no siblings.
• Jennifer has a younger brother, Spencer (age 28), and a half sister, Mitzi.

Figure 3-4 Sample genogram: The Lamensa family.
How to Use a Genogram At the beginning of the interview, the nurse engages the family by informing them that they will be having a conversation so that the nurse can gain an overview of who is in the family and their situation. The nurse can then use the structure of the genogram to discern the family’s internal and external structures as well as context. Thus, the nurse gains an understanding of the family’s composition and boundaries.

Figure 3-5 Sample genogram: Artificial insemination and lesbian couple.
Initially, the nurse starts out with a blank sheet of paper and draws a line or circle for the first person in the family to whom a question is directed.
The following is a sample interview with the Manuyag family:
Nurse: Elena, you said you were 23, and Matias, how old are you?
Matias: Thirty-four.
Nurse: How long have you been married?
Matias: This time or the first time?
Nurse: This time. And then the first time.
Matias: Just 2 years for Elena and me.
Nurse: And the first time?
Matias: Ten years for the first one.
Nurse: And, Elena, have you been married before?
Elena: (Laughs nervously) I’m only 23.
Nurse: Sure, it’s just that many people have lived together in common-law marriages or married when they were very young.
Elena: No. I lived with my parents till I met Matias.
Nurse: Do either of you have children from prior relationships? (Turns to both Matias and Elena)
Matias: Yes, I have two sons.
Elena: No.
Nurse: In addition to Teresita here (Looks at baby on couch), do the two of you have any other children?
Elena: Yes, there’s Manandro.
Matias: Old stinko, you mean.
Nurse: Old stinko?
Matias: He isn’t toilet trained yet.
Nurse: Oh, I see. And he’s how old?
Elena: He’s almost 3. I’ve been trying to train him since I knew I was pregnant with Teresita, but he just doesn’t seem to want to be trained.
Nurse: (Nods) Mm.
Matias: Yeah, old stinko!
Nurse: And Teresita is how many weeks now?
Elena: She’ll be 21 days tomorrow (Smiles at baby).
Nurse: Does anyone else live with you?
Matias: No. Her parents live next door.
The nurse now has a rudimentary genogram of the Manuyag family (Figure 3-6) and has gathered information that may or may not be significant, depending on the way in which the family has responded to various events in the history of their family, such as the following:
• Manandro was conceived before the marriage.
• Manandro is unaffectionately called “old stinko” by his father.
• Elena has been trying to toilet train Manandro since he was 24 months old.
• Elena lived with her family of origin before the marriage; they now live next door.
• Matias has been married before and has two other sons.
After inquiring about the nuclear family, the nurse can continue to inquire about the extended family. It is generally not very important to go into great detail about these relatives, but clinical judgment should prevail. If, for example, the grandparents are involved in a child’s colostomy care, then a three-generational genogram should be constructed. On the other hand, if a child has a sprained wrist or something relatively minor, then a two-generational genogram is sufficient. After asking questions about the husband’s parents and siblings, the nurse should then inquire about the wife’s family of origin. It is important for the nurse to gain an overview of the family structure without getting sidetracked or inundated by a large volume of information. Box 3-1 contains helpful hints for constructing genograms.

Figure 3-6 Genogram of the Manuyag family.
The same question format used for nuclear families is used for stepfamilies, with one exception. It is generally easier to ask one spouse about his or her previous relationships before going on to ask the other spouse the same questions. This idea holds true especially in working with complex family situations involving multiple parenting figures and siblings. Again, it is unnecessary to gather specific information on all extended family members. It is useful to draw a circle around the current family members to distinguish among the various households. Usually it is easiest to indicate the year of a divorce rather than the number of years ago that it happened.
The following is an example of a sample genogram for a stepfamily (Figure 3-7):
• Michael (age 35) and Melanie (age 33) have had a common-law marriage since 2016.
• Melanie is a part-time waitress.
• Melanie has two children by her first marriage, Kathy (age 12) and Jacob (age 11).
• Jacob has attention deficit-hyperactivity disorder (ADHD) and is in a special class in grade 4.
Box 3-1 Helpful Hints for Constructing Genograms
• Determine priorities for genogram construction based on the family situation.
• A three-generational genogram may be useful when the child’s health problem (physical or emotional) is influenced by or affects the third generation.
• A brief two-generational genogram is generally most useful initially, especially for a family that has preventive health-care needs (immunizations) or minor health concerns (sports injury). The nurse can always expand to the third generation if needed.
• Invite as many family members to the initial meeting or visit as possible to obtain each family member’s view and to observe family interaction.
• Engage the family in an exercise to complete the genogram.
• Use the genogram to “break the ice,” provide structure, and introduce purposeful conversation.
• Ask family members how an absent significant family member might answer a question.
• Avoid discussion that is hurtful or blameful, especially of absent family members.
• Take an interest in each family member, and be sensitive to developmental differences.
• Tailor questions to children’s developmental stages so that they become active contributors.
• Notice children’s nonverbal and verbal comments.
• If some members are shy or seem uninterested in participating directly (such as adolescents), ask other family members about them.
• Begin by asking “easy” questions of individuals, followed by an exploration of subsystems.
• Ask concrete, easy-to-answer questions of individuals (especially children) about ages, occupations, interests, health status, school grades, and teachers to increase their comfort levels.
• Move the discussion about individuals to subsystems to elicit family relational data. Inquire about parent-child or sibling relationships, depending on parenting concerns.
• With stepfamilies, ask questions about contact with the noncustodial parent, custody, the children’s satisfaction with visits, and stepfamily relationships.
• Observe family interactions.
• During genogram construction, note the content (what is said) and the process (how it is said).
• Move from the discussion about the present family situation to questions about the extended family if it seems relevant (for example, “Are Ruhi’s parents able to help with the baby’s tracheostomy care? What about babysitting?”).
• When discussing generations, the nurse may find it useful to ask about psychosocial family health history (for example, “Is there a history of alcohol abuse [or violence, learning problems, or mental illness] in your family?”). Questions should be tailored to the family’s particular area of concern rather than generic exploration.
Levac, A. M., Wright, L. M., & Leahey, M. (2002). Children and families: Models for assessment and intervention. In J. Fox (Ed.), Primary healthcare of infants, children and adolescents (p. 14). St. Louis, MO: Mosby. Copyright 2002. Adapted with permission.

Figure 3-7 Sample genogram of a stepfamily.
• Michael married his first wife, Laura, in 2006 and divorced in 2008.
• Michael and Laura had one son, who is now age 11.
• Michael is an only child; his father committed suicide in 2008; his mother is still alive.
• Melanie is the youngest of three daughters, and both of her parents are living.
• Melanie married David in 2006, separated in 2013, and divorced in 2014.
• David (age 36) is a mechanic who is presently living in a common-law marriage with Camille and her three sons.
• Camille and her first husband, Rob, divorced in 2007, reconciled in 2009, and then divorced in 2010.
There are no specific guidelines for drawing genograms illustrating complex stepfamily situations. Generally, however, what works best is for the nurse to start by gathering information about the immediate household. After this, the nurse draws each family’s constellation. Whenever possible, it is best to show children from different marriages in their correct birth order, oldest on the left and youngest on the right. We agree with McGoldrick et al (2008) that the rule of thumb is, when feasible, that different marriages follow in chronological order from left to right. We have sometimes found it helpful to indicate the number of the relationship or marriage in the lower left-hand corner when there have been several relationships. See Figure 3-5, where Adrienne’s husbands are indicated as #1 and #2. It can be useful to draw a circle around each separate household. If one member of a couple is involved in an affair, then their relationship is depicted with a dotted rather than a solid line. Additional pertinent information, such as children moving between two households, can be written to the side of the genogram. It is important for the nurse to remember that the purpose of drawing the genogram is to obtain a visual overview of the family. The genogram is not meant to be an exact chart for genetics.
Other problems arise when there are multiple marriages, intermarriages, and remarriages within the family. For example, when cousins or stepsiblings marry, the clinician should use separate pages to clarify intricacies. With complex family situations, the nurse needs to choose between clarity and level of detail. When computers are used to diagram genograms, complexity can be reduced by zooming in on relevant significant information. We advise nurses to let practicality and possibility be their guide.
Develop a genogram that is useful rather than one that is overly inclusive and too confusing. Sometimes the only feasible way for pediatric nurses to clarify where children were raised is to take chronological notes on each child and draw multiple genograms through time to show the various family constellations the child experienced. With software, specific genograms can be created for specific moments in a person’s life. When discrepancies exist in information shared by various family members, we advise nurses to note this on the genogram but not to take on an investigative role. There can be multiple truths and recollections of information.
Another example of a stepfamily genogram is depicted in Figure 3-8.
The Faris Family
• David (age 42) is a software designer living common-law since 2015 with Patti (age 40), a part-time retail associate.
• David and Patti have a daughter, Madison (age 3), recently diagnosed with juvenile diabetes.
• David’s twin sons, Jack and Ben (age 9), spend alternate weeks at their mom’s townhouse and at David and Patti’s apartment.
• David was divorced in 2010; his former wife has a daughter, age 3.
• Patti has a son, Dan (age 20), by her first husband, Jim, whom she divorced in 2000.
• Dan lives alone and works several part-time jobs in bars.
• Patti has two other daughters: Tamika (age 16), who recently dropped out of school, and Shannon (age 14), in grade 8, from her second marriage, to Lloyd, which ended in divorce in 2009.
• Tamika and Shannon live with their mom and visit Lloyd and his family for 2 weeks most summers.
• The current health concern is Madison’s juvenile diabetes.
• The current household consists of David, Patti, the three girls, and on alternate weeks, the twin boys.
• David’s mom has diabetes, as does his older sister.

Figure 3-8 Sample genogram: Faris stepfamily.
An example of a family in which a child lives with the grandmother and her husband is provided in Figure 3-9:
The Fitzgerald-Kucewicz Family
• Sophia Kucewicz (age 8), lives with her grandmother, Patricia Fitzgerald (age 45); Vincent, Patricia’s common-law partner of 10 years; and Sophia’s aunt, Susan.
• Patricia was previously married to Steven Fitzgerald for 14 years.
• Patricia and Steven had three children: Susan (age 19), Douglas (age 23), and Joan (age 25), who is Sophia’s mother.
• Joan became pregnant with Sophia when she was 16.
• Sophia’s father, Michael Kucewicz, and her mother had a brief relationship, through which she was conceived.
• Michael was aware of the pregnancy; he left the city shortly before Sophia was born, never meeting her.
• When Sophia was 2 years old, Joan had another child, Kayla, who subsequently went to live with her natural father when she was 4.
• When Sophia was 3, her mother moved in with Ben, whom Sophia came to know as her father.
• Joan and Ben had difficulty providing a stable environment for Sophia and Kayla and, from time to time, moved in with Patricia and Vincent.
• Patricia reports that both Joan and Ben used drugs and alcohol and were often unemployed.
• Ben was physically and verbally abusive to Joan, and after a particularly frightening episode between Joan and Ben that took place in the basement of Patricia’s home, Joan called the police. The child welfare department became involved, leading Patricia and Vincent to take guardianship of Sophia.
• Joan and Ben moved to a place of their own, agreeing to take Sophia every other weekend.
• The health concern for this family is Sophia’s nightmares, especially after returning from visits to Joan and Ben’s trailer home.

Figure 3-9 Genogram of the Fitzgerald-Kucewicz family.
Most families are extremely receptive to and interested in collaborating with the nurse to complete a genogram. For some, it is the first time that they have ever seen their family life pictured in this manner. Therefore, the nurse needs to be aware that the family may have a reaction to significant events. One family, for example, may express some sensitive material in a very blasé fashion. If divorce is common in their families of origin, they may not hesitate to discuss their several marriages and those of their siblings. On the other hand, a devout Catholic family may be exquisitely sensitive to seeing the nurse write the word “divorce.”
Ecomap
As with the genogram, the primary value of the ecomap is in its visual impact. The purpose of the ecomap is to depict the family members’ contact with larger systems. Hartman (1978) notes:
The eco-map [sic] portrays an overview of the family in their situation; it pictures the important nurturant or conflict-laden connections between the family and the world. It demonstrates the flow of resources, or the lack of and deprivations. This mapping procedure highlights the nature of the interfaces and points to conflicts to be mediated, bridges to be built, and resources to be sought and mobilized. (p. 467)
Ecomaps shift the emphasis away from the historical genogram to the current functioning of the family and its environmental context. This focus on the present is an important message in our outcome-based health-care climate. The ecomap depicts reciprocal relationships between family members and broader community institutions such as schools, courts, healthcare facilities, and so forth.
How to Use an Ecomap
As with the genogram, family members can actively participate in working on the ecomap during the assessment process.
The family genogram is placed in the center circle, labeled “Family or household.” The outer circles represent significant people, agencies, or institutions in the family’s context. The size of the circles is not important. Lines are drawn between the family and the outer circles to indicate the nature of the connections that exist. Straight lines indicate strong connections, dotted lines indicate tenuous connections, and slashed lines indicate stressful relations. The wider the line, the stronger the tie. Arrows can be drawn alongside the lines to indicate the flow of energy and resources. Additional circles may be drawn as necessary, depending on the number of significant contacts the family has.
An ecomap for the Lamensa family is illustrated in Figure 3-10:
• Raffaele, Silvana, Gemma, and Antonio are placed in the center circle.
• Raffaele has strong connections with his workplace, where he is a foreman and a union representative. He has moderately strong bonds with his “drinking buddies.” These relationships, however, are stressful for him.
• Silvana’s connections are mainly with her mother and the health-care system. She sees her family physician every week “for nerves” and sees a community health nurse (CHN) once a week. Silvana’s mother, Nunziata, visits Silvana every day from 11 a.m. to 10 p.m. There is a strong connection between Silvana and her mother, but Silvana says she really “doesn’t like Mom coming over so often.”
• Antonio has a few friends, most of whom set fires. He is in a special class for his learning disability and enjoys both the teacher and the school.
• Gemma is in junior high school, where she maintains an average grade of D. She frequently does not attend school, and when she does attend, she participates little. She spends about 6 hours a day with her boyfriend.

Figure 3-10 Lamensa family ecomap.
When the CHN completed the ecomap with the Lamensa family, Mrs. Lamensa (Silvana) commented, “I seem to spend all my time with medical or health people.” Mr. Lamensa (Raffaele) then said, “You’re also so busy with your mother that you don’t have time for anybody else.” The nurse was able to use this information from the ecomap to discuss further with the family the types of relationships they wanted both with those inside their household and with those outside the immediate family.
In summary, the genogram and the ecomap can be used in all health-care settings, especially in primary care, to increase the nurse’s awareness of the whole family and the family’s interactions with larger systems and their extended family. Box 3-2 gives helpful hints for drawing ecomaps.
Box 3-2 Helpful Hints for Drawing Ecomaps
Pose questions that explore the family’s connections to other individuals or groups outside the family, such as:
• “What community agencies are you involved with now? Which are most and least helpful?”
• “How would you describe your relationship with school staff?”
• “How did you first become involved with Child Protective Services? What is the nature of your current relationship with them?”
Levac, A.M., Wright, L.M., & Leahey, M. (2002). Children and families: Models for assessment and intervention. In J. Fox (Ed.), Primary healthcare of infants, children and adolescents (p. 14). St. Louis, MO: Mosby. Copyright 2002. Adapted with permission.
DEVELOPMENTAL ASSESSMENT
In addition to understanding the family structure, the nurse must understand the developmental life cycle for each family. Most nurses are familiar with the stages of child development and the literature in the area of adult development. Many are becoming interested in the burgeoning literature about development in the senior years, an interest that has been fostered by the aging of the baby boomer generation. But what of family development? It is more than the concurrent development at different phases of children, adults, and seniors who happen to call themselves “family.” We believe families are people who have a shared history and a shared future.
KEY CONCEPT DEFINED
Developmental Assessment
One of the categories of the Calgary Family Assessment Model (CFAM) that nurses use to identify the developmental life cycle for each family.
Family development is an over-arching concept, but each family has its own developmental path, influenced by its past and present context and its future aspirations. McGoldrick, Garcio Preto, and Carter (2016) believe that “individuals and families transform, and need to transform, their relationships as they evolve, to adapt to changing circumstances over the life course” (p. 7). There is no single family developmental life cycle or model. This is especially evident as our population ages. The natural sequential phases of generational boundaries are not as clear as in the past with, for example, children maturing at earlier ages but living at home longer, the trend toward later marriages, and seniors continuing to work well into their 60s. This blurring of boundaries can sometimes lead to tension and confusion within families.
KEY CONCEPT DEFINED
Family Development
The unique path constructed by a family that is shaped by predictable and unpredictable events and societal trends.
In keeping with postmodernist ideas, we believe that there are limits to describing family development in precise, absolute, universal ways. Postmodernists differ from modernists in that exceptions interest them more than rules; specific, contextualized details more than grand generalizations; difference rather than similarity. We are not concerned with authoritative truth, facts, and rules but rather with the meaning a family gives to its particular story of development over time.
We have found it useful to distinguish between family development and family life cycle. Family development emphasizes the unique path constructed by a family. It is shaped by predictable and unpredictable events, such as illness, catastrophes (e.g., terrorist attacks, fires, earthquakes, hurricanes, floods), and societal trends (e.g., Internet and cell-phone usage, stock market fluctuations, company mergers, changes in crime and birth rates).
Family life cycle refers to the typical path most families go through. The typical life-cycle events are connected to the comings and goings of family members. For example, most families experience certain events in their life cycle, such as birth, child-rearing, departure of children from the household, retirement, and death. These events generate changes requiring a formal reorganization of roles and rules within the family. The life-cycle course of families evolves through a generally predictable sequence of stages, despite cultural and ethnic variations. Although individual variations, timing, and coping strategies exist, biological time clocks and societal expectations for events such as entrance into elementary school and retirement from work are relatively typical in North America.
KEY CONCEPT DEFINED
Family Life Cycle
The typical path most families follow; generally predictable sequence of stages connected to the comings and goings of family members, such as birth, child-rearing, departure of children from the household, retirement, and death.
Given our keen interest in a particular family’s specific development over time, it might be questioned why we include a family developmental section in the CFAM at all. We take the position that an informed “not-knowing” stance is useful when working with families. That is, we seek to be informed by the literature, research, and other families’ stories of development. Yet, we are “not knowing” but curious about this particular family’s developmental story in terms of how the family members progressed through time.
A rich history about family development still pervades clinicians’ thinking. It is useful for nurses to have some understanding of this history. The early proponents of the family life cycle (Duvall, 1977) developed a four-stage model that was subsequently expanded into an eight-stage model featuring successive stages in the progression of primary marriages. With the increase in various family forms, more complex designs were created. Most recently, the Multicontextual Life Cycle Framework for Clinical Assessment developed by McGoldrick et al (2016) has become a helpful framework for conceptualizing the complexities of the life cycle. It provides a visual of the individual within the context of the multigenerational family system, which is embedded in the larger social context, all moving through time simultaneously.
In the field of family therapy, there were “pioneers” in applying the family development framework. Much was written about the interface among family development, functioning, and therapy. Carter and McGoldrick (1988) believed that the family life-cycle perspective viewed symptoms in relation to normal functioning over time and that “therapy” helped to reestablish the family’s developmental momentum. Family therapists such as Haley (1977), Minuchin (1974), and Selvini, Boscolo, Cecchin, and Prata (1980) noted the frequency of symptom appearance with the addition or loss of a family member. These therapists worked with families that did not move smoothly or automatically from one stage in the family life cycle to another, and they focused on the stressful transition points between stages. In doing an assessment and in planning interventions, these therapists paid considerable attention to life-cycle events as markers of change. Although their approaches differed, they similarly sought to understand the relationship between psychopathology and the family’s developmental life-cycle stage.
Family development is now seen as an interactive process in which the historian influences which stories of development are told and emphasized. All of these changes have required a critical rethinking of our assumptions about “normality” and the idea of “family” development. The relationship between demographic changes and alterations in the prevalence, timing, and sequencing of some key family transitions must also be noted.
In our clinical work with families presenting in various forms and at all stages of development, we have found it useful to adopt Falicov’s (2012) ideas about family development. She emphasizes culture and gender relativity rather than universality, transitions rather than stages, dimensions and processes rather than markers, and a resource rather than a deficit orientation. We concur with her idea that a systems approach to family development calls for a dialectical integration of two tendencies: stability and change. The emphasis is on both tendencies rather than one or the other. Change and stability must be addressed simultaneously. We do not find it clinically useful to think of families as “stuck” and unable to bring about change. Rather, we find it clinically useful to look for patterns of continuity, identity, and stability that can be maintained while new behavioral patterns are changing.
There is much evidence to support the position that nurses will find heuristic value in the family development category of the CFAM. They should be aware, however, of some of the problems in its indiscriminate adoption and application. We find it indefensible for some nurses to make sweeping generalizations such as, “The family life cycle is genetically determined,” or, “The family life cycle is culturally universal.” We urge nurses to carefully consider the implications of a family’s ethnicity, race, and social class in applying the family development category.
We also caution nurses against indiscriminately applying the family development category and overemphasizing smooth progression. Contradictions and difficulties inherent in progressing through the life cycle are normal. Families are complex systems that need to deal with many different progressions at once—that is, there are biological, psychological, sociological, and cultural progressions. Tensions and continuing change brought about by contradictions between these progressions are normal. Family life is seldom smooth or bland; rather, it is zestful and active. We therefore encourage nurses, when using the family development category, to have families discuss their joys and satisfactions as well as their tensions and stresses. The family developmental story told by one family member is from that member’s “observer perspective” (Maturana & Varela, 1992).
In addition to delineating stages and tasks implicit in the family life cycle, we have found it useful to notice the attachments between family members. Attachment refers to a relatively enduring, unique emotional tie between two specific persons. Each person has the need for emotional connection while also remaining secure in his or her own individuality.
Bowlby (1977) notes:
Affectional bonds and subjective states of a strong emotion tend to go together…. Thus many of the most intensive of all emotions arise during the formation, the maintenance, the disruption and renewal of affectional bonds which for that reason are sometimes called emotional bonds. In terms of subjective experience the formation of a bond is described as falling in love, maintaining a bond as loving someone, and losing a partner as grieving over someone. Similarly the threat of loss arouses anxiety and actual loss causes sorrow, while both situations are likely to arouse anger. Finally the unchallenged maintenance of a bond is experienced as a source of security and renewal of a bond as a source of joy. (p. 203)
Although the terms bonding and attachment are sometimes used to describe different relationships, we have chosen in this book and in our clinical work to make no distinction between these terms. We recognize the complexity of relationships that arise from international connections between family members and the relationship stresses and the hard choices economic and social immigrants face with separations and reunions of parents, young children, and elderly family members. When working with a family, we tend to pay the most attention to the reciprocal nature of an attachment and the quality of the affectional tie.
We illustrate these bonds between family members by drawing attachment diagrams. The symbols used in these diagrams (Figure 3-11) are similar to those used in the structural assessment diagrams. It is important for us to emphasize that there is no one right level of attachment or best attachment configuration.
We are partial to the idea of the network paradigm as a useful base to integrate attachment and family systems theories. Such a paradigm integrates dyadic and family systems as simultaneously distinct and yet interconnected. The clinician holds multiple perspectives in mind, considers each system level as both a part and a whole, and shifts the focus between levels as required. We like this concept because it expands attachment to include multiple system levels and networks, which is especially important as the baby boomer cohort increases in age. Attachment theory is relevant to more than just parent-infant bonding; it is important for all ages. The key elements of attachment processes (affect regulation, interpersonal understanding, information processing, and the provision of comfort within intimate relationships) are as applicable to family systems as they are to individual development.

Figure 3-11 Symbols used in attachment diagrams.
In the CFAM developmental category, we discuss family life-cycle stages, the emotional process of transition (namely, key principles), and second-order changes—the issues dealt with and tasks often accomplished during each stage. In an effort to emphasize the variability of family development, we discuss six sample types of family life cycles:

1. Middle-class North American family life cycle
2. Divorce and post-divorce family life cycle
3. Remarried family life cycle
4. Professional and low-income family life cycles
5. Adoptive family life cycle
6. Lesbian, gay, bisexual, queer, intersex, transgender and twin-spirited family life cycles
   Middle-Class North American Family Life Cycle
   We are grateful to McGoldrick et al (2016) for delineating six phases in the North American middle-class family life cycle (summarized in Table 3-1). We highlight the expansion, contraction, and realignment of relationships as entries, exits, and development of family members occur. Although the relationship patterns and family themes may sound familiar, we wish to emphasize that the structure and form of the North American family are changing radically. It is important for nurses to have a positive conceptual framework for what is: dual-career families, permanent single-parent households, unmarried couples, homosexual couples, remarried couples, and sole-parent adoptions. Transitional crises should not be thought of as permanent traumas. It is imperative that the use of language that links us to previous stereotypes be dropped. For example, we try to eliminate such phrases as “children of divorce,” “working mother,” “out-of-wedlock child,” “fatherless home,” and so forth, from the language we use about families. Also, we urge nurses to critically reflect on how culture, ethnicity, gender, race, and sexual orientation influence a family’s developmental stages and tasks as well as attachments.
   TABLE 3-1 Phases of the Family Life Cycle
   FAMILY LIFE CYCLE PHASE EMOTIONAL PROCESS OF TRANSITION: KEY PREREQUISITE ATTITUDES SECOND-ORDER TASKS/CHANGES OF THE SYSTEM TO PROCEED DEVELOPMENTALLY
   Emerging young adults Accepting emotional and financial responsibility for self a. Differentiation of self in relation to family of origin
   b. Development of intimate peer relationships
   c. Establishment of self in respect to work and financial independence
   d. Establishment of self in community and larger society
   e. Establishment of one’s worldview, spirituality, religion, and relationship to nature
   f. Parents shifting to consultative role in young adult’s relationships
   Couple formation: the joining of families Commitment to new expanded system a. Formation of couple system
   b. Expansion of family boundaries to include new partner and extended family
   c. Realignment of relationships among couple, parents and siblings, extended family, friends, and larger community
   Families with young children Accepting new members into the system a. Adjustment of couple system to make space for children
   b. Collaboration in child-rearing and financial and housekeeping tasks
   c. Realignment of relationships with extended family to include parenting and grandparenting roles
   d. Realignment of relationships with community and larger social system to include new family structure and relationships
   Families with adolescents Increasing flexibility of family boundaries to permit children’s independence and grandparents’ frailties a. Shift of parent–child relationships to permit adolescent to have more independent activities and relationships and to move more flexibly into and out of system
   b. Families helping emerging adolescents negotiate relationships with community
   c. Refocus on midlife couple and career issues
   d. Begin shift toward caring for older generation
   Launching children and moving on at midlife Accepting a multitude of exits from and entries into the system a. Renegotiation of couple system as a dyad
   b. Development of adult-to-adult relationships between parents and grown children
   c. Realignment of relationships to include in-laws and grandchildren
   d. Realignment of relationships with community to include new constellation of family relationships
   e. Exploration of new interests/career, given the freedom from childcare responsibilities
   f. Dealing with care needs, disabilities, and death of parents (grandparents)
   Families in late middle age Accepting shifting generational roles a. Maintaining or modifying own and/or couple and social functioning and interests in the face of physiological decline: exploration of new familial and social role options
   b. Supporting more central role of middle generations
   c. Making room in the system for the wisdom and experience of the elders
   d. Supporting older generation without overfunctioning them
   Families nearing the end of life Accepting the realities of family members’ limitations and death and the completion of one cycle of life a. Dealing with loss of spouse, siblings, and other peers
   b. Making preparations for death and legacy
   c. Managing reversed roles in caretaking between middle and older generations
   d. Realignment of relationships with larger community and social system to acknowledge changing life cycle relationships
   McGoldrick, Monica; Carter, Betty; Garcia-Preto, Nydia. (Eds.). (2016). The Expanded Family Life Cycle: Individual, Family and Social Perspectives, 5th edition, copyright 2016, pp 24 – 25. Reprinted by permission of Pearson Education, Inc. Upper Saddle River, NJ.
   Phase One: Emerging Young Adults
   In outlining the phases of the middle-class North American family life cycle, we have chosen to start with the stage of young adults. The primary task of young adults is to come to terms with their family of origin by remaining connected and yet separate, without cutting off or fleeing reactively to a substitute emotional source. The family of origin has a profound influence on who, when, how, and whether the young adult will marry. There have been sharp increases in the proportion of never married, primarily among men and women in their late 20s and early 30s who continue to live in the family home.
   This phase may last for several years in a family’s development. It is an opportunity for young adults to sort out emotionally what they will take along from the family of origin, what they will leave behind, and what they will establish for themselves as they progress through succeeding stages of the family life cycle. For both men and women, this is a particularly critical phase. During this stage, men sometimes have difficulty committing themselves to relationships and form a pseudoindependent identity centered on work. Women may choose to define themselves in relation to a man and postpone or forgo establishing an independent identity. We find it helpful to be curious in our clinical work and try to understand the client’s views and legacies regarding marital status and the flexibility of the young person’s expectations about pathways to adulthood.
   Tasks
7. Differentiation of self in relation to family of origin. The young adult’s shift toward adult status involves the development of a mutually respectful form of relating with his or her parents in which the young adult’s parents can be appreciated for who they are. The young adult adjusts the view of the parents by neither making them into what they are not nor blaming them for what they could not be. The complexity of this task is not to be underestimated. Each ethnic and racial group has norms and expectations regarding acceptable ways to be attached and connected to family and about issues of dependence versus independence.
8. Development of intimate peer relationships. The emphasis is on the young adult’s passing from an individual orientation to an interdependent orientation of self. There is no single template of social experience for young adults to follow as they develop intimate relationships. During this task, young adults strive to bridge the gap between autonomy and attachment as they share themselves with others rather than using others as the source of self. With the increased use of Internet dating sites, social media, and chat rooms, the young adult will be exposed to a wide variety of personal styles and personalities.
9. Establishment of self in respect to work and financial independence. In a young adult’s 20s and 30s, the “trying on” of various identities to test or refine career skills and interest is typical. The young adult who is committed to a career path or occupational choice by his or her late 20s or early 30s is less vulnerable to self-doubt or decreased self-esteem than the young adult without direction. Issues of competitiveness, expectations, and differences regarding work and financial goals require sorting through by the young adult and his or her family of origin.
10. Establishment of self in community and larger society. The future of how young adults relate to others as a responsible citizen depends on the development of self management.
11. Establishment of one’s worldview, spirituality, religion and relationship to nature. The social responsibility gets determined in this phase where young adult’s development of self management shifts.
12. Parents shifting to consultative role in young adult’s relationships. The relationship between parents and the young adult changes. Parents role shifts as the young adult develops new ways to relate.
    Attachments
    There are no right or wrong attachments for young adults in stage one. Rather, it is important for the nurse to draw forth from family members their beliefs about attachment to one other and how they regard these attachments. These beliefs are influenced by culture, gender, race, sexual orientation, and social class as well as by whether the young adult lives at home. Some sample attachments for phase one are given in Figure 3-12. The first diagram illustrates a young adult who is bonded equally with her father and mother. The second diagram illustrates a young adult who is more closely attached to each parent than the parents are to each other; the parents are negatively bonded. Of significance in the second diagram is that there was a death of a sibling during the childhood of the young adult. It could be hypothesized that his difficulties in establishing his own identity are related to the family’s hesitancy to come to grips with his deceased sister and the parents’ living alone without children.

Figure 3-12 Sample attachments in phase one.
Questions to Ask the Family.
• “Which of your parents is most accepting of your career plans? How does he or she show this?”
• “What does your sister, Maria, think of your parents’ reaction to your career plans?”
• “If your father were more accepting of your desire to move into an independent living situation with people not of the Jewish faith, how do you think your mother would react?”
• “If you continue to wear hijab because it is integral to your religious beliefs, would this reassure your parents?”
Phase Two: Couple Formation: The Joining of Families
Many couples believe that when they marry, it is just two individuals who are joining together. However, both spouses have grown up in families that have now become interconnected through marriage. Both spouses, although in some ways differentiated from their families of origin in an emotional, financial, and functional way, carry their whole family into the relationship. This is particularly relevant if the marriage is an arranged one. Marriage is a two-generational relationship with a minimum of three families coming together: one spouse’s family of origin, the other spouse’s family of origin, and the new couple. Given the current prevalence of stepfamilies, the likelihood of several families coming together is increased exponentially. Also, the certainty that the couple will be heterosexual is not evident because, in both the United States and in Canada, same-sex marriages and civil unions have increasingly been formally recognized.
Tasks

1. Formation of couple system. The new couple must establish itself as an identifiable unit. This requires negotiation of many issues that were previously defined on an individual level. These issues include routine matters such as eating and sleeping patterns, sexual contact, and use of space and time. The couple must decide which traditions and rules to retain from each family and which ones they will develop for themselves. They must develop acceptable closeness-distance styles and recognize individual differences in adult attachment styles. Although the majority of studies on the quality and stability of marriage focus on couple communication, we believe that love is the decisive factor for quality and stability. For some cultures, however, the concept of a “love marriage” as compared to an arranged marriage is quite different.
2. Expansion of family boundaries to include new partner and extended family.
3. Realignment of relationships among couple, parents and siblings, extended family, friends, and larger community. A renegotiation of relationships with each spouse’s family of origin has to take place to accommodate the new spouse. This places no small stress on both the couple and each family of origin to open itself to new ways of being. Some couples deal with their parents by cutting off the relationship in a bid for independence. Other couples choose to handle this task of realignment by absorbing the new spouse into the family of origin. The third common pattern involves a balance between some contact and some distance.
   Attachments
   Figure 3-13 illustrates a sample attachment for a couple in phase two: the development of close emotional ties between the spouses. The first diagram illustrates how they do not have to break ties with their families of origin but rather maintain and adjust ties with them. The second diagram illustrates a different type of attachment that can occur if both members of a couple do not align themselves together. The wife is more heavily bonded to her family of origin than she is to her husband. The husband is more tied to outside interests (such as work and friends) than to his wife. We have found that negative attachment-related events occurring early in the marriage are especially distressing for the couple. These and other attachment injuries can be characterized by a betrayal of trust during a critical moment of need.

Figure 3-13 Sample attachments in phase two.
Questions to Ask the Family.
• “Which family members were most in favor of your marriage?”
• “How did you incorporate Greek and American traditions in your marriage?”
• “How did your siblings show that they supported your marriage?”
• “What does your spouse think of your parents’ marital relationship?”
• “If you two as a couple were to model your marriage on your parents’ marriage, what would you incorporate into your marriage?”
• “How did the diagnosis of multiple sclerosis influence your bonding as a couple?”
Phase Three: Families With Young Children
During this stage, the adults now become caregivers to a younger generation. The birth and rearing of a baby present varying challenges. Moreover, taking responsibility for and dealing with the demands of dependent children are challenging for most families when financial resources are stretched and the parents are heavily involved in career development. The disposition of child-care responsibilities and household chores in dual-career households is a particular struggle. We have found that men and women often differ in the coping strategies they use to deal with this issue. Women with young children tend to use cognitive restructuring, delegation, limiting of avocational activities, and social support significantly more often than do men. The work-family issue of juggling child care and other household accountabilities is a social problem to be dealt with by the couple, not a “woman’s problem” for her to struggle with alone.
Tasks

1. Adjustment of couple system to make space for children. The couple must continue to meet each other’s personal needs as well as their parental responsibilities. With the introduction of the first child, challenges for personal space, sexual and emotional intimacy, and socializing exist. Both mothers and fathers are increasingly aware of the need for emotional integration of the child into the family. Children can be brought into three types of environments: (1) there is no space for them, (2) there is space for them, or (3) there is a vacuum that they are expected to fill. If the child has a disability, the couple may face more stress as they adjust their expectations and deal with their emotional reactions. We have found that normal family processes in couples becoming parents include shifts in the sense of self, shifts in relationships with families of origin, shifts in relation to the child, changes in stress and social support, and changes in the couple.
2. Collaboration in child-rearing and financial and housekeeping tasks. The couple must find a mutually satisfying way to deal with child-care responsibilities and household chores that does not overburden one partner. Balancing the budget and juggling family and other responsibilities is a major task. The emotional and financial cost of solutions to deal with child-care responsibilities must be addressed. Parents contribute to the child’s development and can do so in different or similar ways. Physical and playful stimulation of the child complements verbal interaction. Parents can either support or hinder their children’s success in developing peer relationships and doing well academically at school. Some families, responding to intense pressure from the school system, tend to stress the values of academic achievement and productivity, whereas other families may respond to this pressure with feelings of alienation. Recent immigration experiences and whether the children are documented or undocumented can also influence peer and school interaction.
3. Realignment of relationships with extended family to include parenting and grandparenting roles. The parents must design and develop their new parenting roles in addition to the marital role rather than replacing it. Members of each family of origin also take on new roles, for example, grandfather or aunt. In some cases, grandparents who perhaps were opposed to the marriage in the beginning become very interested in the young children. For many older adults, this is an especially gratifying time because it allows them to have intimacy with their grandchildren without the responsibilities of parenting. It also permits them to develop a new type of adult-adult relationship with their children. Opportunities for intergenerational support or conflict abound as expectations about child-rearing and health-care practices are expressed.
4. Realignment of relationships with community and larger social system to include new family structure and relationships.
   Attachments
   Parents need to maintain a marital bond and continue personal, adult-centered conversations in addition to child-centered conversations. Space for privacy and time spent together are important needs.
   Children require security and warm attachments to adults, as well as opportunities to develop positive sibling relationships. We believe teaching interdependence is a central goal of parenting, helping children see themselves as part of a community and living cooperatively with others.
   In Figure 3-14, sample attachment diagrams are given for this phase. A competitive, negative relationship (illustrated by the wavy line) exists between the children and spouses in the second diagram. The mother is overbonded to the daughter, and the father is underinvolved with the daughter. The father is overattached to the son, and the mother is underinvolved with the son. This is an example of same-sex coalitions existing cross-generationally.
   Questions to Ask the Family.
   • “What percentage of your time do you spend taking care of your children?”
   • “What percentage do you spend taking care of your marriage? Is this a comfortable balance for the two of you?”
   • “What effect does this pattern have on your children?”
   • “If your children thought that you should be closer, how might they tell you this?”
   • “What impact did the miscarriages have on your marriage?”

Figure 3-14 Sample attachments in phase three.
Phase Four: Families With Adolescents
This period has often been characterized as one of intense upheaval and transition, in which biological, emotional, and sociocultural changes occur with great and ever-increasing rapidity. Peers; Internet technology, such as instant messaging, social media, pornography, and sports; and other activities all compete for the adolescent’s attention. This stage is highly influenced by socioeconomic level. Adolescence can begin early within poor, inner-city, or rural communities where, at a very young age, children are often faced with pressures related to sexuality, household responsibility, drugs, and alcohol use. In many middle-class families, adolescence can last well into the young adult’s 20s and 30s, with the young person being financially dependent on the parents and continuing to live in the family home.
Tasks

1. Shift in parent-child relationships to permit adolescent to have more independent activities and relationships and to move more flexibility into and out of system. The family must move from the dependency relationship previously established with a young child to an increasingly independent relationship with the adolescent. Growing psychological independence is frequently not recognized because of continuing physical dependence. Conflict often surfaces when a teenager’s independence threatens the family. For example, teenagers may precipitate marital conflict when they question who makes the family rules about the car: Mom or Dad? Families frequently respond to an adolescent’s request for increasing autonomy in two ways: (1) they abruptly define rigid rules and recreate an earlier stage of dependency, or (2) they establish premature independence. In the second scenario, the family supports only independence and ignores dependent needs. This may result in premature separation when the teenager is not really ready to be fully autonomous. The teenager may thus return home defeated. Parents need to shift from the parental role of “protector” to that of “preparer” for the challenges of adulthood. The challenge for parents to shift responsibility to their teens in a balanced way is often complicated if there are health problems.
2. Families helping emerging adolescents negotiate relationship with community.
3. Refocus on midlife couple and career issues. During this stage, parents are often struggling with what Erickson (1963) calls generativity, the need to be useful as a human being, partner, and mentor to another generation. The socially and sexually maturing teenager’s frequent questioning and conflict about values, lifestyles, career plans, and so forth can thrust the parents into an examination of their own marital and career issues. Depending on many factors, including cultural and gender expectations, this may be a period of positive growth or painful struggle for men and women.
4. Begin shift toward caring for older generation. As parents are aging, so too are the grandparents. Parents (especially women) sometimes feel that they are besieged on both sides: teenagers are asking for more freedom, and grandparents are asking for more support. With the trend of women having children later in life and seniors living longer, this double demand for attention and resources most likely will intensify. Celebrating the wisdom of seniors and intergenerational reciprocity are key tasks.
   Attachments
   All family members continue to have their relationships within the family, although teenagers become increasingly more involved with their friends than with family members. These transitions through the family life cycle can be stressful because they challenge attachment bonds among family members. We advocate open communication and the addressing of primary emotions. A decrease in parental attachment is normative and developmentally appropriate for adolescents. The young person’s widening social network, however, does not preclude strong family relationships, although family relationships are altered. The husband and wife need to reinvest in the marital relationship while this is taking place.
   An example of an attachment pattern is illustrated in Figure 3-15. In the second diagram, the mother is overinvolved with the eldest son and has a negative relationship with the husband. The father tends to be minimally involved with all family members. There is conflict between the two sons.
   Questions to Ask the Family.
   • “What privileges do your teenagers have now that they did not have when they were younger?”

Figure 3-15 Sample attachments in phase four.
Ask the adolescents:
• “How do you think your parents will handle it when your younger sister, Nena, wants to date? Will it be different from when you wanted to date?”
• “On a scale of 1 to 10, with 10 being the highest, how much confidence do your parents have in your ability to say no to marijuana?”
Phase Five: Launching Children and Moving On at Midlife
Many middle-class North Americans whose children are grown up used to assume they would have an empty nest. However, this expectation is in the process of change. Adult children may return to the family home after graduating from college; they may return, along with their children, after their marriages end; or they may never have moved out. Rising housing costs and beginning pay rates that have not risen as fast as those of more experienced workers have been singled out as some of the causes of this trend. A different explanation is that young North Americans are having difficulty growing up and are unwilling to go out on their own and settle for less affluence than their parents afford them.
Tasks

1. Renegotiation of couple system as a dyad. In many cases, a thrust to alter some of the basic tenets of the marital relationship occurs. This is especially true if both partners are working and the children have left home. The couple bond can take on a more prominent position. The balance between dependency, independency, and interdependency must be re-examined.
2. Development of adult-to-adult relationships between parents and grown children. The family of origin must relinquish the primary roles of parent and child. They must adapt to the new roles of parent and adult child. This involves renegotiation of emotional and financial commitments. The key emotional process during this stage is for family members to deal with a multitude of exits from and entries into the family system.
3. Realignment of relationships to include in-laws and grown children. The parents adjust family ties and expectations to include their child’s spouse or partner. This can sometimes be particularly challenging if the parents’ expectation is for a heterosexual son-in-law or daughter-in-law of the family’s race, religion, and ethnicity and the child chooses someone different. The once-prevalent idea that the time after a grown child marries is a lonely, sad time, especially for women, has been replaced. Increases in marital satisfaction have frequently been noted.
4. Realignment of relationships with community to include new constellation of family relationships.
5. Exploration of new interests/career, given the freedom from child care responsibilities.
6. Dealing with health needs, disabilities, and death of parents (grandparents). Many families regard the disability or death of an elderly parent as a natural occurrence. It can be a time of relishing and finding comfort in the happy memories, wisdom, and contributions of the elder. If, however, the couple and the elderly parents have unfinished business between them, there may be serious repercussions, not only for the children but also for the new third generation. The type of disability afflicting the seniors determines the effects on the immediate family. For example, caregivers who do not understand Alzheimer dementia and its effects on cognitive function and behavior often attempt to deal with inappropriate or disruptive behavior in ineffective and counterproductive ways. Thus, they inadvertently intensify their own stress.
   We recommend that health professionals, in addition to attending to the family’s multigenerational legacies of illness, loss, and crisis, also note intergenerational strengths and wisdom. Tracking key events, transitions, and coping strategies helps elicit resiliencies.
   Attachments
   Each family member continues to have outside interests and establish new roles appropriate to this phase. Sample attachment patterns are illustrated in Figure 3-16. A problem may arise when both husband and wife hold on to their last child. They may avoid conflict by allowing the eldest child to leave home and then focusing on the next child.

Figure 3-16 Sample attachments in phase five.
Questions to Ask the Family.
• “How did your parents help you to leave home?”
• “What is the difference between how you left home and how your son, Zubin, is leaving home?”
• “Will your parents get along better, worse, or the same with each other once you have left home?”
• “Who, between Mom and Dad, will miss the children the most?”
• “As you see your child moving on with a new relationship, what would you like your child to do differently than you did?”
• “If your parents are still alive, are there any issues you would like to discuss with them?”
Phase Six: Families in Later Life
This stage can begin with retirement and last until the death of both spouses. It is hard to say, however, when the stage actually begins for each family because it is dependent on social, economic, and personal factors relative to each family. Potentially, this stage can last 20 to 30 years for many couples. Key emotional processes in this stage are to flexibly adjust to the shift of generational roles and to foster an appreciation of the wisdom of the elders.
Tasks
• Maintaining or modifying own and/or couple and social functioning and interests in the face of physiological decline: exploration of new familial and social role options. Marital relationships continue to be important, and marital satisfaction contributes to both the morale and ongoing activity of both spouses. We have noted that the husband’s morale is often strongly associated with health, socioeconomic status, income, and to a lesser extent, family functioning. The wife’s morale is most strongly associated with family functioning and, to a lesser extent, with health and socioeconomic status.
As the couple in later life find themselves in new roles as grandparents and mother-in-law and father-in-law, they must adjust to their children’s spouses and open space for the new grandchildren. Difficulty in making the status changes required can be reflected in an older family member refusing to relinquish some of his or her power, for example, refusing to turn over a company or make plans for succession in a family business. The shift in status between the senior family members and the middle-aged family members is a reciprocal one. Difficulties and confusion may occur in several ways. Older adults may give up and become totally dependent on the next generation, the next generation may not accept the seniors’ diminishing powers and may continue to treat them as totally competent, or the next generation may see only the seniors’ frailties and may treat them as totally incompetent.
• Supporting more central role of middle generations.
• Making room in the system for the wisdom and experience of the elders. The task of supporting the older generation without overfunctioning for them is particularly salient because, in general, people are living longer. It is not uncommon for a 90-year-old woman to be cared for by her 70-year-old daughter, with both of them living in close proximity to a 50-year-old son and grandson. The “young-old” age group, those between 55 and 75 years of age, are often highly motivated to participate in self-help groups and are generally interested in improving their quality of life through counseling, traditional and alternative health activities, and education. Many have found “new” family connections through the use of e-mail, social media, and cell phones. They do not live by the aging myths of the past. Rather, as consumers, they expect and demand a good quality of life. Many grandparents continue to be involved in child-rearing.
• Supporting older generations without overfunctioning for them.
Attachments
The couple reinvests and modifies the marital relationship based on the level of functioning of both partners. This phase is characterized by an appropriate interdependence with the next generation. The concept of interdependence is particularly important for nurses to understand when working with families with adult daughters and their parents. Middle-class older men and women seem equally likely to aid and support their children, especially daughters. Frequency of contact, however, tends to be higher with daughters than with sons. Thus, the possibility of strong intergenerational attachments between a daughter and her parents exists. In the attachment patterns illustrated in Figure 3-17 and shown previously in Figure 3-16, the couple project their conflicts onto the extended family. This causes difficulty for the succeeding generations.

Figure 3-17 Sample attachments in phase six.
Questions to Ask the Family.
• “When you look back over your life, what aspects have you enjoyed the most?”
• “What has given you the most happiness?”
• “About what aspects do you feel the most regret?”
• “What would you hope that your children would do differently than you did? Similarly to what you did?”
• “As your health is declining, what plans have you and your daughter, Aminah, made for her because of her schizophrenia?”
Phase Seven: Families Nearing the End of Life
During this phase, one has to deal with the realities of family member’s limitations and death and completion of one cycle of life.
• Dealing with loss of spouse, siblings, and other peers. This is a time for life review and taking care of unfinished business with family as well as with business and social contacts. Many people find it helpful to discuss their lives, review life events, and enjoy the opportunity of passing this information along to succeeding generations.
• Making preparation for death and legacy.
• Managing reversed roles in caretaking between middle and older generation.
• Realignment of relationships with larger community and social system to acknowledge changing life cycle relationships.
Divorce and Post-Divorce Family Life Cycle
Many changes in marital status and living arrangements are prevalent in North America today, such as increased divorce rates and single-parent families. Whether divorce rates or the number of single-parent families will level off, climb, or decline is a matter of speculation that can be backed up by various theories. Families experiencing divorce are often under enormous pressure. Single-parent families, whether a result of divorce or unmarried parents separating, must accomplish most of the same developmental tasks as two-parent families but without all the resources. This places extra burdens on the remaining family members, who must compensate with increased efforts to accomplish family tasks such as physical maintenance, social control, and tension management. We caution nurses, however, not to assume that single-parent status alone will influence family functioning. We have found that family composition alone is too broad a variable to predict health outcomes, and we recommend a focus on more specific variables such as parental cooperation in parenting following divorce.
Single-parent households generally experience challenges in managing shortages of time, money, and energy. Some parents voice serious concerns about the failure to meet perceived family and societal expectations for living “in a normal family” with two parents. Some women feel they must display behaviors that are contradictory to those they assume they should exhibit if they were to remarry. They perceive ongoing pressure from family, friends, and possibly their faith community to marry again to give their children a “normal” family. These women report being caught in a double-bind, trying to demonstrate behaviors such as compliance that might attract a new husband while trying to use seemingly opposing behaviors such as assertiveness to successfully manage their lives. We encourage nurses working with single-parent families to explore the parent’s feelings about opposing expectations. This is a way of helping these parents plan their responses to various paradoxical situations.
It is also important for nurses engaged in relational family nursing practice to focus on the positive changes experienced by many separated spouses. Separated women often use growth-oriented coping, such as becoming more autonomous and furthering their education, and experience positive changes, such as increased confidence and feelings of control, in the postseparation phase.
Resilience in the post-divorce period is another focus for nurses. Resilience commonly depends on the ability of parents and children to build close, constructive, mutually supportive relationships that play a significant role in buffering families from the effects of related adversity. Factors that promote resiliency and positive adjustment to divorce include those associated with children’s living arrangements. Whether family relationships post-divorce improve, remain stable, or get worse is dependent on a complex interweaving of many factors.
In our clinical supervision with nurses, we encourage focusing on the siblings, a subsystem that generally remains undisrupted during the process of family reorganization. Siblings are often the unit of continuity. We also try to notice and support cooperative post-divorce parenting environments such as mutual parental support; teamwork; clear, flexible boundaries; high information exchange; constructive problem solving; and knowledgeable, experienced, involved, and authoritative parenting. Because many fathers are not used to taking care of their children without their wives orchestrating things, fathers often fade out of their children’s lives. They want to avoid ex-wives and conflict and may feel uncomfortable if they have an unclear role of authority in their children’s lives. Nurses can be extremely helpful in intervening in these situations and fostering mutually agreeable post-divorce arrangements for the benefit of the children. For families locked in intractable disputes, we encourage them to develop a good-enough climate in which parents maintain distance from one another and conflict and triangulation are minimized.
Divorce may occur at any stage of the family life cycle and with any family, irrespective of socioeconomic status, ethnicity, or race. However, it has a different impact on family functioning depending on its timing and the diversity of individuals involved in the process. The marital breakdown may be sudden, or it may be long and drawn out. In either case, emotional work is required so that the family may deal with the shifts, gains, and losses in family membership. Some additional phases involved in divorce and post-divorce are depicted in Table 3-2. Column 1 lists the phase. Column 2 gives the prerequisite attitudes that will assist family members to make the transition and come through the developmental issues listed in column 3 en route to the next phase. We believe that clinical work directed at column 3 will not succeed if the family is having difficulty dealing with the issues in column 2.
TABLE 3-2 The Developmental Tasks for Divorcing and Remarrying Families
PHASE TASK PREREQUISITE ATTITUDE TRANSITION DEVELOPMENTAL ISSUES
Divorce Decision to divorce Acceptance of inability to resolve marital problems sufficiently to continue relationship Acceptance of one’s own part in the failure of the marriage
Planning breakup of the system Supporting viable arrangements for all parts of the system a. Working cooperatively on problems of custody, visitation, and finances
b. Dealing with extended family about the divorce
Separation a. Willingness to continue cooperative co-parental relationship and joint financial support of children
b. Working on resolution of attachment to spouse a. Mourning loss of original family;
b. Restructuring marital and parent-child relationships and finances; adaptation to living apart
c. Realignment of relationships with extended family; staying connected with spouse’s extended family
Divorce Working on emotional divorce: overcoming hurt, anger, guilt, etc. a. Mourning loss of original family; giving up fantasies of reunion
b. Retrieving hopes, dreams, expectations from the marriage
c. Staying connected with extended families
Post-divorce family Single parent (custodial household or primary residence) Willingness to maintain financial responsibilities, continue parental contact with ex-spouse, and support contact of children with ex-spouse and his or her family a. Making flexible visitation arrangements with ex-spouse and family
b. Rebuilding own financial resources
c. Rebuilding own social network
Single parent (noncustodial) Willingness to maintain financial responsibilities and parental contact with ex-spouse and to support custodial parent’s relationship with children a. Finding ways to continue effective parenting
b. Maintaining financial responsibilities to ex-spouse and children
c. Rebuilding own social network
Remarriage Entering new relationship Recovery from loss of first marriage (adequate emotional divorce) Recommitment to marriage and to forming a family with readiness to deal with the complexity and ambiguity
Conceptualizing and planning new marriage and family Accepting one’s own fears and those of new spouse and children about forming new family Accepting need for time and patience for adjustment to complexity and ambiguity of:

1. Multiple new roles
2. Boundaries: space, time, membership, and authority
3. Affective issues: guilt, loyalty conflicts, desire for mutuality, unresolvable past hurts a. Working on openness in the new relationships to avoid pseudo-mutuality
   b. Planning for maintenance of cooperative financial and coparental relationships with ex-spouses
   c. Planning to help children deal with fears, loyalty conflicts, and membership in two systems
   d. Realignment of relationships with extended family to include new spouse and children
   e. Planning maintenance of connections for children with extended family of ex-spouses
   Remarriage and reconstruction of family Resolution of attachment to previous spouse and ideal of original family; Acceptance of different model of family with permeable boundaries a. Restructuring family boundaries to allow for inclusion of new spouse-stepparent
   b. Realignment of relationships and financial arrangements to permit interweaving of several systems
   c. Making room for relationships of all children with all parents, grandparents, and other extended family
   d. Sharing memories and histories to enhance stepfamily integration.
   Renegotiation of remarried family at all future life cycle transitions Accepting evolving relationships of transformed remarried family a. Changes as each child graduates, marries, dies, or becomes ill
   b. Changes as each spouse forms new couple relationship, remarries, moves, becomes ill, or dies
   McGoldrick, Monica; Carter, Betty; Garcia-Preto, Nydia. (Eds.). (2016). The Expanded Family Life Cycle: Individual, Family and Social Perspectives, 5th edition, copyright 2016, pp 413 – 414. Reprinted by permission of Pearson Education, Inc. Upper Saddle River, NJ.
   Questions to Ask the Family.
   • “How do you explain to yourself the reasons for your divorce?”
   • “Who initiated the idea of divorce? Who left whom?”
   • “Who was most supportive of developing viable arrangements for everyone in the family? How did your ex-husband, Luis, show his willingness to continue a cooperative co-parental relationship with you? How did you respond to this?”
   • “As you changed your attachment to Luis, what changes did you notice in your children? What would your in-laws say about how you have fostered your children’s relationship with them? What would your children say?”
   • “What methods have you found most successful in resolving conflicting issues with Luis? What advice would you give to other divorced parents on how to resolve conflictual issues with their ex-partners?”
   • “How have your children helped you and your ex-spouse to maintain a supportive environment for them?”
   Remarried Family Life Cycle
   The family emotional process at the transition to remarriage consists of struggling with fears about investment in new relationships: one’s own fears, the new spouse’s fears, and the fears of the children (of either or both spouses). It also consists of dealing with hostile or upset reactions of the children, extended families, and ex-spouse. Unlike biological families, in which family membership is defined by bloodlines, legal contracts, and spatial arrangements and is characterized by explicit boundaries, the structure of a stepfamily is less clear. Nurses must address the ambiguity of the new family organization, including roles and relationships.
   We have found it helpful to use attachment theory as a framework for conceptualizing the impact of structural change and loss on stepfamily adjustment. We believe nurses can assist stepfamilies in increasing emotional connectivity and stability.
   Ahrons and Rodgers (1987) have advocated for models of healthy, well-functioning binuclear families. Having been angered by a predominant emphasis on pathology in the divorce literature, Ahrons began to study what she calls “binuclear families.” This term not only refers to joint-custody families or to families in which the relationship between ex-spouses is friendly but indicates a different familial structure, without inferring anything about the nature or quality of the ex-spouses’ relationship. Ahrons (1999) advocates a normative process model of divorce rather than focusing on evidence of pathology or dysfunction.
   We encourage nurses working with divorced and remarried families to bring to their patients research knowledge of what works and does not work to foster continuing family relationships. Nurses should be cautious, however, because complex problems seldom have simple answers. For example, predictors such as a child’s age and gender, the frequency and regularity of father/mother-child visitation, father/mother-child closeness, and the effect of parental legal conflict on the child’s self-esteem have different implications for different groups of 6- to 12-year-old children and for children in different situations.
   We also encourage nurses working with stepfamilies to increase their knowledge about stepfamily issues and respect the uniqueness of complex stepfamily life. We encourage nurses to educate themselves about the beliefs of a particular stepfamily because uninformed clinicians may unwittingly increase rather than decrease family tensions if they communicate to stepfamilies that they should be like biological families.
   Questions to Ask the Family.
   • “Reeves, what were the differences between you and your wife, Lily, in how you each successfully recovered from your first marriage?”
   • “What most helped each of you deal with your own fears about remarriage? About forming a stepfamily?”
   • “How did Lily invite your children to adjust to her?”
   • “What do your children think was the most useful thing you did in helping them deal with loyalty conflicts?”
   • “What advice do you have for other stepfamilies on how to create a new family?”
   • “What are you most proud of in how you have helped your stepfamily successfully make the transition from what they were before to what they are now?”
   Professional and Low-Income Family Life-Cycle Stages
   We align with Madsen (2013), who uses the term “families living in poverty” and who states that progression throughout the family life-cycle phases is often more accelerated for those families living in poverty than for those in working-class and middle-class families. As such, the family life cycle of families living in poverty can be organized into three stages (McGoldrick et al, 2016):
   Stage 1: Adolescence and emerging adulthood
   Stage 2: Coupling and raising young children
   Stage 3: Families in later life
   We encourage nurses to consider the effects of ethnicity and religion, socioeconomic status, race, and environment on when and how a family makes transitions in its life cycle. This is especially important in relational family nursing practice in primary care.
   Adoptive Family Life Cycle
   In adoption, the family boundaries of all those involved are expanded. Reitz and Watson (1992) define adoption as
   a means of providing some children with security and meeting their developmental needs by legally transferring ongoing parental responsibilities from their birth parents to their adoptive parents; recognizing that in so doing we have created a new kinship network that forever links those two families together through the child, who is shared by both. (p. 11)
   We agree with this definition. As with marriage, the new legal status of the adoptive family does not automatically sever the psychological ties to the earlier family. Rather, family boundaries are expanded and realigned. We believe that nurses should be aware of the trends and special circumstances in forming adoptive families. For example, most agencies offer adoption services along a continuum of openness. Some potential benefits of open adoption for birth parents include increased empathy for adoptive parents, reassurance that the child is safe and loved, and a reduction of shame and guilt. For adoptive parents, benefits include increased empathy for the birth parents, reduced stress imposed by secrecy and the unknown, and an embracing from the start of an affirmative acceptance of the child’s cultural heritage. For the child, benefits include increased empathy for the adoptive parents, enriched connections with them, and reduced stress of disconnection. Simultaneously, the child experiences increased empathy for the birth parents, a reduction in fantasies about them, and—with clear, consistent information—increased control in dealing with adoptive issues. We believe that these potential benefits are very significant, especially for families adopting babies from different cultures and races. Adoptive families can include divorced, single-parent, married, or remarried families as well as extended families and families with various forms of open dual parentage.
   The adoption process, including the decision, application, and final adoption, can be a stressful as well as joyful experience for many couples. During the preschool developmental phase, the family must acknowledge the adoption as a fact of family life. The question of the permanency of the relationship sometimes arises from both the child and the parents. In our clinical work with adoptive families, we have found it useful to consider many aspects of the adoption, including the following:
4. Genetic, hereditary factors in the child
5. Deficiencies in the child’s prenatal and perinatal care
6. Adverse circumstances of adoption, including the child’s having had multiple disruptions in early life
7. Conditions in the adoptive home, including pre-existing and current family resiliencies, problems, and strengths
8. Temperamental similarities and differences between the adoptee and the adoptive parents or family
9. Fantasy system and communication regarding adoption, including parental attitudes about adoption
10. Difficulties establishing a firm sense of identity during adolescence
11. Greater age difference than usual between parents and adoptees
    We believe that it is important in relational family nursing practice to recognize adoptive families’ strengths and resources as they deal with challenging issues. During the adolescent stage of family development, a major task is to increase the flexibility of family boundaries. In adoptive families, altercations may give rise to threats of desertion or rejection. During the young adult or launching phase, the young adult may “adopt” the parents in a recontracting phase.
    As the adopted child proceeds to develop his or her own family of procreation, the integration of the adoptee’s biological progeny can be a developmental challenge for everyone. Adoptive parents may be delighted with the psychological and social continuity. Simultaneously, they may mourn the loss of biological grandchildren and the pain of genealogical discontinuity. For the adoptee, reproduction includes the thrill of a biological relationship and possibly some fears of the unknowns in their own genetic history.
    We believe that nurses can play an important role in helping families navigate the complexities of the adoption process and life cycle. When complexity is accepted, when the losses are acknowledged and resolved, when parents and their children feel satisfied with adoption as a legitimate route to becoming a family, and when the community of family, friends, and professionals who surround them is affirming, then the outcomes for adoptive families are very positive.
    Lesbian, Gay, Bisexual, Queer, Intersex, Transgender, Twin-Spirited Family Life Cycles
    Until recently, popular culture has ignored LGBQITT people in couple or family relationships or has portrayed them as part of an invisible subculture. Much of what we see, read, and hear in the media and society at large expresses a patriarchal, Anglo-Saxon, white, Christian, male, middle-class, ableist, and heterosexual view of the world. More recently, with open discussion about same-sex marriage or union, more attention is being focused on these relationships and their structures, developmental life cycles, challenges, strengths, and issues. We believe that the popular family life-cycle model may not apply to lesbians and gays because it is based on the notions that child-rearing is fundamental to family and that blood and legal ties constitute criteria for definition as a family.
    Furthermore, the transmission of norms, rituals, folk wisdom, and values from generation to generation is not typically associated with lesbian and gay life. In many cases, the family of origin may not know what name to call their daughter’s partner or spouse.
    We believe, however, that more differences exist within traditionally defined families than between LGBQITT families and those families designated as traditional. There are also many differing beliefs within diverse couples. For many clinicians, sexual nonexclusivity challenges fundamental beliefs. Our view of family life is socially constructed, as is the view held by each nurse. Managing multiple views of relationships is an important task for nurses working with families.
    The stages of the traditional family life cycle can be applied to lesbians and gays, with some unique differences. During adolescence, which can be a tumultuous time for most families, gays and lesbians face similar identity and individuation tasks as heterosexuals but often without the support of such rituals as proms or “going steady.” Parents frequently struggle more with parenting to “protect” than to “prepare” the young person to live in a homophobic social environment.
    The stages of leaving home, single young adulthood, and coupling present challenges for the young person who needs to learn from the gay/lesbian world about dating and cannot rely on the family of origin for modeling in this area. Couch-surfing and seeking hospitality from friends’ parents, LGBQITT-friendly shelters, and transitional living programs are examples of the living-arrangement options for what some have called “throwaway” youth (i.e., LGBQITT youth in crisis). These are young people who have “come out” to their families and were then pushed out of the family home.
    In discussing their same-sex relationship with their parents, many lesbian and gay couples have found it useful to focus on the strengths of their relationship. When parents see that the relationship has such strengths and can be beneficial for their son or daughter, they often adjust more easily. Dealing with the core issues of coupling—money, work, and sex—involves addressing gender scripts. During midlife and later life, the LGBQITT family continues to adapt and renegotiate with their families of origin. These relationships may be influenced by illness within either the aging family or the midlife chosen family. Intergenerational responsibility for caregiving and legacy issues may need to be addressed. We believe nurses engaged in relational practice can be helpful in providing a context for these conversations between family members.
    We recommend an oppression-sensitive approach to working with LGBQITT families. This approach invites a stance of respectful curiosity for exploring domains of convergence and difference.
    Questions to Ask the Family.
    • “In what area do you feel privileged? Oppressed?”
    • “How do you as a couple deal with these similarities and differences?”
    • “How does the more privileged one respond to the other’s sense of oppression?”
    • “How does each member of the couple deal with heterosexism? With your families of origin? With the dominant gay culture?”
    • “What are your strengths as a couple?”
    • “How does spirituality influence your relationship?”
    We encourage nurses to avoid the alpha bias of exaggerating differences between groups of people and the beta bias of ignoring differences that do exist. In their privileged role in working with families who are dealing with health issues, nurses can play a significant part in modeling inclusivity and respect for diversity.
    In this CFAM developmental category, we have presented six sample types of family life cycles. Nursing is beginning to recognize the special characteristics of diverse family forms, such as lesbian and gay couples. We encourage nurses to broaden their perspectives when interacting with various family forms. What we do know is that great variety exists: the poor and homeless family, the lesbian or gay couple, the single parent, the adopted child with parent, the stepfamily, the divorced family, the separated family, the foster family, the nuclear family, the extended family, the household of children raising children without a parent present, and so forth.
    FUNCTIONAL ASSESSMENT
    The family functional assessment deals with how individuals actually behave in relation to one another. It is the here-and-now aspect of a family’s life that is observed and that the family presents. There are two basic aspects of family functioning:
    • Instrumental
    • Expressive
    KEY CONCEPT DEFINED
    Functional Assessment
    One of the categories of the Calgary Family Assessment Model (CFAM) that nurses use to identify how individuals actually behave in relation to one another; the here-and-now aspect of a family’s life that is observed and that the family presents.
    Instrumental Functioning
    The instrumental aspect of family functioning refers to routine activities of daily living, such as eating, sleeping, preparing meals, giving injections, changing dressings, and so forth. For families with health problems, this area is particularly important. The instrumental activities of daily life are generally more numerous and more frequent and take on a greater significance because of a family member’s illness.
    Examples:
    • A quadriplegic requires assistance with almost every instrumental task.
    • If a baby is attached to an apnea monitor, the parents almost always alter the manner in which they take care of instrumental tasks. (For instance, one parent will leave the apartment to do a load of wash only if the other parent is sufficiently awake to attend to the infant.)
    • If a senior family member is unable to distinguish what medication to take at a specific time, other family members often alter their daily routines to telephone or drop in on the senior.
    The interaction between instrumental and psychosocial processes in clients’ lives is an important consideration for nurses. For example, nurses can pay attention to a family’s routines around eating and bedtime rituals and incorporate new health-care practices into the family’s routine rather than “adding on” to the family’s already busy schedule.
    We recommend that health professionals understand that caregiving, whether given to a spouse who has cancer by an elderly spouse or to a parent by his or her partner, constitutes a major challenge in adaptation. Elderly spouses often rate the overall burden of caregiving and personal strain (the subjective component) as heavier than do their children and the cancer patients themselves. The importance of family nursing care is thus highlighted.
    As the nurse hypothesizes about the family’s possible stage of health and illness and inquires into their ordinary routines of living alongside illness, the nurse and family will discover resiliencies and areas for possible assistance. Effective assistance consists of a series of events rather than single interactions. The trajectory of cardiac illness, for instance, suggests that interventions may be most effective when provided during all stages of illness and may best be tailored to meet the specific needs of individuals and families in each stage.
    Expressive Functioning
    The expressive aspect of functioning refers to nine categories:
12. Emotional communication
13. Verbal communication
14. Nonverbal communication
15. Circular communication
16. Problem solving
17. Roles
18. Influence and power
19. Beliefs
20. Alliances and coalitions
    These nine subcategories are derived in part from the Family Categories Schema developed by Epstein, Sigal, and Rakoff (1968) and later published by Epstein, Bishop, and Levin (1978). These categories were expanded by Tomm (1977) and later published by Tomm and Sanders (1983). Early work (Westley & Epstein, 1969) suggested that several of these categories distinguished emotionally healthy families from those that were experiencing more than the usual emotional distress.
    We have expanded on these works in our earlier editions of Nurses and Families to include nonverbal and circular communication, beliefs, and power. However, we do not use any of these categories as determinants of whether a family is emotionally healthy. Rather, it is the family’s judgment of whether they are functioning well that is most salient. With the exception, of course, of issues such as violence and abuse, we encourage nurses to find ways to support the family’s definition of health versus imposing their own definition on the family.
    Before discussing each subcategory, we would like to point out that most families must deal with a combination of instrumental and expressive issues.
    Example: A 79-year-old woman has a burn. The instrumental issues revolve around dressing changes and an exercise program. The expressive or affective issues might center on roles or problem solving. The family might be considering the following questions:
    • “Whose role is it to change Gram’s dressing?”
    • “Are women better ‘nurses’ than men?”
    • “Whose turn is it to call the physical therapist?”
    • “Why is it that Jas never gets involved in Gram’s care?”
    • “How can we get Jas to drive Gram to her doctor’s visit?”
    If a family is not coping well with instrumental issues, expressive issues almost always exist. However, a family can deal well with instrumental issues and still have expressive or emotional difficulties. Therefore, it is useful for the nurse and the family together to delineate the instrumental from the expressive issues. Both need to be explored when the nurse and the family have a conversation about family functioning.
    Although both past behaviors and future goals are taken into consideration in the functional assessment, the primary focus is on the here and now. It is helpful for both the nurse and family to identify a family’s strengths and limitations in each of the aforementioned subcategories. We find it helpful to remember that the very conversation the nurse and family have about the family system shapes that system. People continually and actively reauthor their lives and stories. Our commitment to families is to show curiosity, delight, interest, and appreciation for their resiliency. Naturally, this does not mean that we condone family violence or abuse. Rather, it means that we recognize that families are trying to make sense of their lives and stories. Our job is to witness this.
    Patterns of interaction are the main thrust of the expressive part of the functional assessment category. Families are obviously composed of individuals, but the focus of a family assessment is less on the individual and more on the interaction among all of the individuals within the family. Thus, the family is viewed as a system of interacting members. In conducting this part of the family assessment, the nurse operates under the assumption that individuals are best understood within their immediate social context. The nurse conceives of the individual as defining and being defined by that context. Each individual’s relationships with family members and other meaningful members of the larger social environment are thus very important. If we do not attend to ideas and practices at play in the larger social context, we run the risk of focusing too narrowly on small, rather tight, recursive feedback loops. We have found this to be especially important considering current social, political, environmental, and economic trends because families may struggle to adapt to constant changes.
    By interviewing family members together, the nurse can observe how they spontaneously interact with and influence each other. Furthermore, the nurse can ask questions about the impact family members have on one another and on the health problem. Reciprocally, the nurse can inquire about the impact of the health problem on the family. If the nurse thinks “interactionally” rather than “individually,” each individual family member’s behavior will not be considered in isolation but rather will be understood in context.
    It is important for nurses to remember that if they embrace a postmodernist worldview, they will not be able to conduct an objective family evaluation. Rather, the nurse and the family, in talking about the family’s patterns of interacting, will bring forth a new story, rich in contextualized details. Particular attention is paid to the ways that even the small and the ordinary—single words, single gestures, minor asides, trivial actions—can provide opportunities for generating new meanings. Unlike modernist nurses who define themselves as separate from the family with whom they are working, nurses with postmodernist views assume that each participant in the family interview—wife, husband, partner, nurse—makes an equal and often different contribution to the process. It is the nurse’s task to help family members engage in conversations to make sense of their lives rather than to explain their behavior.
    Emotional Communication
    This subcategory refers to the range and types of emotions or feelings that families express or the practitioner observes. Families generally express a wide spectrum of feelings, from happiness to sadness to anger, whereas families with difficulties commonly have quite rigid patterns within a narrow range of emotional expression. For example, some families experiencing difficulties almost always argue and rarely show affection. In other families, parents may express anger but children may not, or the family may have no difficulty with women expressing tenderness but feel that men are not permitted to express it.
    Questions to Ask the Family.
    • “Who in the family tends to start conversations about feelings?”
    • “How can you tell when your dad is feeling happy? Angry? Sad? How about your mom? What effect does your anger have on your son Noah?”
    • “What does your mom do when your dad is angry?”
    • “If your grandmother were to express sadness about her upcoming chemotherapy to your parents, how do you think your parents would react?”
    • “When your brother Henry was killed in the accident, what most helped your family to cope with the grief?”
    Verbal Communication
    This subcategory focuses on the meaning of an oral (or written) message between those involved in the interaction. That is, the focus is on the meaning of the words in terms of the relationship.
    Direct communication implies that the message is sent to the intended recipient. An elderly woman may be upset by what her husband is saying but corrects her grandson’s inconsequential fidgeting with the comment, “Stop doing that to me.” This could represent a displaced message, whereas the same statement directed at her husband would be considered direct.
    Another way of looking at verbal communication is to distinguish between clear versus masked messages. In a clear message, there is a lack of distortion in the message. A father’s statement to his child, “Children who cry when they get needles are babies” may be masked criticism if the child is fighting back tears at the time of his injection. The old child management strategy of “say what you mean, and mean what you say” is a good guideline for clear, direct communication.
    Questions to Ask the Family.
    • “Who among your family members is the most clear and direct when communicating verbally?”
    • “When you state clearly to your young adult son that he has to pay rent to you, what effect does that have on him?”
    • “When your teenagers talk directly to each other about the use of condoms, what do you notice?”
    • “If your adolescents were to talk more with you and your husband about safer sex, what do you think your husband’s reaction might be?”
    • “What ways have you found for you and Manuel to have good, direct conversations? In person? On the cell phone? By e-mail? Through text messaging?”
    Nonverbal Communication
    This subcategory focuses on the various nonverbal and paraverbal messages that family members communicate. Nonverbal messages include body posture (slumped, fidgeting, open, closed), eye contact (intense, minimal), touch (soft, rough), gestures, facial movements (grimaces, stares, yawns), and so forth. Personal space, the proximity or distance between family members, is also an important part of nonverbal communication. Paraverbal communication includes tonality, guttural sounds, crying, stammering, and so forth. Nurses must remember that nonverbal communication is highly influenced by culture. Nurses should note the sequence of nonverbal messages as well as their timing.
    Example: When an older man starts to talk about his terminal illness and his adult daughter turns her head and casts her tear-filled eyes toward the floor, the nurse can infer that the daughter is sad about her father’s impending death. The daughter’s sequence of nonverbal behavior is congruent with sadness and the topic of conversation. Note, however, that this behavior sequence may not necessarily be the most supportive for her father.
    Nonverbal communication is closely linked to emotional communication. We encourage nurses to inquire about the meaning of nonverbal communication when it is inconsistent with verbal communication.
    Questions to Ask the Family.
    • “Who in your family shows the most distress when your foster father is drinking?”
    • “How does Sheldon show it?”
    • “What does your foster mother do when your foster father is drinking?”
    • “When your sister Seema turns her head and stares out the window as your stepfather is talking, what effect does it have on you?”
    • “If your dad were to stop talking at the same time as your stepmother, would you think she might move closer to him?”
    Circular Communication
    Circular communication refers to reciprocal communication between people (Watzlawick, Beavin, & Jackson, 1967). A pattern exists in most relationship issues. For example, a common circular pattern occurs when a wife feels angry and criticizes her husband; in return, the husband feels angry and avoids both the issues and her. The more he avoids, the angrier she becomes. The wife tends to see the problem only as her husband’s, whereas the husband identifies the wife’s criticism as the only problem. This type of pattern is often called the demand/withdraw pattern. The circularity of this pattern is the most important aspect in understanding interaction in dyads. Each person influences the behavior of the other. More information about this topic is available in Chapter 2.
    KEY CONCEPT DEFINED
    Circular Communication
    Reciprocal communication between people; a subcategory of expressive functioning in the functional assessment category of the Calgary Family Assessment Model (CFAM).
    Circular communication patterns can also be adaptive. For example, an older parent feels competent and negotiates well with the landlord; the adult son feels proud and praises his parent. The more reinforcement the adult son gives, the more confident and self-assured the senior feels. This pattern is diagrammed in Figure 3-18.
    Circular pattern diagrams (CPDs) concretize and simplify the repetitive sequences noted in a relationship. This method of diagramming interaction patterns, first developed by Tomm in 1980, may be applied to relationships between family members or between the nurse and the family. Because the nurse and the family also mutually influence each other, the nurse is encouraged to think interactionally about situations and offer the family an opportunity to think interactionally.

Figure 3-18 Adaptive circular pattern diagram.
KEY CONCEPT DEFINED
Circular Pattern Diagrams (CPDs)
A method of diagramming interaction patterns developed by Tomm (1980); may be applied to relationships between family members or between the nurse and the family.
The simplest CPD includes two behaviors and two inferences of meaning. The inferences can be cognitive, affective, or both. Inferences about cognition refer to ideas, concepts, or beliefs, whereas inferences about affect refer to emotional states. Affect and/or cognition propels the behavior. Figure 3-19 illustrates the relationship between these elements. As noted by Tomm (1980), “The inference is entered inside the enclosure and represents some internal process (what is going on inside each interactant). The connecting arrows represent information conveyed from each person to the other through behavior. The circular linkage implies an interaction pattern that is repetitive, stable, and self-regulatory” (p. 8). CPDs encourage a position of curiosity rather than a passion for particular values and a stand against others.
Although CPDs can be used to foster circular thinking, one must be mindful of their limitations. CPDs can tempt us to look within families for collaborative causation of problems. This may distract from personal responsibility for unacceptable behavior such as violence. Small, tight feedback loops may be highlighted, and the “big picture” of the negative influence of particular values, institutions, and cultural practices may be forgotten. Another limitation of CPDs is that they may encourage nurses to believe that they are outside the family system. As a participant observer in the larger system, the nurse is shown and hears about circular patterns reflecting family functioning. The interdependence of the nurse interviewer and family must be recognized. Both the nurse and family members cannot be decontextualized from their social and historical surroundings.

Figure 3-19 Basic elements of a CPD.
In what has come to be called the “feminist critique” of systems, some have taken exception to the simplistic causation ideas advanced by a circular perspective. CPDs, by virtue of their neutral context, ignore power differentials and imply a discourse or relationship between equals. These writers criticize circularity for not being transparent about responsibility and minimizing power differentials in relationships. Of particular concern are such issues as incest, abuse, violence, intimidation, and battering.
Despite these valid criticisms, we believe that it is still useful in clinical work with families to subscribe to the notion of circularity but simultaneously hold to the idea of personal responsibility. An example of a circular argument is illustrated in Figure 3-20. Each party blames and threatens the other. An example of a supportive relationship is illustrated in Figure 3-21. The husband trusts his wife and reveals his needs and fears. She is concerned and, in turn, sustains and supports him. This leads him to trust her more, and the relationship progresses.

Figure 3-20 CPD of a circular argument.
Sample Conversation With the Family
Nurse: You say your wife “always” criticizes you. (Nurse conceptualizes Figure 3-22). What do you do then? (Nurse tries to fill in the husband’s behavior in Figure 3-23.)
Niz: I don’t like to discuss things. I avoid conflict. I leave. I go in the other room. What else can I do? She is always telling me what I did wrong. I go to the computer.

Figure 3-21 CPD of a supportive relationship.

Figure 3-22 Beginning conceptualization of CPD.

Figure 3-23 CPD illustrating husband’s and wife’s behaviors.
Nurse: So she expresses her needs, and you leave. How do you think that makes her feel? (Nurse tries to fill in the inferred emotion in the wife’s circle in Figure 3-24.)
Zara: I’ll tell you. I get annoyed. I feel ignored, rejected.
Nurse: So you’re annoyed when he leaves and ignores you. And then you become more critical. Is that right?
Zara: Well I don’t really criticize, I just…
Niz: Yeah, you got it, Nurse.
Nurse: So, when you try to express your concerns, how do you think it makes him feel? (Nurse tries to fill in the inference in the square in Figure 3-24.)
Zara: I don’t know.

Figure 3-24 CPD illustrating wife’s emotion.
Nurse: If he thinks you’re lecturing and avoids the issues by leaving the room and going to the computer, what effect do you think your talking might be having on him?
Zara: Well, I suppose he could be feeling frustrated. He sulks.
Nurse: So the pattern seems to be that, no matter who starts it, the circle completes itself. Sometimes you’re annoyed and you criticize. Your husband feels frustrated and ignores you. He sulks in another room. Other times he avoids issues, and this arouses your frustration and criticism. (Nurse explains Figure 3-25.)
Zara: It’s a vicious circle.
Niz: I don’t want it to go on this way anymore. We both get too upset.
Once the nurse has elicited a CPD, the nurse should ask the family members to contextualize their discussion. One context might be that Zara is exhausted by her factory job and all the housework and child care. Niz does not see why he should change his life because his wife has a stressful job and works long hours. They may engage in this particular negative circular interaction pattern every night while caring for their 3-year-old child with asthma.

Figure 3-25 Nurse’s conceptualization of this couple’s communication pattern.
Problem Solving
This subcategory refers to the family’s ability to solve its own problems effectively. Family problem solving is strongly influenced by the family’s beliefs about its abilities and past successes. How much influence the family believes it has on the problem or illness is useful to know. Who identifies the problems is important. Is it characteristically someone from outside the family or from inside the family?
Once the problems are identified, are they mainly instrumental (routine, day-to-day logistics) or emotional problems? Families sometimes encounter difficulties when they identify an emotional problem as an instrumental one.
Examples:
• A mother who states that she cannot get her child who has food allergies to maintain the diet is really discussing an emotional issue rather than an instrumental one; she has difficulty influencing her child. As more families cope with issues such as childhood obesity, this is a particularly important distinction for nurses to notice. Is the obesity an instrumental or emotional problem? An individual, family, or societal problem?
• A couple dealing with the wife’s myeloma might decide to harvest stem cells as a proactive measure. What are the family’s solution patterns? Are they proactive in planning for issues that might arise?
• Older parents move to a retirement community. The wife breaks her hip. The husband is used to being self-reliant or, in a pinch, depending on his middle-aged daughter. The older couple know few people in their new community. The husband is reluctant to accept help from the visiting nurse. He states that he can manage all of his wife’s care despite the fact that he is losing weight and getting insufficient rest. The husband’s solution pattern conflicts with that of the nurse. Many close-knit extended families rely on relatives for assistance in time of need. Others tend to seek help from professionals. Knowing a family’s usual solution style can give the nurse insight into why this family may seem to be “stuck” at this particular time with this particular issue.
• A 68-year-old grandmother tells Katherine, the nurse, “I can’t afford to let myself cry about the death of my son’s newborn baby. I have to go on for the sake of my other children.” Knowledge of whether a family evaluates the cost of its solutions can be helpful to the nurse. Katherine was able to evaluate with the grandmother the cost of her solution pattern. Neither the grandmother nor the son discussed the baby’s death with each other. The grandchildren’s questions about why the baby did not come home from the hospital were left unanswered. There was considerable tension between the son and the grandmother, and the son was particularly overprotective of his 4-year-old boy (the only surviving male child). By gently exploring the cost of the solution (tension and over-protection), the nurse was able to suggest other solution patterns (e.g., shared grieving).
Questions to Ask the Family.
• “Who first noticed the problem?”
• “Are you the one who usually notices such things?”
• “What most helped you to take the first step toward eliminating the addiction and violence pattern?”
• “What effect did it have when Toya also took steps to stop the cycle of violence in your family?”
• “How did the relationship between your son, Jeremiah, and your husband change when the violence stopped? When the addiction stopped?”
• “If a violent episode were to occur again, how do you think you and your daughter would deal with it?”
• “If his cocaine addiction were to flare up again, what steps would you take to protect your family?”
Roles
This subcategory refers to the established patterns of behavior for family members. A role is consistent behavior in a particular situation. Roles, however, are not static but are developed through an individual’s interactions with others. Roles are thus influenced by culture, race, and others’ sanctions and norms. In Hispanic families, for example, machismo can be very significant for the hierarchical male role, and simpatía, or the avoidance of conflict and the ability to get along well, is often highly valued in the female role.
The psychological cost of providing care for a parent with Alzheimer disease is often anxiety, depression, guilt, and resentment in the caregiver. The fact that women dominate as adult caregivers reflects a North American pattern. The gender differences clearly profile women’s more frequent, intensive, affective involvement with the caregiver role.
Women’s roles have changed in recent years and are now less defined by the men in their lives. The birth rate has fallen below replacement levels, and many more women are concentrating on jobs and education. In many cases, a husband’s income is negatively related to role sharing, and a wife’s education is positively related to role sharing.
Although role change is increasingly prevalent for both men and women in today’s society, what is important for nurses to assess is how family members cope with their roles. Nurses should consider the following:
• Does role conflict or cooperation exist?
• Are roles determined solely by age, rank order, or gender?
• Do additional criteria, such as social class and culture, influence roles?
• Are the women in the family more involved with a wider network of people for whom they feel responsible?
• Do the men hear less than the women in the family about stress in their family network?
Formal roles are those for which the community has broadly agreed on a norm. Examples include the roles of mother, husband, and friend. Informal roles refer to the established patterns of behavior that are idiosyncratic to particular individuals in certain settings. Examples include the roles of “bad kid,” “angel,” and “class clown.” These serve a specific function in a particular family. If Dad is the “softie,” most likely Mom is the “heavy.” If Giffy is the “good daughter,” Kweisi is probably the “black sheep.” The roles of “parentified child,” “good child,” and “symptomatic child” have been identified in many families. Auxiliary roles of “child advocate,” “analyst,” “peacemaker,” and “therapist” have also been described.
It is helpful for the nurse to learn how family roles evolved, their impact on family functioning, and whether the family believes they need to be altered. It is important for nurses to conceptualize the functional assessment category of roles in a family-oriented rather than an individual-oriented way. According to Hoffman (1981):
The individual-oriented approach badly misrepresents the subject. For instance, to speak of the “role of the scapegoat” is to present the deviant as a person with fixed characteristics rather than a person involved in a process. “Scapegoating” technically applies to only one stage of a shifting scenario—the stage where the person is metaphorically cast out of the village. After all, the term originates from an ancient Hebrew ritual in which a goat was turned loose in the desert after the sins of the people had been symbolically laid on its head. The deviant can begin like a hero and go out like a villain, or vice versa. There is a positive-negative continuum on which he can be rated depending on which stage of the deviation process we are looking at, which sequence the process follows, and the degree to which the social system is stressed.
At the time, the character of the deviant may vary in another direction, depending on the way his particular group does its typecasting. Which symptoms crop up in members of a group is itself a kind of typecasting. Thus the deviant may appear in many guises: the mascot, the clown, the sad sack, the erratic genius, the black sheep, the wise guy, the saint, the idiot, the fool, the imposter, the malingerer, the boaster, the villain, and so on. Literature and folklore abound with such figures. (p. 58)
Questions to Ask the Family.
• “To whom do most of you go when you need someone to talk to?”
• “What effect does it have on Maxine when Ken helps with the baby’s care?”
• “When Maxine and Ken collaborate instead of competing, who would be the first to notice? If Ken were to be more responsible for initiating contact with the relatives around Cherie’s day-care arrangements and babysitting, how do you think Maxine would feel?”
Influence and Power
This subcategory refers to behavior used by one person to influence or affect another’s behavior. Power is the ability of a person to regulate the criteria by which differing views of “reality” are judged and resources apportioned. Power addresses hierarchical and egalitarian positions in relationships. In a hierarchical relationship, a person can be in a one-up or a one-down position in the relationship and can be dominant in one context and subordinate in another. In an egalitarian relationship, there is equality in the relationship. In an egalitarian relationship, a give-and-take negotiation of individual needs, goals, and desires with an expectation of reciprocal attunement to the needs of the relationship or each other occurs.
Gender, race, and cultural issues are frequently intermingled with power issues. For example, in many relationships, women tend to raise issues and draw men out in the early phase of a discussion, whereas men tend to control the content and emotional depth of the later discussion phases and largely dominate the outcome. Shifts in power are preceded by changes in “reality,” an expansion from a single perspective to a multiverse. We encourage nurses to adopt a postmodernist worldview because it offers useful ideas about how power and “truth” are socially constructed, constituted through language, organized, and maintained in families and larger cultural contexts.
A nurse who is unaware of power differences among family members, in terms of roles, gender, economics, or social class, can inadvertently encourage family members in positions of less power to accept goals that decrease their power and constrain their choices.
Whether all family members contribute equally to problems and share responsibility for resolution is something that the nurse can pose for consideration. We believe that the most clinically useful stance to take with regard to the idea of power is to say, “Power is….” It can be used positively or negatively, overtly or covertly, to enhance or constrain options. Power relations exist among family members, their health-care providers, and institutions. McGoldrick et al. (2008, p. 78) have depicted a negative power and control pyramid that includes eight levels and combines racism, heterosexism, and sexism:

1. “Isolation, controlling whom she can see and when and where
2. Sexual abuse, abusive touching, sexual acts against her will, having affairs, exposing her to HIV
3. Using children, being abusive, controlling, guilt-inducing or under-responsible regarding visitation, etc.
4. Physical abuse, hitting, shoving, choking, kicking, grabbing, etc.
5. Economic abuse, controlling her financially, not sharing financial information or resources, challenging her every purchase
6. Threats and intimidation, threatening to hurt her physically, to commit suicide, have an affair, divorce, report her to welfare, take away children or cut off her emotional support system, putting her in fear by looks, actions, destroying property, stalking, driving car too fast
7. Using immigration status, using her undocumented status to threaten deportation, loss of children, job, healthcare, etc.
8. Emotional abuse and use of male privilege, putting her down, name calling, making her think she’s crazy, playing mind games, stonewalling, treating her like a servant, assuming right to make all major decisions or to neglect ‘2nd shift’ home responsibilities such as housework and childcare.”
   Instrumental influence, power, or control refers to the use of objects or privileges (e.g., money; television watching; computer, car, or cell-phone use; candy; vacations; and so forth) as reinforcers. Psychological influence or power refers to the use of communication and feelings to influence behavior. Examples include directives, praise, criticism, threats, and guilt induction. Corporal control refers to actual body contact, such as hugging, spanking, and so forth. It is important to note the positive and negative influences used in the family, especially with infants and seniors. Abuse of seniors by informal and sometimes formal caregivers is not infrequent, and abuse by family members may occur as well.
   We have found that the most important positive predictors of compliance for children are consistency of enforcement of rules, encouragement of mature action, use of psychological rewards such as praise and approval, and play with the child. The most important negative one is the amount of physical punishment. The use of praise is positively related to success, whereas physical punishment and verbal, psychological punishment are constraining influences.
   Questions to Ask the Family.
   • “Which of your parents is best at getting Nirvana to take her medication?”
   • “When Devin dominates the conversation, what effect does that have on Jamie?”
   • “What does your mother feel about how your stepfather disciplines your sister?”
   • “If your stepfather were to be more positive with your sister Tiffany, how might his relationship with your mother change?”
   • “Whose interests are most reflected in major decisions in the Veliz family?”
   • “Who is more likely to accommodate to the other person, Gustavo or Fines?”
   Beliefs
   This subcategory refers to fundamental attitudes, premises, values, and assumptions held by individuals and families. Beliefs are the blueprint from which people construct their lives and intermingle them with the lives of others. Families co-evolve an ecology of beliefs that arise from interactional, social, and cultural contexts (Wright & Bell, 2009). When illness arises, our beliefs about health are challenged, threatened, or affirmed. During times of illness, nurses may assess the beliefs of patients, family members, or even their own beliefs to be constraining or facilitating. Constraining beliefs can enhance suffering and decrease solution options, whereas facilitating beliefs can soften illness suffering and increase solution options for managing an illness (Wright & Bell, 2009). Which illness beliefs are determined to be constraining or facilitating is determined by the clinical judgment of the nurse in collaboration with the family.
   Beliefs and behaviors are intricately connected. Every action and every choice that families and individuals make evolves from their beliefs. Consequently, beliefs shape the way in which families adapt to chronic and life-threatening illness. For example, if a family believes that the best treatment for colon cancer is a nontraditional approach, it makes good sense for the family to pursue acupuncture. Because North American culture tends to use a paradigm of control about symptoms (it is good to be in control and bad to be out of control), nurses might find it useful to explore family members’ beliefs about control and mastery over their symptoms.
   Beliefs are intricately intertwined with familial and socioeconomic contexts.
   Examples:
   • The meaning of pregnancy loss is intricately intertwined with the woman’s emotional needs at the time of the loss. If a mother was very happy about being pregnant and felt devastated by her miscarriage, then her emotional needs would differ dramatically from those of another mother who did not want to be pregnant and felt relieved by her miscarriage. Feelings about pregnancy loss can range from feelings of devastation to relief.
   • A 51-year-old father of two teenage girls wrote to a nurse about his beliefs about his chronic pain:
   I think each person has a different threshold of pain. Every day I try to disassociate the pain…. I try to “get into” my work and life. I am not always successful … but I try as hard as I can. The why, is because of my family, friends, and faith (gushy, eh?, but it’s true). I think you have to find out what is important in your life and let it motivate you, as terrible as this will be to say, there are always thoughts of “ending it all” … but then you think about the sadness you would leave with the ones you love … it keeps you going. I really think the key is to find one important thing as a start, and let that be the fuel that keeps you motivated to do the things you would like to do. I wish there were more I could say…. It’s a day to day struggle.
   Wright and Bell (2009) have suggested that the most relevant beliefs to explore with patients and their families are beliefs about etiology, diagnosis, prognosis, healing, and treatment; spirituality and religion; mastery and control; role of family members; and role of health-care providers.
   Box 3-3 provides a list of areas for nurses to explore when assessing family beliefs about the health problem.
   Questions to Ask the Family.
   • “What do you believe is the cause of your sexual addiction?
   • “How much control do you believe your family has over chronic pain?
   • “How much control does chronic pain have over your family?
   • “What do you believe the effect, if any, would be on chronic pain if you and your wife agreed on treatment?
   • “Who do you believe is suffering the most in your family because of the changes in your family life due to your multiple sclerosis?
   • “What do you believe has been the most useful thing health professionals have offered to help you cope with your suffering from fibromyalgia? What has been the least helpful?”
   • “Have any of your Buddhist beliefs helped you to cope with the tragic loss of your son?”
   Box 3-3 Beliefs About the Health Problem
   A. Beliefs about:
9. Diagnosis
10. Etiology
11. Prognosis
12. Healing and treatment
13. Mastery, control, and influence
14. Religion and spirituality
15. Place of illness in lives and relationships
16. Role of family members
17. Role of health-care professionals
    B. Influence of the family on the health problem
18. Resource utilization
    a. Internal (to family)
    b. External
19. Medication and treatment
    C. Influence of the health problem on the family
20. Client response to the illness
21. Family members’ responses to illness
22. Perceived difficulties and changes related to the health problem
    D. Strengths related to the health problem at present
    E. Concerns related to the health problem at present
    Adapted from Family Nursing Unit records, Faculty of Nursing, University of Calgary, Calgary, Alberta.
    Alliances and Coalitions
    This subcategory focuses on the directionality, balance, and intensity of relationships between family members or between families and nurses. Complementary and symmetrical are terms used to describe a two-person relationship (see Chapter 2). A term commonly used to distinguish a three-person relationship is triangle, a term first coined by Bowen (1978). Bowen, a psychiatrist and family therapist, explains:
    The two-person relationship is unstable in that it has a low tolerance for anxiety and it is easily disturbed by emotional forces within the twosome and by relationship forces from outside the twosome. When anxiety increases, the emotional flow in a twosome intensifies and the relationship becomes uncomfortable. When the intensity reaches a certain level the twosome predictably and automatically involves a vulnerable third person in the emotional issue. The twosome might “reach out” and pull in the other person, the emotions might “overflow” to the third person, or the third person might be emotionally programmed to initiate the involvement. With involvement of the third person, the anxiety level decreases. It is as if the anxiety is diluted as it shifts from one to another of the three relationships in a triangle. The triangle is more stable and flexible than the twosome. It has a much higher tolerance of anxiety and is capable of handling a fair percentage of life stresses. (p. 400)
    Most family relationships are organized around threesomes or triangles. Triangular alliances can be helpful or unhelpful. We have learned that in families of combat veterans experiencing post-traumatic stress disorder, the veteran can sometimes become triangulated with a dead buddy without the spouse’s knowledge. With soldiers returning from the Iraq or Afghanistan War, the ongoing impact of their military alliances may be a useful area for the nurse to explore if the family is having difficulty realigning as a unit. Restless days, fractured relationships, and vials of pills that help with some types of pain, but not all types, have commonly been reported by these families. Relationships are not unidirectional, even if one member of the triangle is an infant, an older person, or a person who has a handicap. The intensity of each relationship and the total amount of interaction are often fairly balanced. If one relationship becomes more intense, another one or two become less intense. Also, if one member of a threesome withdraws, the other two become closer.
    We believe that it is important for the nurse to note the degree of flexibility and fluidity within the family as they adjust to new arrivals, death, or illness. Experienced community health nurses have often noticed triangulation in infancy support. For example, if the father acts intrusively while playing with his baby, the infant often averts and turns to the mother. The regulation of this intrusion-avoidance pattern at the family level sheds some light on the couple alliance. When co-parenting is supportive, the mother validates the infant’s bid for help without interfering with the father. Thus, the problematic pattern is contained within the dyad of father-baby. If co-parenting is hostile/competitive, the mother ignores the infant’s bid or engages with her in a way that interferes with her play with her father. In this case, triangulation occurs and tension is lessened, but at a cost. The nurse can identify these patterns with the couple and then collaborate with them to design effective interventions.
    As nurses address this functional subcategory of alliances and coalitions, they will be aware of its interconnection with structural and developmental categories. The structural subcategory of boundaries is an important part of the alliance or coalition subcategory. The boundary defines who is part of the triangle and who is not. Of course, there are many triangles and many shifting alliances and coalitions within families. What is important for the nurse and family to note, therefore, is whether these are problematic or enriching.
    An example of what can inadvertently occur in a family is if a patient’s illness is seen as “his problem” versus “our challenge.” If the condition becomes defined as the affected patient’s problem, a fundamental split occurs between the patient, the well partner, and other family members. By introducing the concept of “our challenge” early on, the nurse can provide an opportunity for all family members to examine cultural and multigenerational beliefs about the rights and privileges of ill and well family members. An alternate example of a positive coalition is when family members join together to help another family member stop smoking or stop drinking alcohol. They collectively voice their concerns to the individual and their intent to provide support and help.
    We have observed that cross-generational coalitions sometimes coincide with symptomatic behavior. In addition to noting the connection between the structural subcategory of boundaries and the functional subcategory of alliances and coalitions, nurses should be aware of the interconnection with the developmental subcategory of attachments. Family attachments, or underlying emotional bonds that have an enduring or stable quality, are similar to alliances in that they are both unions. Attachments tend to differ from coalitions, however, in that the latter implies an alignment between two members, with a third member being split off or opposed.
    Questions to Ask the Family.
    • “When Deanna and Logan argue, who is most likely to get in the middle of the fight?”
    • “If the children are playing very well together, who would most likely come along and start them fighting? Who would stop them from fighting?”
    • “What impact has Don’s brain tumor had on family members coming together or becoming further distanced?”
    CASE SCENARIO: JOHN AND VALERIE
    John and his wife, Valerie, were very excited about having their first baby. Valerie’s pregnancy was uneventful, and the labor and delivery were normal. They happily welcomed Hannah, a beautiful baby girl. Valerie was doing well at the hospital with feeding Hannah and, with the exception of a couple of unexplained crying spells that the nurses explained to her as “the baby blues,” she was coping well.
    Two weeks after they got home with the baby, John started feeling down. He was tired and feeling useless in helping Valerie and in caring for her and their new daughter. John was feeling as though he couldn’t be the father and husband he dreamed of when Valerie was pregnant. John was trying to balance long hours at work, helping Valerie around the house, and spending time cuddling his new baby. Valerie’s mother lives a distance away and planned to come for a couple of weeks, but unfortunately, Valerie’s father fell ill, and her mother had to stay and take care of him. As the weeks went by, John was feeling overwhelmed, useless, and anxious about not fulfilling his role. One night, John told Valerie that he thought they had made a mistake in having the baby. “I am just not a good dad,” he said, “and I’m afraid that you and Hannah are going to hate me.”
    Valerie and John have brought Hannah to the well-child clinic for her 2-month appointment. During the infant assessment, John shares his thoughts about being a failure as a father with the public health nurse. Valerie tells the public health nurse that she is concerned about John. She did not expect this to happen. John has always been such a competent, strong husband who wanted nothing more than to have a family. She was sure he would be happy and would be a wonderful dad. She did not know what to do to help him.
    Reflective Questions
23. How would constructing a genogram and ecomap with John and Valerie be helpful for the nurse?
24. What questions could the nurse ask John and Valerie in order to assess the structural components of their family, such as roles, subsystems, and boundaries?
    a. How can the nurse use this information when working with John and Valerie?
    CRITICAL THINKING QUESTIONS
25. Identify a family in your clinical practice and complete the three major categories of the CFAM:
    a. Structural (including a genogram and ecomap)
    b. Developmental
    c. Functional
26. What are three questions you would ask the family from each of the categories in order to obtain information?

Chapter 4
The Calgary Family Intervention Model
Learning Objectives
• Explain the Calgary Family Intervention Model (CFIM).
• Identify the domains of family functioning.
• Describe examples of interventions directed at each domain of family functioning.
• Compare the difference between linear and circular questions.
Key Concepts
Affective domain of family functioning
Behavioral domain of family functioning
Behavioral-effect questions
Calgary Family Intervention Model (CFIM)
Circular questions
Cognitive domain of family functioning
Commendations
Difference questions
Hypothetical or future-oriented questions
Illness narrative
Linear questions
The Calgary Family Intervention Model (CFIM) is a companion to the Calgary Family Assessment Model (CFAM) (see Chapter 3). To our knowledge, the CFIM is the first family intervention model to emerge within nursing. There is increasing evidence of the importance of nursing interventions with families in the literature; more detail can be found in Chapter 1. In addition, the focus of health-care providers has shifted from deficit- or dysfunction-based family assessments to strengths- and resiliency-based family interventions. For example, the McGill Model of Nursing developed by faculty and students from McGill University under the guidance of Dr. Moyra Allen states that one of its goals is to “help families use the strengths of the individual family members and of the family as a unit, as well as resources external to the family system” (Feeley & Gottlieb, 2000, p. 11). Gottlieb and Gottlieb (2017) identify strengths-based nursing as family nursing, and it is a growing movement across disciplines.
KEY CONCEPT DEFINED
Calgary Family Intervention Model (CFIM)
An organizing framework conceptualizing the intersection between a particular domain—cognitive, affective, or behavioral—of family functioning and a specific intervention offered by health-care professionals; a companion to the Calgary Family Assessment Model (CFAM).
The CFIM is a strengths- and resiliency-based model. We believe that this type of shift in emphasis from deficits and dysfunction to strengths and resiliency in family nursing practice greatly influences the types of interventions offered to and chosen by families within our model. It is important to note that Gottlieb (2012) has devoted an entire book to the importance of focusing on strengths in nursing care and continues to advocate for its importance (Gottlieb & Gottlieb, 2017).
This chapter presents our definition and description of the CFIM, examples of interventions in three domains of family functioning, and actual clinical examples using the CFIM. This chapter concludes with intervention ideas for family situations that nurses commonly encounter.
DEFINITION AND DESCRIPTION
If a comprehensive family assessment has been completed and family intervention is indicated, a nurse must then consider how to intervene to facilitate change. The CFIM is an organizing framework for conceptualizing the intersection between a particular domain of family functioning and the specific intervention offered by the nurse (Figure 4-1). The elements of the CFIM are as follows:
• Interventions
• Domains of family functioning
• “Fit” or meshing (i.e., effectiveness)

Figure 4-1 CFIM: Intersection of domains of family functioning and interventions.
The CFIM visually portrays the fit or meshing between a domain of family functioning and a nursing intervention; it answers these questions:
• In what domain of family functioning does this intervention intend a change?
• Is it a fit for this family?
The CFIM focuses on promoting, improving, and sustaining effective family functioning in three domains or areas:
• Cognitive
• Affective
• Behavioral
Interventions can be designed to promote, improve, or sustain family functioning in any or all of the three domains, but a change in one area can affect the other domains. We believe that the most profound and sustaining changes are the ones that occur within the family’s beliefs (cognition) (Bell & Wright, 2011; Wright, 2015; Wright & Bell, 2009). In other words, as a family thinks, so it is. In many cases, one intervention can actually simultaneously influence all three domains of family functioning.
We believe that nurses can only offer interventions to the family within a relational stance; they cannot instruct, direct, demand, or insist on a particular kind of change or way of family functioning. Such directive practices by nurses do not result in satisfying family-nurse relationships for either the nurse or the family, nor do they result in beneficial outcomes. Families are more open to the ideas offered by nurses when the relationships are in the context of collaborative interaction (e.g., inviting, asking, encouraging, supporting) rather than instructive interaction (e.g., instructing, directing, lecturing, demanding).
Whether the family is open to an intervention also depends on its genetic makeup and the family’s history of interactions among family members and between family members and health professionals (Maturana & Varela, 1992). Openness to certain interventions is also profoundly influenced by the relationship between the nurse and the family (Bell, 2016; Moules & Johnstone, 2010; Sigurdardottir, Svavarsdottir, Rayens, & Adkins, 2013; Svavarsdottir & Sigurdardottir, 2013; Sveinbjarnardottir, Svavarsdottir, & Saveman, 2011; Wright, 2015) and the nurse’s ability to help the family reflect on their health problems (Bell & Wright, 2011; Wright & Bell, 2009; Wright & Levac, 1992). Second-order cybernetics and the biology of cognition (Maturana & Varela, 1992) have influenced our ideas in this area (see Chapter 2).
Intervening in a family system in a manner that promotes or facilitates change and healing is the most challenging and exciting aspect of clinical work with families. The intervention process represents the core of clinical practice with families. It provides an appropriate context in which the family can make necessary changes that enhance the possibilities of healing. Myriad interventions are possible, but nurses need to tailor their interventions to each family and to the chosen domain of family functioning.
An awareness of ethical considerations is necessary for the nurse. Specific interventions usually vary for each family, although in some instances the same intervention may be used for several families and for different problems. We wish to emphasize, however, that each family is unique and that although labeling particular interventions is an important part of putting our practice into language, it does not represent a “cookbook” approach. We also wish to emphasize that the interventions we list are examples of interventions that can be used; they are not intended to be all-inclusive. The interventions that we cite are based on several important theoretical foundations: postmodernism, systems theory, cybernetics, communication theory, change theory, and the biology of cognition (see Chapter 2).
In summary, the CFIM is not a list of family functions or a list of nursing interventions. Rather, it provides a means to conceptualize a fit or meshing between domains or areas of family functioning and selected interventions offered by the nurse. The CFIM assists in determining the domain of family functioning that predominantly needs changing, usually where there is the greatest suffering, and the most useful interventions to effect change in that domain.
We use the qualitative terms fit or meshing to emphasize whether or not the interventions effect change and/or ease suffering in the presenting problem. Fit involves recognizing reciprocity between the nurse’s ideas and opinions and the family’s illness experience. Therefore, determining fit or meshing may involve some experimentation or trial and error. It also entails a belief by nurses that each family is unique and has particular strengths. In Chapter 7, we outline techniques for enhancing the likelihood that interventions will stimulate change in the desired domain of family functioning.
INTERVENTIVE QUESTIONS
One of the simplest but most powerful nursing interventions for families experiencing health problems is the use of interventive questions. These questions are intended to actively effect change in any or all of the three domains. However, nurses conducting family interviews should remember that knowing when, how, and why to pose questions is more important than simply choosing one type of question over another (Wright & Bell, 2009).
KEY CONCEPT DEFINED
Linear Questions
Questions asked by the nurse during family interviews that are meant to inform the nurse about the family’s descriptions or perceptions of a problem.
Linear Versus Circular Questions
Interventive questions are usually of two types (Tomm, 1987, 1988):
• Linear (investigative)
• Circular (reveal explanations)
KEY CONCEPT DEFINED
Circular Questions
Questions asked by the nurse during family interviews that are meant to reveal the family’s understanding of its problems.
The important difference between these kinds of questions is their intent. Linear questions are meant to inform the nurse, whereas circular questions are meant to effect change (Tomm, 1985, 1987, 1988).
Linear Questions
These types of questions explore and investigate a family member’s descriptions or perceptions of a problem.
Example: When exploring parents’ perceptions of their daughter Cheyenne’s anorexia nervosa, the nurse could begin with linear questions, such as: “When did you notice that your daughter had changed her eating habits?” and “What do you think caused your daughter to stop eating as she normally would?”
These linear questions inform the nurse of the history of the young woman’s eating patterns and help illuminate family perceptions or beliefs about eating patterns. Linear questions are frequently used to begin gathering information about a family’s problems, whereas circular questions reveal a family’s understanding of problems.
Circular Questions
These types of questions aim to reveal explanations of problems.
Example: With the same family, the nurse could ask: “Who in the family is most worried about Cheyenne’s anorexia?” and “How does Mother show that she is the one who worries the most?”
Circular questions help the nurse to discover valuable information because they seek out information about relationships between individuals, events, ideas, and/or beliefs.
The effect of these different question types on families is quite distinct. Linear questions tend to limit any further understanding, whereas circular questions are generative and open possibilities for new understandings. Circular questions introduce new cognitive connections or a change in the illness beliefs of families, paving the way for new or different family behaviors. Linear questioning implies that the nurse knows what is best for the family and is therefore operating under the “sin of certainty” or objectivity without parentheses (Maturana & Varela, 1992). It also implies that the nurse has become purposive and invested in a particular outcome. Linear questions are intended to correct behavior; circular questions are intended to facilitate behavioral change.
The primary distinction between circular and linear questions lies in the notion that information reveals differences in relationships (Bateson, 1979). With circular questions, a relationship or connection between individuals, events, ideas, or beliefs is always sought and in a context of compassion and curiosity. With linear questions, the focus is on cause and effect. The idea of circular questions evolved from the concept of circularity and the method of circular interviewing developed by the originators of Milan Systemic Family Therapy (Selvini-Palazzoli, Boscolo, Cecchin, & Prata, 1980; Tomm, 1984, 1985, 1987).
Circularity involves the cycle of questions and answers between families and nurses that occurs during the interview process. The nurse’s skillful questions are based on thoughtful assessment, conceptualization, and hypotheses that can foster understanding and that can obtain information the family gives in response to the questions the nurse asks, and thus the cycle continues. The family’s responses to questions provide information for the nurse and the family. The nurse is not an outside interpreter or narrator in this process but rather a participant in the relationship and interaction. Questions in and of themselves can also provide new information and answers for the family, and so they become interventions. Interventive questions may encourage family members to perceive their problems in a new way, which eases their suffering and allows them to see new solutions. Thus, as the family’s answers provide information for the nurse, the nurse’s questions may provide information for the family.
Circular questions have various applications in family nursing and family therapy. Østergaard et al (2018) conducted a randomized multicenter trial to explore the effect of family nursing therapeutic conversations on health-related quality of life, self-care, and depression among outpatients with heart failure. Circular questions were used as an intervention, with a focus on commendations, strengths, and resources within the family, which was beneficial to building family relationships. Wright and Bell (2009) demonstrated the therapeutic aspect of circular questions with families experiencing chronic illness, life-threatening illness, and psychosocial problems. In family therapy, Spain et al (2017) conducted a literature review to evaluate the effectiveness of enhanced communication and coping for individuals with autism spectrum disorder (ASD) and their family members and found that family therapists utilized various interventions, such as circular and reflective questions. Utilizing the CFIM, Duhamel and Talbot (2004) found that nurses considered interventive questioning useful because it stimulated discussion on specific topics: “One of the questions was formulated as ‘What were the most significant changes that occurred in the family since the onset of the illness?’ This question led to the identification of efforts made by the couples to comply with medical recommendations, and of their progress in the rehabilitation process” (p. 23).
KEY CONCEPT DEFINED
Commendations
Comments by the nurse during family interviews and counseling that emphasize observed positive patterns of behavior, such as family and individual strengths, competencies, and resources.
Tomm (1987) embellished the types of circular questions used by the Milan Systemic Family Therapy team and identified, defined, and classified various circular questions. The ones we have found most useful in relational clinical practice with families are as follows:
• Difference questions
• Behavioral-effect questions
• Hypothetical or future-oriented questions
KEY CONCEPT DEFINED
Difference Questions
Questions asked by the nurse during family interviews that explore differences between people, relationships, time, ideas, and/or beliefs.
KEY CONCEPT DEFINED
Hypothetical or Future-Oriented Questions
Questions asked by the nurse during a family interview that explore family options and alternative actions or meanings in the future.
We have expanded the use of circular questions by providing examples of questions that can be asked to intervene in the cognitive, affective, and behavioral domains of family functioning (Table 4-1).
KEY CONCEPT DEFINED
Behavioral-Effect Questions
Questions asked by the nurse during family interviews that explore the effect of one family member’s behavior on another.
TABLE 4-1 Circular Questions to Invite Change in the Cognitive, Affective, and Behavioral Domains of Family Functioning

1. Type: Difference Question
   Definition: Explores differences between people, relationships, time, ideas, and/or beliefs.
   COGNITIVE AFFECTIVE BEHAVIORAL
   ■ What is the best advice that you have received about managing your son’s HIV? ■ Who in the family is most worried about how HIV is transmitted? ■ Who in the family is best at getting your son to take his medication on time?
   What is the worst advice you have received? ■ Who finds your disclosure of sexual abuse most difficult? ■ When you first disclosed your sexual abuse, what actions by professionals were most helpful?
   What information would be most helpful to you about managing the effects of sexual abuse?
   ■ Who in the family would benefit most from the information?
2. Type: Behavioral-Effect Question
   Definition: Explores the effect of one family member’s behavior on another.
   COGNITIVE AFFECTIVE BEHAVIORAL
   ■ How do you make sense of your husband not visiting your son in the hospital? ■ What do you feel when you see your son crying after his treatments? ■ What do you do when your husband does not visit your son in the hospital?
   ■ What do you know about the effect of life-threatening illness on children? ■ How does your mother show that she is afraid of dying? ■ What could your father do to indicate to your mother that he understands her fears?
3. Type: Hypothetical/Future-Oriented Question
   Definition: Explores family options and alternative actions or meanings in the future.
   COGNITIVE AFFECTIVE BEHAVIORAL
   ■ What do you think will happen if these skin grafts continue to be so painful for your son? ■ If your son’s skin grafts are not successful, what do you think his mood will be? Sad? Angry? Resigned? ■ How much longer do you think it will be before your son engages in treatment for his contractures?
   ■ If the worst occurs, how do you think your family will cope? ■ If your grandmother’s treatment does not go well, who will be most affected? ■ How long do you think your grandmother will have to remain in the hospital?
   ■ If you decide to have your grandmother institutionalized, with whom would you discuss the decision? ■ If your grandmother stays longer in the hospital, what new self-care behaviors will she be doing?
   In summary, difference questions, behavioral-effect questions, and hypothetical questions can be used to facilitate change in any or all of the domains of family functioning. Figure 4-2 illustrates the intersection of various types of circular questions and the domains of family functioning. We strongly emphasize that the effectiveness, usefulness, and fit of the question, rather than the specific question itself, are most critical in effecting change.

Figure 4-2 Intersection of circular questions and domains of family functioning.
Other Examples of Interventions
To illustrate the intersection of the three domains or areas of family functioning (cognitive, affective, and behavioral) and various interventions, we have chosen a few examples of interventions that can be used in addition to circular questions. This list is not exhaustive; rather, it is a selection of interventions that we have found useful and effective in our clinical practice and research. Examples include the following:
• Commending family and individual strengths
• Offering information and opinions
• Validating, acknowledging, or normalizing emotional responses
• Encouraging the telling of illness narratives
• Drawing forth family support
• Encouraging family members to be caregivers and offering caregiver support
• Encouraging respite
• Devising rituals
These interventions can influence change in any or all of the domains of family functioning. For example, the nurse can offer information to promote change in cognitive, affective, or behavioral family functioning (Figure 4-3).
The following section describes each intervention and offers a case example illustrating its application. We have grouped the sample interventions around a particular domain of family functioning. However, we do not wish to imply that one intervention can be used to facilitate change in only one domain of family functioning or that one intervention is a “cognitive intervention” and another an “affective intervention.” Rather, these are examples of the fit between a specific problem or illness, a particular intervention, and a domain of family functioning.

Figure 4-3 Intersection of intervention (offering information) and domains of family functioning.
INTERVENTIONS TO CHANGE THE COGNITIVE DOMAIN OF FAMILY FUNCTIONING
Interventions directed at the cognitive domain of family functioning usually offer new ideas, opinions, beliefs, information, or education on a particular health problem or risk. The treatment goal or desired outcome is to change the way in which a family perceives its health problems so that members can discover new solutions to these problems. The following interventions are examples of ways to change the cognitive domain of family functioning.
KEY CONCEPT DEFINED
Cognitive Domain of Family Functioning
Interventions used in the Calgary Family Intervention Model (CFIM) that offer new ideas, opinions, beliefs, information, or education on a particular health problem or risk.
Commending Family and Individual Strengths
We routinely commend family and individual strengths, competencies, and resources observed during interviews. Commendations differ from compliments and are instead an observation of patterns of behavior that occur across time. Example of a commendation: “Your family members are very loyal to one another.” A compliment is usually an observation of a one-time event. Example of a compliment: “You were very praising of your son today.”
Families coping with chronic, life-threatening, or psychosocial problems commonly feel defeated, hopeless, or unsuccessful in their efforts to overcome or live with these problems. We choose to emphasize strengths and resilience rather than deficits, dysfunctions, and deficiencies in family members.
Example: An adopted son’s behavioral and emotional problems had kept the family involved with health-care professionals for 10 years. The nurse commended this family by telling them that she believed they were the best family for this boy because many other families would not have been as sensitive to his needs and probably would have given up years ago. Both parents became tearful and said that this was the first positive statement made to them as parents in many years.
By commending a family’s competence, resilience, and strengths and offering them a new opinion or view of themselves, a context for change is created that allows families to then discover their own solutions to problems and enhance healing. Box 4-1 suggests helpful hints for offering commendations. Further discussion about commendations can found in Chapter 9.
Box 4-1 Helpful Hints for Offering Commendations
• Be a “family strengths” detective and look for opportunities to commend families when strengths are discovered and uncovered.
• Ensure that sufficient evidence for the commendation is present; otherwise it may sound insincere and overly ingratiating.
• Use the family’s language and integrate important family beliefs to strengthen the validity of the commendation.
• Offer commendations within the first 10 minutes of meeting with a family to enhance the practitioner-family relationship and to increase family receptivity to later ideas.
• Routinely include commendations to families at the end of an interaction or meeting and before offering an opinion.
From Levac, A. M. C., Wright, L. M., & Leahey, M. (2002). Children and families: Models for assessment and intervention. In J. Fox (Ed.), Primary health care of infants, children, and adolescents (2nd ed.). St. Louis, MO: Mosby, p. 13. Reprinted by permission.
Offering Information and Opinions
The offering of information and opinions from health-care professionals is one of the most significant needs for families experiencing illness, especially if the illness is complex.
Adams, Mannix, and Harrington (2017) conducted a literature review on nurses’ perceptions of their role when communicating with families in adult intensive care units (ICUs). This review found that intensive care nurses wanted to help families to understand a broader picture of their patients’ situations and prioritized their role as interpreters of information and plans while also having an active role in providing information to families.
Example: Families with young children
Nurses working with families with young children often provide important information to parents about the following:
• Child’s current health situation
• Treatment plans, medications, diagnostic screening
• Health education and promotion
• Physiological, emotional, and cognitive development
• Developmental milestones
In this example, the information provided by the nurse can influence the way in which the parents may think about or understand a situation and in turn impact decisions.
Example: Families with a chronic or acute illness
Families with a chronic or acute illness often identify that obtaining information is a high priority. Many families have expressed to us their frustration at their inability to readily obtain information or opinions from health-care professionals. Nurses can offer information about the impact of chronic or life-shortening illnesses on families.
Example: Families with complex health issues
A family of two aging parents who are the caregivers of their 34-year-old son, who has severe multiple sclerosis, has not had any respite for several months. The nurse asked the son if he would be willing to challenge his beliefs about his “helplessness.” The nurse asked him to take the leadership role in exploring possible resources for caregivers so that his parents could have a vacation. Because of his search, the son discovered that he was eligible for many financial benefits of which he had previously been unaware, including benefits to hire professional caregivers. Shortly afterward, the son arranged for 24-hour in-home nursing care when his parents took a vacation. His parents reported that they felt much less stressed and that their son was much happier. He began making efforts to walk using parallel bars, which he had not done in several months.
In this example, the nurse was able to empower the son to change his thinking about his current situation. The intervention fit the cognitive domain, and results took place in the affective and behavioral domains of family functioning.
In all of these examples, nurses are able to empower families to obtain information and resources that impact health outcomes. Box 4-2 suggests helpful hints for offering information and opinions.
Box 4-2 Helpful Hints for Offering Information and Opinions
• Use language that is relevant, clear, and specific.
• Provide easy-to-read literature; write out key points on a small card.
• Inform families of community support groups and resources. Determine if these resources have been helpful to families who have used them and how they were helpful.
• Build on family abilities by encouraging family members to independently seek resources. Inquire about the family’s reaction after seeking resources.
• Offer ideas, information, and reflections in a spirit of learning and wondering (e.g., “I wonder what would happen if you tried a slightly different approach to talking with Manisha about sex and birth control. Perhaps you might …”).
• Do not be invested in the outcome. If the family does not apply the teaching materials, be curious about what did not fit for them rather than becoming judgmental and angry with them.
From Levac, A. M. C., Wright, L. M., & Leahey, M. (2002). Children and families: Models for assessment and intervention. In J. Fox (Ed.), Primary health care of infants, children, and adolescents (2nd ed.). St. Louis, MO: Mosby, p. 13. Reprinted by permission.
INTERVENTIONS TO CHANGE THE AFFECTIVE DOMAIN OF FAMILY FUNCTIONING
Interventions aimed at the affective domain of family functioning are designed to reduce or increase intense emotions that may be blocking families’ problem-solving efforts. The following interventions are examples of ways to change the affective domain of family functioning.
KEY CONCEPT DEFINED
Affective Domain of Family Functioning
Interventions used in the Calgary Family Intervention Model (CFIM) that reduce or increase intense emotions that may be blocking families’ problem-solving efforts.
Validating, Acknowledging, or Normalizing Emotional Responses
Validation or acknowledgment of intense affect can reduce or cushion feelings of isolation and loneliness, ease suffering, and help family members to make the connection between a family member’s illness and their emotional response (Wright, 2008).
Example: Diagnosis of a life-shortening illness
Families frequently feel out of control or frightened for a period of time after learning of this kind of diagnosis. It is important for nurses to acknowledge these strong emotions and to reassure and offer hope to families that, in time, they can adjust and learn new ways to cope. A nurse may say: “Feeling overwhelmed and frightened is common because there can be a lot of emotions and feelings of uncertainty at this time. Let’s talk about some of the changes that are occurring and strategies that might help you cope.”
Encouraging the Telling of Illness Narratives
Too often, family members are encouraged to tell only the medical story or narrative of their illness rather than the story of their own unique experience of their illness, or illness narrative. However, when nurses encourage family members to tell their illness narratives, not only are stories of sickness and suffering told but also stories of strength and tenacity (Wright & Bell, 2009). Through therapeutic conversations, nurses can create a trusting environment for open expression of family members’ fears, anger, and sadness about their illness experience (Sigurdardottir et al, 2013; Svavarsdottir & Sigurdardottir, 2013; Wright & Bell, 2009).
KEY CONCEPT DEFINED
Illness Narrative
An individual’s story of his or her own unique experience of illness.
These conversations are particularly important for complex family types involving multiple parents and siblings. Having an opportunity to express the illness’s impact on the family and the influence of the family on the illness from each family member’s perspective validates their experiences.
Listening to, witnessing, and documenting illness stories can also have a profound impact on the nurse. This approach is very different from limiting or constraining family stories to symptoms, medication use, and physical treatments. By providing a context for family members to share the illness experience, nurses allow intense emotions to be legitimized.
Drawing Forth Family Support
Nurses can enhance family functioning in the affective domain by encouraging and helping family members to listen to each other’s concerns and feelings. This technique can be particularly useful because talking can be healing. By fostering opportunities for family members to express feelings about a painful or positive experience, the nurse can enable them to draw forth their own strengths and resources to support one another. The nurse can be the catalyst that facilitates communication between family members or between the family and other health-care professionals. This type of family support can prevent families from becoming unduly burdened or defeated by an illness. Intervening in this manner is especially important in primary health-care settings.
INTERVENTIONS TO CHANGE THE BEHAVIORAL DOMAIN OF FAMILY FUNCTIONING
Interventions directed at the behavioral domain help family members to interact with and behave differently in relation to one another. This change is most often accomplished by inviting some or all the family members to engage in specific behavioral tasks. Some tasks are given during a family meeting so that the nurse can observe the interaction; other tasks or homework assignments are given for family members to complete between interactions. In some cases, the nurse must review with the family the details of the particular task or experiment in order to verify that the family understands what has been suggested. The following interventions are examples of ways to change the behavioral domain of family functioning.
KEY CONCEPT DEFINED
Behavioral Domain of Family Functioning
Interventions used in the Calgary Family Intervention Model (CFIM) that help family members interact with and behave differently in relation to one another and are most often accomplished by inviting some or all of the family members to engage in specific behavioral tasks.
Encouraging Family Members to Be Caregivers and Offering Caregiver Support
Family members are often timid or afraid to become involved in the care of their ill family member unless a nurse supports them. However, in our experience, we have found that family members greatly appreciate opportunities to help their hospitalized family member. They report that it makes them feel less helpless, anxious, and out of control. Of course, family caregivers are also susceptible to the well-known phenomenon of caregiver burden. Health professionals must be alert to the risks involved in family caregiving and be willing to intervene when necessary by offering caregiver support, which means providing the necessary information, advocacy, and support to facilitate patient care by people other than health-care professionals (Barbabella et al, 2016; Blanton, Dunbar & Clark, 2018; Ducharme, 2011). In a study about grandparents’ experience of childhood cancer in their grandchildren, grandparents revealed their often unattended and unacknowledged role of both providing and needing support (Moules et al, 2012). Therefore, these authors recommended that an inquiry regarding the resources and support needs of grandparents is essential for optimal family care. We encourage nurses to weigh with family members the ethical, emotional, and physical balance between too much caregiving and not enough caregiving.
Encouraging Respite
Family caregivers commonly do not allow themselves adequate respite. Too frequently, family members feel guilty if they need or want to withdraw themselves from the caregiving role. This is especially true of female caregivers. Even the ill member must occasionally disengage himself or herself from the usual caregiving and reject another person’s assistance. Each family’s need for respite varies. Factors affecting respite include the severity of the chronic illness, availability of family members to care for the ill person, and financial resources. All of these issues must be considered before a nurse can recommend a respite schedule. Caregiving, coping, and caring for one’s own health need to be balanced.
Examples: The following examples of “time-outs” or “times away” can be essential for families facing excessive caregiving demands:
• A family could buy a less expensive prosthesis and use the extra money for a family vacation.
• A couple with a child with leukemia have the grandparents babysit for a day while the couple spends time together.
• A postpartum mother is extremely exhausted and has her partner take their newborn to a close friend’s house to allow her to rest.
Devising Rituals
Families engage in many types of rituals: daily (e.g., bedtime reading), yearly (e.g., vacation), and cultural (e.g., festivals, celebrations). Roberts (2003) defines rituals as
co-evolved symbolic acts that include not only the ceremonial aspects of the actual presentation of the ritual, but the process of preparing for it as well. It may or may not include words, but does have both open and closed parts which are “held” together by a guiding metaphor. Repetition can be a part of rituals through the content, the form, or the occasion. There should be enough space in therapeutic rituals for the incorporation of multiple meanings by various family members and clinicians, as well as a variety of levels of participation. (p. 9)
The findings of Smith et al (2017) suggest that structure provided through family routines and family rituals creates meaning within the family and can support family health. Santos, Crespo, Canavarro, Alderfer, and Kazak (2016) explored family rituals in relation to financial burden and mothers’ adjustment in pediatric cancer cases. They concluded that the relationship between financial burden and anxiety symptoms was buffered for mothers who reported high levels of family ritual meaning during their children’s cancer treatments and within 5 years after the end of treatment. In our clinical practice, we have observed that chronic illness and psychosocial problems frequently interrupt the usual rituals and routines a family may have. Nurses may want to suggest therapeutic rituals that are not or have not been observed by the family as an intervention to influence the behaviors.
Example: Parents in a new blended family who cannot agree on parenting practices commonly give conflicting messages to their families. This can result in chaos and confusion for their children. The introduction of an odd-day/even-day ritual (Selvini-Palazzoli et al, 1978) can typically assist the family. The mother could experiment with being responsible for the children on Mondays, Wednesdays, and Fridays and the father on Tuesdays, Thursdays, and Saturdays. On Sundays, they could behave spontaneously. On their “days off,” parents could be asked to observe, without comment, their partner’s parenting.
CLINICAL EXAMPLES
The following clinical examples illustrate the use of the CFIM. These examples of interventions were chosen to facilitate change in all three domains (cognitive, affective, and behavioral) of family functioning. Remember, it is not always necessary or efficient to try to “fit” interventions to all three domains of family functioning simultaneously. Whether this can be done successfully depends on how well the family is engaged and on prior assessment of the nature of the illness, problems, or concerns.
Clinical Example 1: Difficulty Putting 3-Year-Old Child to Bed
To illustrate a specific family intervention aimed at all three domains of family functioning, consider a parenting problem commonly presented to community health nurses (CHNs): parents having difficulty putting their young children to bed each night. The parents’ efforts are generally met with annoyance from the child, then anger, and then tears. In their efforts, the parents also become frustrated and commonly end up angry with each other and with their child. The family intervention offered was in the form of information and opinions. In describing this case example, we will also discuss executive skills the nurse can use to operationalize the intervention. These skills are also outlined in Chapter 5.
Parent-Child System Problem
Parents’ chronic inability to get their 3-year-old to go to bed and stay there at required time. See Table 4-2 for parent-child interventions.
Clinical Example 2: Elderly Father Complains His Children Do Not Visit Often Enough
This example demonstrates the intervention of encouraging family members to be caregivers and offering caregiver support. This intervention entails inviting family members to be involved in the emotional and physical care of the patient and offering support. Again, the accompanying executive skills to operationalize the interventions are given.
TABLE 4-2 Interventions
DOMAINS OF FAMILY FUNCTIONING INTERVENTIONS: OFFERING INFORMATION AND OPINIONS
Cognitive ■ Offer information, such as a parenting book that explains what bedtime means to children with suggestions on how to put children to bed.
Affective ■ Discuss with the parents the importance of admitting their frustrations to each other, especially if one spouse made an effort to put the child to bed but was not successful.
■ The other parent may give emotional support (e.g., “You tried really hard; he was being very difficult”).
Behavioral ■ Teach the parents that, when they put their son to bed, they should not respond to his efforts to gain attention (e.g., asking for a glass of water). Rather, parents should be sure that these needs have been attended to as part of his bedtime rituals.
■ Discuss with parents that, before they can change their child’s behavior of leaving his bed or continually calling them to his bedroom, his behavior will worsen for a few nights while he makes greater efforts to get his parents to respond. If the parents continue in a matter-of-fact way to put him back in his room and respond “no” to any further requests, his behavior should improve dramatically in a few nights.
Parent-Child System Problem
Elderly father wants his adult children to visit him more often. The adult children do not enjoy visiting their father at the long-term care center because he always complains that they do not visit often enough. See Table 4-3 for parent-child interventions.
It is important to note that in the examples provided, many other interventions and executive skills could have been offered. There is no one “right” intervention, only “useful” or “effective” interventions. How useful or effective an intervention is can be evaluated only after it has been implemented. The element of time must be taken into account. With some interventions, the change or outcome may be noted immediately. However, in many cases, changes (outcomes) are not noticed for a long time. Most problems do not occur overnight; therefore, their resolutions also require reasonable lengths of time.
Clinical Example 3: Enuresis and Discipline Problems With a Child
To illustrate that change is observed over time, we now offer two more actual case examples, from beginning to end, with the emphasis on the interventions that were used.
TABLE 4-3 Interventions
DOMAINS OF FAMILY FUNCTIONING INTERVENTIONS: ENCOURAGING FAMILY MEMBERS TO BE CAREGIVERS AND OFFERING CAREGIVER SUPPORT
Cognitive ■ Discuss with the adult children that their father may have difficulty remembering their visits (short-term memory deficits), a normal change associated with aging.
Affective ■ Empathize with the father by saying that you understand that it must be lonely at times being a resident in a long-term care center. The adult children might appreciate knowing that their parent is lonely so that they can respond appropriately.
■ Encourage the father to let his children know how lonely he feels at times and that he is happy that they come to visit rather than complaining to the children that they do not visit often enough.
Behavioral ■ Encourage the adult children to stop giving excuses for why they cannot visit more often. Instead, obtain a guest book or calendar and write down each visit. Write down who visited, on what day, and perhaps any interesting news so that the aging parent may read this between visits.
A family was referred to one of our graduate nursing students with the complex presenting problems of enuresis and disciplinary problems at school in the elder child, an 8-year-old boy. The family was composed of the father, age 28, self-employed; the stepmother, age 21, homemaker; and two sons, ages 8 and 6. The couple had been married for approximately 1 year. The family was seen (both as a whole family and in various subsystems) for six sessions over 13 weeks from initial contact to termination. A thorough family assessment (using the CFAM model) revealed problems in the whole family system, in the parent-child subsystem, and at the individual level.
Whole-Family System Problem
Adjustment to Being a Stepfamily
When the couple married, a new family was formed, and all family members had to adjust to a new family structure.
After being married for only a short time, the stepmother found herself thrust into a parenting role when she and her husband became responsible for his two children. The birth mother had deserted the children after living with them for 2 years in her home. The children had to adjust to a new set of parents, new surroundings, and no contact with their biological mother. See Table 4-4 for family interventions.
Providing information about the adjustment process seemed to relieve the parents a great deal. Initially, the parents were hesitant about the children having contact with the biological mother, but they later stated that they understood this contact was important for the children. The eldest child’s enuresis was conceptualized as a response to the adjustment to a stepfamily and the loss of his mother. This new opinion, also directed at the cognitive domain of family functioning, had a very positive effect on the family. The enuresis improved dramatically over the course of treatment.
TABLE 4-4 Interventions
DOMAINS OF FAMILY FUNCTIONING INTERVENTIONS: OFFERING INFORMATION AND OPINIONS
Cognitive ■ Acknowledge that the problems the family members are experiencing are a usual part of the adjustment process of stepfamilies and provide them information about the adjustment process.
Behavioral ■ Encourage the parents to allow the children to have contact with their biological mother when she again seeks them out.
Parent-Child Subsystem Problem
Maladaptive Interactional Pattern Between Stepmother and Eldest Son (see Figure 4-4) Because of the initial experience of the loss of their father (as a result of the biological parents’ divorce) and then the abandonment by their biological mother, the children, particularly the elder child, feared being abandoned again. Thus, the elder child, hoping to be reassured that he would not be abandoned again, frequently reminded his young stepmother that she was not his real mother.
Initially, the stepmother made efforts to reassure him, but she eventually withdrew in frustration and felt rejected. This encouraged the child to maintain the maladaptive interactional pattern because he perceived this withdrawal as further evidence that he would again be abandoned. The vicious cycle was evident.
In deciding which interventions to offer the family, the graduate nursing student was at first overwhelmed by the complexity of their situation. Then she considered which area had the most leverage for change. See Table 4-5 for parental interventions.
The stepmother reported that when she offered more reassurance to the boy, he stopped rejecting her. With decreased rejection, the stepmother was able to offer even more reassurance. Thus, a virtuous cycle began.
Individual Problem
Elder Child’s Behavioral Problems at School
To further assess this behavioral problem, the graduate nursing student met with the child’s teacher at school and also discussed the problem twice with the teacher by telephone. The stepmother was also present during the session at school.

Figure 4-4 Circular pattern diagram.
TABLE 4-5 Interventions
DOMAINS OF FAMILY FUNCTIONING INTERVENTIONS: PROVIDING PARENT SUPPORT AND EDUCATION
Cognitive ■ Encourage the stepmother to stop withdrawing and to offer the child continual and sustained reassurance by stating; “I know I am not your mother, but your father and I love and care for you and want to look after you. We will not leave you.”
■ Provide commendations of family strengths to the stepmother for her efforts to fulfill her role.
Affective ■ Encourage the stepmother to stop withdrawing and to offer the child continual and sustained reassurance by stating: “I know I am not your mother, but your father and I love and care for you and want to look after you. We will not leave you.”
Behavioral ■ Encourage the stepmother to stop withdrawing and to offer the child continual and sustained reassurance by stating: “I know I am not your mother, but your father and I love and care for you and want to look after you. We will not leave you.”
The main objective of the interventions was to enhance the elder child’s self-esteem by focusing on his positive behavior. See Table 4-6 for interventions.
On termination with this family, the graduate student recommended to the parents some readings on stepfamilies and informed them of a self-help group for stepfamilies. These two interventions of offering ideas and opinions in books and providing information on community resources were targeted at all three domains of family functioning: cognitive, affective, and behavioral.
TABLE 4-6 Interventions
DOMAINS OF FAMILY FUNCTIONING INTERVENTION: ENHANCE ELDEST CHILD’S SELF-ESTEEM
Behavioral ■ Encourage the teacher to acknowledge the child’s positive behavior in front of his classmates to give him a different status than “class clown.”
■ Recommend that the stepmother minimize her contact with the school and allow the teacher to assume more responsibility for the boy’s behavior in class.
It might seem that the interventions the graduate student chose in this example were “simple.” However, in many cases, nurses either try to use overly complex interventions to address issues or they have difficulty collaborating with the family to determine areas with leverage for change. In both cases, nurses commonly become frustrated and immobilized by the complexity of the family situation. A thorough exploration of the presenting issue and then an offering of interventions designed to ameliorate that problem generally works best to foster change.
Clinical Example 4: Social Isolation and Physical Complaints of Elderly Woman
During one of our undergraduate nursing students’ field placement in a community-health facility, she encountered a family whose presenting problems were social isolation and frequent physical complaints from the 78-year-old widowed mother. The widow lived in a government-subsidized, one-bedroom apartment. She had six adult children (sons ages 51, 48, 41, 37, and 35 years and a daughter, age 44 years) and 12 grandchildren. Five of the children were married, and all six lived in the same city as their mother. The family was seen as a whole and in various subsystems for eight home visits over a period of 2 months. After a thorough family assessment (using the CFAM model) and individual assessments, the following core problem was identified.
Whole-Family System Problem
The Mother’s Lack of Social Contact Beyond Her Immediate Family.
It became apparent that this older woman was overly dependent on her adult children and, therefore, did not make an effort to be involved with her peers or in social activities appropriate to her age group. This resulted in frequent disagreements between the mother and the children over the frequency of visits with the mother.
The problem was further exacerbated by the fact that the mother had no friends. After the death of her husband, approximately 10 years earlier, she had lived intermittently with some of her children but had been living alone for the past 4 years. At the time of intervention, the youngest son visited most often and did the mother’s grocery shopping.
The nursing student’s first significant intervention was to broaden the context in order to expand her view and understanding of this family’s concerns. Thus, the student initially interviewed the mother alone and then interviewed her with her youngest son (the adult child who visited most frequently). Then the student took on the ambitious task of arranging an interview with the mother and her six children. This was a significant effort on the student’s part to create a context for change by obtaining each family member’s view of the problem. In the interview with the mother and her youngest son, the mother agreed to contact the children. However, when the student followed up with the mother, the mother said that she had not called any of her children because she expected her youngest son to do it. This was further evidence of the mother’s overdependence on her children. Because the youngest son was anxious to have the meeting take place, he had taken on the task of inviting all of his siblings to an interview with his mother and the nursing student.
At the family interview, all of the siblings were present, and two of their spouses attended as well. Interestingly, the daughters-in-law were more vocal than their husbands and stated that they were very involved with their mother-in-law. In this large family interview, the mother’s social isolation (apart from her family) was discussed. Through the process of circular questioning, the expectations for family contact of both the mother and children were assessed. Initially, the student encouraged the family to explore solutions to their mother’s lack of social activities and peer interactions (an intervention aimed at the behavioral domain of family functioning). To this intervention, the family responded that they had no ideas beyond what they had already tried. Therefore, the student suggested more specific interventions in an attempt to uncover solutions to the mother’s social isolation.
This interview revealed that the woman had always relied on her children for her main social interaction. She had never been a “joiner.” In the past few years, she had even discontinued her attendance at church. Throughout her life, she had few close friends. The assessment also revealed that, collectively, the children had generally been supportive of their mother. Each week, she had lunch with one or more of them. They included her in all special family occasions. However, the children always had to initiate contact. They were genuinely concerned about their mother’s loneliness and lack of additional social contact but had exhausted their ideas for changing her situation.
One of the first interventions the nursing student attempted was directed at both the cognitive and behavioral domains of family functioning: offering information regarding community resources that are available to older people. Specifically, the student made the family aware of the Community Services Visitor Program. The mother agreed to contact this program, and the children agreed to provide support. The mother also expressed interest in becoming involved in a choir again. The student offered to accompany her to a senior citizens’ choir practice and introduce her to other participants.
The final major intervention discussed in that family session was directed at the behavioral domain. The student nurse asked the mother if she would initiate contact with one of her children during the next week. After the contact, the child would ask the mother to come for a visit as soon as possible. This intervention was important because the interest of family members in an older parent’s activities typically increases the parent’s motivation. It is important to emphasize that the mother was involved in and receptive to these interventions.
The effects and outcomes of these interventions were as follows:
• The mother followed through on contacting the Community Services Visitor Program. The coordinator of the program then contacted the mother and arranged for a regular visitor.
• The student nurse accompanied the mother to the senior citizens’ choir. The older woman enjoyed the experience and telephoned two of the other women in the choir afterward!
• The mother took the initiative to contact a couple of her children, and they, in turn, invited her for a family visit, which she accepted. The children reported that they enjoyed having their mother call them, and this new dynamic appeared to increase their own desire to have more frequent contact with her.
In subsequent interviews, the student nurse encouraged the mother to reconnect with her church. The student also solicited the support of the children in this endeavor by requesting that they take an interest in and inquire about their mother’s church and choir activities when they called her.
Because this mother was accustomed to a good deal of family support, it was not appropriate to remove that support totally. However, physical instrumental support (i.e., doing things for the mother) was reduced without the mother feeling abandoned. Verbal (emotional) support for the mother’s attempts at independence was most appropriate. When the mother began to increase her social contacts and activities, her nonspecific physical complaints decreased.
The student concluded treatment with this woman in a face-to-face interview. To involve the children in the termination process, the student sent a therapeutic letter to each of them. The letter highlights the major interventions and solicits further assistance from the children and includes some of the family strengths.
Dear …:
I wish to thank you for your help and cooperation in my family assignment. I enjoyed meeting each of you and appreciated your individual input and assessment of your family. Your willingness to work together is certainly an excellent family strength.
I visited your mother on several occasions during my time with the Outreach Program. She continued to express her desire to be more socially independent. She has been able to make some increased community contact. She attended the choir and several of the choir ladies have called her to encourage her in continued participation. She met with the gentleman from the church and spoke with his wife. The coordinator of the visitor program visited; she is arranging for a friend who will visit with your mother. Hopefully, they will develop some outside interests together. She has also been out to shop on her own on a few occasions.
I did contact Kerby Centre, as well as other seniors from Carter Place who go there, but was unable to find anyone going to the Wednesday lunch or any other suitable transportation. I have discussed this with your mother and she felt it might be something she could pursue on her own in the future.
Your mother expressed positive feelings about her attempts to be more socially active. However, she still looks to her children for her main support. At times, I found she needed more encouragement not to overly worry about her health to the point that she thinks she is unable to participate in any activities. I believe that each of you may help your mother by encouraging her in this area. I might suggest that if she says that she is unwell that she see her doctor. If there is no serious problem, gentle support for her independent activities might be helpful. This may be somewhat difficult at first, but if you are able to present a united front to your mother and support each other in a mutual approach to her being more socially active, she may be more able to accomplish this.
I am very impressed with the cohesiveness of your family and the continued concern and support you show toward your mother. Thank you very much again for letting me work with you.
Yours truly,
Leslie Henderson
Undergraduate Nursing Student
Faculty of Nursing, University of Calgary
This therapeutic letter sent by the student is an intervention in and of itself (Bell, Moules, & Wright, 2009; Moules, 2009; Wright & Bell, 2009). Several interventions were outlined in the letter, and these interventions were aimed at all three areas of family functioning. Specifically, the student offered commendations and opinions directed at the cognitive domain of functioning. She invited the adult children to encourage their mother, which aimed at changes in the behavioral domain. By summarizing the clinical work with the family in the form of a therapeutic letter, the student intended to effect changes in both the affective and cognitive domains of family functioning. This clinical example demonstrates how to effectively involve families in health care by the use of family assessment and intervention models with clear treatment goals.
CASE SCENARIO: HARVEY JOHNSON
Harvey Johnson is an 85-year-old male who lives alone in his own home. His wife of 65 years, Patricia, recently was moved into a long-term care facility after she was diagnosed with Alzheimer disease, and Harvey was no longer able to care for her at home. Patricia’s memory has declined rapidly, and she no longer remembers who Harvey is or where she is. Harvey and Patricia’s four children live 30 minutes away and have families of their own. They visit Harvey regularly but have recently been concerned about how their father is coping at home alone. Their oldest son has requested that a home-care nurse visit Harvey at home. During an initial phone conversation with the son, the home-care nurse was able to find out that Harvey and Patricia had never spent a night apart until Patricia moved to the long-term care facility. They were devoted to each other and mostly kept to themselves. They were like “teenagers in love” even after 65 years of marriage. Their son stated that Harvey has become increasingly irritable, appears very tired, and has lost weight since Patricia was moved to long-term care.
When the home-care nurse arrives at Harvey’s home, there are dishes piled in the kitchen sink and newspapers piled on the kitchen table, and the temperature is very cold in the home. The home-care nurse asks Harvey about how he is coping, and he states: “It doesn’t matter anymore how I am. Patricia doesn’t remember who I am, and the kids are so busy with their own families. What is the point?”
Reflective Questions

1. What are three linear questions and three circular questions the nurse could ask Harvey to gain further understanding of the family’s concerns?
2. Identify a potential intervention and expected outcome aimed at each domain of family functioning.
3. How can the nurse involve Harvey’s children in the development and implementation of the interventions?
   CRITICAL THINKING QUESTIONS
4. Reflect on an interaction you had with a family:
   a. How did you use intervention questions?
   b. What linear questions did you ask?
   c. What circular questions did you ask?
5. Consider your own clinical practice to answer the following question:
   a. What interventions do you implement to direct change at the cognitive, affective, and behavioral domains of family functioning?

Chapter 7
How to Conduct Family Interviews
Learning Objectives
• Summarize the guidelines for each stage of an initial family interview.
• Explain strategies used to engage and establish a therapeutic relationship with a family.
• Describe various types of questions used during the assessment phase to identify the problem, explore the relationship between family interaction and the health problem, and explore the attempted solutions for solving problems and achieving family goals.
• Discuss how to plan and deal with complexity during a family assessment.
• Identify factors to consider when deciding to intervene with a family.
Key Concepts
Assessment stage
Engagement stage
Intervention stage
Miracle question
Termination stage
Once a nurse and a family have decided to meet, the nurse can begin to consider how to conduct the meeting. Just as there is an interviewing procedure, there is also a process in initial family interviews. This process provides the nurse with an interview structure and can help to allay the nurse’s anxiety. It is not uncommon to move back and forth between the stages of a family interview to obtain more clarity or additional assessment information about the concerns. Sometimes it is even necessary to return to the engagement guidelines to strengthen the therapeutic relationship before further intervention ideas can be offered. Thus, there should be fluidity between these stages so that they remain true guidelines rather than a rigid prescription for how to conduct a family interview.
GUIDELINES FOR FAMILY INTERVIEWS
The stages that generally occur in initial interviews are briefly presented in Table 7-1 and discussed in detail in the following subsections.
KEY CONCEPT DEFINED
Engagement Stage
The stage during the family interview in which the family is greeted and made comfortable and the relationship continues; based on compassion, collaboration, and consultation.
TABLE 7-1 Stages of Initial Interviews
STAGE OBJECTIVES
Engagement The family is greeted and made comfortable, and the relationship continues.
Assessment Problem identification—the nurse explores the family’s presenting concerns and/or suffering.
Relationship between family interaction and health problem—the nurse explores the family’s typical responses to the health problem and how the health problem is affecting their family life and relationships.
Attempted solutions—the family and nurse talk about the solutions the family has tried and their effects on the presenting issues.
Goal exploration—the nurse draws together the information, and the family members specify what goals, changes, or outcomes they are seeking. (Note: if family members are suffering from the impact of an illness, it is also important to clarify if they desire an alleviation or easing of their suffering in the emotional, physical, and/or spiritual domains).
Intervention The nurse and family collaborate on areas for desired change.
Termination The nurse and family conclude the interview.
Engagement Stage
During the engagement stage, or first stage of the interview, the nurse and the family begin to establish a therapeutic relationship. The goal is for family members and the nurse to develop a mutual alliance so that they can collaborate on the desired changes (Box 7-1).
In the beginning, the nurse is often perceived as a stranger, unknown, untrusted, and potentially helpful or unhelpful. Because family members do not know what to expect from the nurse, the nurse must establish a relationship with the members by demonstrating understanding, competence, and caring (Box 7-2). Family nursing is relational nursing practice, acknowledging the expertise and knowledge of families.
We encourage nurses to consider the type of relationship that they would like to establish with families. Research in the area of health-care professionals establishing relationships with families is minimal. Thorne and Robinson (1989) have described various stages of the evolution of relationships between families experiencing chronic illness and their health-care professionals: naïve trust, disenchantment, and guarded alliance. They propose that naïve trust among the chronically ill, their families, and healthcare providers is inevitably shattered in the face of unmet expectations and conflicting perspectives. Anxiety, frustration, and confusion often result in disenchantment. Trust can then be reconstructed on a more guarded basis so that the chronically ill patient, the family, and the nurse can continue to engage in health-care activities. Wong, Liamputtong, Koch, and Rawson (2015) conducted a qualitative study about families’ experiences of their interactions with nurses in intensive care units. The findings indicated that nurses facilitating communication and interacting in supportive ways helped alleviate anxiety and distress among families with a critically ill member. Examples of nursing responses included providing reassurance, responding to nonverbal cues, and being open and honest.
Box 7-1 Purpose of Engagement
• Promote a positive nurse-family relationship by developing an atmosphere of comfort, mutual trust, and cooperation between the nurse and the family.
• Recognize that family members bring strengths and resources to this relationship that may have previously gone unnoticed by health-care professionals.
• Prevent potential nurse-family misunderstandings or problems later on in the therapeutic relationship.
Levac, A. M. C., Wright, L. M., & Leahey, M. (2002). Children and families: Models for assessment and intervention. In J. A. Fox (Ed.), Primary health care of infants, children, and adolescents (2nd ed., p. 11). St. Louis, MO: Mosby. Copyright 2002. Adapted with permission.
Reciprocal trust is a critical dimension to consider during the engagement phase of family interviewing. The nurse helps the patient and family to feel more confident in their own competence in managing illness. In order to develop a high degree of trust in the nurse, the patient and family are encouraged to explicitly state their expectations for health care. The nurse provides the opportunity for family members to express their desires. If the patient and family are to have a high degree of trust in their own competence, family members and health-care providers must acknowledge the family’s resources. This is further supported by a literature review conducted by Dinc and Gastmans (2013) that suggests that the development of trust is important in establishing a nurse-family relationship; it is a process during which trust can be broken or reestablished depending on the nurse’s competencies and interpersonal caring attributes (p. 501). Reeves and colleagues (2015) found that “family members noted that their experience on the intensive care unit was particularly positive when they felt they had a trusting relationship with the staff. Staff knowledge of patient’s history, frequent communication regarding the patient’s condition and informal communication with the family helped to facilitate this positive relationship” (p. 234).
Box 7-2 The ABCs of Engaging Families
A B C
• Assume an active, confident approach.
• Ask purposeful questions that draw forth family assessment data.
• Address all who are present, including small children.
• Adjust the conversation to children’s developmental stages. • Begin by providing structure to the meeting (time frame, orientation to the context).
• Behave in a curious manner, and take an equal interest in all family members, whether present or not.
• Build on family strengths by offering commendations to the family.
• Bring relevant resources to the meeting (list of agencies, phone numbers, pamphlets). • Create a context of mutual trust.
• Clarify expectations about your role with the family.
• Collaborate in decision making, health promotion, and health management.
• Cultivate a context of racial and ethnic sensitivity.
• Commend family members.
Levac, A. M. C., Wright, L. M., & Leahey, M. (2002). Children and families: Models for assessment and intervention. In J. A. Fox (Ed.), Primary health care of infants, children, and adolescents (2nd ed., p. 11). St. Louis, MO: Mosby. Copyright 2002. Adapted with permission.
One way of reminding ourselves not to fall into the trap of certainty, judgmentalness, and expertness on the family’s situation has been to develop a strong sense of curiosity. When initiating engagement, we assume a position of neutrality or curiosity. Cecchin (1987) draws connections between neutrality or curiosity and hypothesizing. He maintains that curiosity is a delight in the invention and discovery of multiple patterns. “Curiosity helps us to continue looking for different descriptions and explanations, even when we cannot immediately imagine the possibility of another one … hypothesizing is connected to curiosity. Hypothesizing has more to do with technique. Curiosity is a stance, whereas hypothesizing is what we do to try to maintain this stance” (p. 411). We believe that curiosity nurtures circularity and is useful in the development of hypotheses. We have found hypothesizing, circularity, and curiosity to be extremely important components of our clinical work.
We agree with Cecchin (1987), who states, “circular questioning can be understood as a method by which a clinician creates curiosity within the family system and therapy system” (p. 412). (See Chapters 2 and 3 for more information about circularity, and see Chapter 6 for additional ideas about hypothesizing.) By using hypothesizing, circularity, and curiosity, nurses become more open to families, and families, in turn, develop more reciprocal trust. The family perceives the nurse as inquisitive when he or she does not take sides with any one member or subgroup. Nurses who are inquisitive are seen as aligned with everyone and no one in particular at the same time. They are seen as nonjudgmental and accepting of everyone.
To enhance engagement, the nurse must provide structure, be active and empathic, and involve all members of the family. To provide structure, the nurse might say something such as, “We’ll meet now for about 10 minutes so that I can get a better sense of your expectations and any concerns you have about hospitalization. We can then talk about what I might be able to help you with. How does that sound to you?” By stating the structure at the beginning of the meeting, the nurse reduces the family’s anxiety about how long they will meet and also gives some direction for the conversation. Sundet’s (2011) findings that families found it helpful when the clinician asked questions, gave time, and structured the work further support this idea.
One way in which the nurse can be active during the engagement phase of the interview is to find out who is present. Many times, we have found that “extra” family members attend interviews in the hospital. Leahey, Stout, and Myrah (1991) found that of families invited to meetings on an inpatient mental health unit in a Canadian community hospital, 94% attended. Extra family members attending interviews held constant over a 7-year period. In many cases, family members of whom the nurse was unaware showed up for the family meeting. For example, extended family members or former spouses might have been invited by the patient or other family members who believed it was important for them to be present.
Some nurses have found it useful to start an interview by working with the family in constructing a genogram or ecomap (see Chapter 3). Duhamel and Campagna’s genograph (2000) is a particularly helpful educational tool that can assist nurses in drawing a genogram and determining what questions to ask. Families generally find that constructing a genogram is an easy way to involve themselves in giving the nurse relevant information. The genogram can be obtained reliably and accurately in a brief interview. Furthermore, genograms obtained by a health-care provider are likely to have more influence on care and health outcomes than those completed by the patient or health assistant and placed on file.
At the start of the interview, the nurse should ask questions of each member. This is particularly important for nurses working with families with adolescents. Engaging adolescents by asking what their favorite computer games or school subjects are and why, whether they play sports, what musical groups they like, and whether they have any special talents and hobbies can sometimes be useful. The purpose of these questions is to start establishing a shared habit (between the nurse and the young person) of discussion and banter about the young person’s opinions about personal aspects of his or her life. However, we do not recommend that this type of conversation go on for longer than 5 minutes because it seems easier for families to engage around the presenting problem than to chat in a general nature. We believe it is important for the nurse to create an environment where the client expects to get down to business, work on the hard issues, and make the necessary changes to improve family functioning in the context of illness, loss, or disability. Box 7-3 provides tips on dealing with verbose clients.
Box 7-3 Tips for Working With Verbose Clients
• Let the person tell his or her illness story or particular concern.
• Set the time frame at the beginning, such as, “We have 20 minutes to meet. What are the most important things that we need to discuss?”
• Say, “I know we only have time to skim the surface today in talking about your experiences, so what shall we focus on?”
• Explain, “I’m not connecting what you’re telling me with the reason you’ve come in today. Could you help me out on this, please?”
• Take a break to pull your thoughts together or to seek a consult.
• Stop the discussion and set limits, such as, “We can spend 10 minutes talking about the poor addiction services in our city and 10 minutes on what you said your goals were and how you’re addressing them. How does that sound as a plan for today?”
• Use humor and interrupt by saying something such as, “Seems like we could talk all day about this issue, but I’m mindful of the time.”
• Determine who is most interested in the client being seen if the client has been referred by another health professional: “The note from your physician indicated she wants you to have … Is this your understanding of why you are here today? Did you have another goal for our meeting?”
Nurses should initially attempt to spend an equal amount of time with each family member. We suggest that the nurse ask the same or a similar question of each member to gather each person’s ideas about a particular topic. We believe that when families answer questions, they are not retrieving particular experiences. Rather, in the conversation with the clinician, family members put forth their own storytelling of their unique experiences, suggest beginnings and endings for these experiences, and highlight portions of experiences while diminishing or excluding others.
If the engagement between the nurse and family does not proceed well or if a fit cannot be established, we recommend that the nurse stop and think about the relationship. We have found the following ideas about relationships with families helpful to keep in mind in our clinical practice:
• Both the health-care provider and patient and/or family members are experts. The patient is expert in the illness experience, and usually, but not always, the health-care provider is expert in the physiology of the disease process, illness management, and easing suffering.
• The health-care provider will try to facilitate change, but the ultimate agent of change is the patient/family.
• To construct a workable management plan, the patient/family and the health-care provider’s interpretation of the symptoms must both be acknowledged.
The engagement stage is also the phase of the interview in which a context for change is created that constitutes the central and enduring foundation of the therapeutic process (Bell & Wright, 2011; McLeod, Tapp, Moules & Campbell, 2010; Wright & Bell, 2009). Wright and Bell suggest that all obstacles for change need to be removed during this stage so that a full and meaningful nurse-family engagement may be made. Examples of obstacles to change in working with families include a family member who does not want to be present or who attends the meeting under duress, previous negative experiences with health-care professionals, and unrealistic or unknown expectations of the referring person about treatment.
Most central to this stage, however, is that the family members should feel that the nurse is willing to listen and witness their voices, to “do hope,” as Weingarten (2000) calls it. But hope does not reside within one individual; it is not solitary. Hope is something we do with others. “It is the responsibility of those who love you to do hope with you” (Weingarten, 2000, p. 402). One study sought to understand couples’ experiences in nurse-initiated health-promoting conversations about hope and suffering during home-based palliative care. It was revealed that couples found these conversations with nurses to be a healing experience that also enabled them to learn and find new ways for managing daily life (Benzein & Saveman, 2008). Ward and Wampler (2010) suggest distinguishing categories of hope on a continuum from lost hope to ambivalent/low hope to solid hope. Parents of children suffering from cancer found that when health-care professionals went above and beyond in the care they provided, it increased the parents’ connection to the health-care providers and strengthened the parents’ hope for their children (Conway, Pantaleao, & Popp, 2017). This type of connection is considered essential if families are to experience comfort and hope (Angström-Brännström, Norberg, Strandberg, Söderberg, & Dahlqvist, 2010).
We find this notion useful in our clinical work. Especially during the engagement phase, nurses should follow the clients’ lead, listening for and adopting their language, worldview, goals, and ideas about the problem and legitimizing their illness experiences to foster a trusting relationship nested in hope. We encourage nurses to get to know their clients outside of the influence of the problem and connect with them in their lives. For example, a nurse could appreciate the lived experiences of a family’s past hardships (death, loss, illness, divorce, immigration, war, and other difficulties) and could wonder how this stamina might now serve the family as they stand together against illness.
Assessment Stage
During the assessment stage, the nurse and family explore four areas:
• Problem identification
• Relationship between family interaction and the health problem
• Attempted solutions to solving problems
• Goals
KEY CONCEPT DEFINED
Assessment Stage
A stage during the family interview when problem identification and exploration occurs, including delineation of strengths; an ongoing process.
Problem Identification: Exploration and Definition
During this phase of the family interview, the nurse asks family members about their main concerns, complaints, or suffering. The nurse could ask, for example, “What is the concern that each family member would most like to see addressed or changed?” A focus on change and expectation for something to happen is important for time-effective therapeutic meetings. Slive and Bobele (2011) have demonstrated this in their landmark work documenting single-session walk-in therapy. After exploring each family member’s perception of the most pressing concern (once adequate engagement has occurred), we have found it useful to ask the “why now?” question: “What made you decide to come in today?” We assume the family probably consulted others prior to meeting with the nurse and are curious about why, at this point in time, the client chose to seek help.
Another useful question is the “one-question question” suggested by Wright (1989): “If you could have only one question answered during our work together, what would that one question be?” (For more information about the one-question question, see Chapter 8.)
It is important to emphasize that an effective interview does not depend on the use of one type of question but on the knowledge of when, how, and to what purpose questions are used with particular family members at particular points in time. (For more information on various types of questions, see Chapters 4 and 8.)
Table 7-2 gives examples from Leahey and Wright (1987) of how to elicit the family’s concerns by asking circular questions that focus on the present, past, and future.
TABLE 7-2 Circular Questions to Elicit a Family’s Concerns
PRESENT PAST FUTURE
■ What is the family’s main concern now about Shaheena’s cyberbullying?
■ How is this concern a problem for the family now as compared with before?
■ Who agrees with you that this is a problem? Is this a problem that Mom believes she has control over?
■ What is your explanation for this? ■ Differences: How was Shaheena’s behavior before her cyberbullying was noticed?
■ Agreement or disagreement: Who agrees with Dad that this was the main concern when the family lived in Uganda?
■ Explanation or meaning: What do you think was the significance of Shaheena’s decision to stop using the family computer for her messaging? ■ If Rahim suddenly developed renal disease, how would things be different from the way they are now?
■ Does Rahim agree with you?
■ If this were to happen, how would you explain the change in Shaheena’s relationship with Mom?
Leahey, M., & Wright, L. M. (1987). Families and chronic illness: Assumptions, assessment and intervention. In L. M. Wright & M. Leahey (Eds.), Families and chronic illness (pp. 55–76). Springhouse, PA: Springhouse Corp.
One thing to consider is that children or adolescents may be reluctant to identify concerns in the family, and the nurse may need to ask the children alternative questions. Children may hesitate to disagree with their parents’ description of the situation. A nurse can ask a child what he or she would like to see different in the family or how he or she would know if the problems went away. For example, one 8-year-old, Brian, repeatedly stated that there were no difficulties surrounding his brother’s diabetes and his mother’s intense involvement with the sick child. However, when the nurse asked a future-oriented question about what differences he would notice in the family if his brother did not have diabetes, Brian said that he and his mother could go to basketball games after school. At the time of the interview, the mother had stated she was hesitant to leave the house after the boys returned from school for fear that her older son, Ray, would have an insulin reaction.
Whatever strategy is used to engage young people in conversation, we recommend nurses be aware of the importance of inviting active thinking by children and adolescents versus the expectation of compliance with adult thinking. This is foundational to relational practice. Box 7-4 presents ideas for involving children and adolescents in family interviews.
In exploring the presenting concern, the nurse should obtain a clear and specific definition of the situation. We recommend that nurses pay attention only to the concern as defined by the family, setting aside their own definition of the problem. We believe it is helpful to coevolve a problem description using the family’s language and to initiate conversations about family members’ preferences. Table 7-3 lists some factors for the nurse to consider when defining the problem.
In our conversations with families, we try to remember that each family expresses its pain and suffering in a unique way. For example, nurses need to consider how culture, ethnicity, religion, gender, age, personal coping practices, life experiences, and education could all impact how individuals and families may express pain and suffering. When differences among family members exist, the nurse should clarify the issues further to help define the problem for which the family is seeking change. The nurse can also ask questions of each member about his or her own explanation for the current situation. It is important for nurses to attend to how clients talk about the concerns that prompted them to show up for a meeting. Box 7-5 provides questions the nurse could ask to bring a family focus to situations.
Wright and Bell (2009) believe that exploring the family’s illness beliefs in the first meeting and at times of crisis is particularly important. If the family members think that their beliefs or explanations about the illness are not acknowledged, they may feel marginalized. The nurse can ask them to explain, for example, why they believe this problem exists at this point in time. We believe it is also important to ask if the client and family have any control over the problem. The simplest way to do this is to ask direct, explanation-seeking questions such as,” What do you think is the reason for your son’s violence toward his peers? Do you think Sara has any control over the problem?”
Box 7-4 Ideas for Involving Children in Family Interviews
• Art techniques (drawing a family picture)
• Verbal techniques (“Columbo” strategy of taking a position of not knowing)
• Role-playing or make-believe
• Storytelling techniques to allow families to personify, reframe, and externalize problems
• Puppet and doll techniques to ask the family about interactions
• Video games
• Experiential techniques (family sculpture)
TABLE 7-3 Factors to Consider in Defining the Problem
PRESENTING PROBLEM PROBLEM IDENTIFICATION PROBLEM EVOLUTION
■ Specify ■ Who in the family was the first to identify the problem? And then who?
■ When was the problem identified?
■ What were the concurrent life events or stressors at the time of identification of the problem?
■ Who else (family members, friends) agrees that it is a problem? Who disagrees?
■ How does the family understand that this problem developed (beliefs)? ■ What behaviors became problematic?
■ Pattern of development
■ Frequency of problem emergence
■ Time intervals of quiescence
■ Factors aggravating
■ Factors alleviating
■ Who in the family is most and least concerned?
Adapted from Family Nursing Unit records, Faculty of Nursing, University of Calgary
Box 7-5 Questions to Bring Family Focus to the Situation
• Has anyone else in the family had this problem?
Rationale: Addresses family history.
• What do other family members believe caused the problem or could treat the problem?
Rationale: Explores the individual’s explanatory model and health beliefs.
• Who in the family is most concerned about the problem?
Rationale: Helps to understand the relational context of the concern.
• Along with your illness and symptoms, have there been any other recent changes in your family?
Rationale: Addresses family stress and change.
• How can your family be helpful to you in dealing with this problem?
Rationale: Focuses on family support.
Another idea is to ask clients to use their imagination to discuss an explanation. The interviewer can also offer a variety of alternative explanations or “gossip in the presence” by asking triadic questions such as, “William, what do you think is Zack’s explanation for your mother’s depression?” In exploring the family’s preexisting explanations, it is essential for the interviewer to be curious and to avoid agreeing or disagreeing with the explanation.
There are several advantages to exploring the family’s causal explanations, including improving cooperation between the interviewer and the family, developing systemic empathy with all family members versus selective empathy with one or two, detaching oneself from explanations provided by other professionals, recognizing and avoiding coalitions, loosening firmly held explanations, diluting negative explanations, and developing an ability to speculate with the clients about the effects of believing in one explanation or the other.
The problem-defining process, or “co-evolving the definition,” is a critical aspect of family work. Cecchin (1987) warns clinicians to accept neither their own nor the client’s definition too quickly, and Maturana and Varela (1992) caution clinicians to adopt an attitude of permanent vigilance against the temptation of certainty. By remaining curious, a clinician has a greater chance of escaping the “sin of certainty,” or the sin of being too invested in one’s own opinion. As clinicians, nurses need to avoid being preoccupied with their own brightness or ideas. Rather, each nurse should ask, “What does the client need from me? What are the client’s beliefs, thoughts, hunches, and theories about the problem? About the extent of their control over the problem? Their solutions?” We try to always “keep the problem on the table” as we engage with families.
Relationship Between Family Interaction and the Health Problem
Once the main problems have been identified, the nurse asks questions about the relationship of family interaction to the health problem. Box 7-6 lists some factors to consider in exploring family interactions related to the presenting problem. The nurse conceptualizes the information that has already been gathered from the family in light of the meaning it has for the family and the hypotheses generated before the interview. For example, a home-care nurse talking with parents caring for a technology-dependent child at home might be mindful of the parents’ new role as care specialists, the transformation of family space and privacy with the introduction of multiple health-care professionals, and the financial drain on their resources.
The nurse then begins to develop additional questions that focus on interactional behaviors dealing with the three time frames of present, past, and future. Within each time frame, the nurse once again explores differences, agreements and disagreements, and explanations or meanings. It is important to emphasize that the purpose of asking these questions is not merely to gather data—that is, by asking circular questions, the nurse generates new ideas and explanations for the nurse and the family to consider.
Box 7-6 Factors to Consider in Exploring Family Interaction Related to the Problem
• Current manifestations of the problem
• Typical responses of family members and others to the problem
• Other current associated problems, challenges, or concerns
• How the problem influences family functioning
• What family members appreciate about how they have coped with this challenging situation
• How family members understand that they have not been successful in conquering this problem (beliefs)
Adapted from Family Nursing Unit records, Faculty of Nursing, University of Calgary.
Present
In exploring the present situation, the nurse could ask, “Who does what, when? Then what happens? Who is the first to notice that something has been done?” The nurse should steer away from asking about traits that are supposedly intrinsic to a person, for example, being shy. Rather, the nurse might ask, “When does Ari act shy?” or “To whom does he show shyness?” Then, “What does Jennifer do when Ari shows shyness?” The nurse can explore areas of difference, inquire about areas of agreement or disagreement, and explore the family’s explanation for the sequence of interaction. The following example questions might be used.
Difference:
• “Who is better at getting Grandmother to make her meals, Shanghi or Puichun?”
• “Do your ex-husband and José fight more or less than your ex-husband and Nadiya?”
• “Do you worry more, less, or the same about your wife’s health since her emergency surgery?”
Agreement/Disagreement:
• “Who agrees with you that Brandon is most likely to forget to give your mother her eye drops three times per day?”
• “Who disagrees with you?”
Explanation/Meaning:
• “How do you understand Brandon’s tendency to be most forgetful about the eye drops?”
• “Are there times when he does remember?”
• “What seems to be different about the times when he remembers?”
Past
In exploring the past, the nurse should use similar questions to explore difference, agreement or disagreement, and explanation or meaning.
Difference:
• “How was Brandon’s caregiving different before he had high-speed Internet?”
• “How does that differ from now?”
Agreement/Disagreement:
• “Who agrees with Murdock that Dad was more involved in Genevieve’s exercise program?”
Explanation/Meaning:
• “What does it mean to you that, after all this time, things between your wife and her mother have not changed?”
In addition to exploring how the family members saw the problem in the past, we have found it extremely useful to explore how they have seen changes in the problem. Change in the problem situation frequently occurs before the first meeting with the interviewer. If prompted, family members can often recall and describe such changes. It is important to note that in many cases, the family must be prompted to emerge from their problem-saturated view of the situation. For example, a man may tell the nurse at the community mental health center that his male partner drinks very heavily and has done this “until recently.” If the nurse is attuned to inquiring about pretreatment changes, the nurse will ask questions about the differences that the man has noticed recently. For example, the nurse might inquire, “Is his recent behavior the kind of change you would like to continue to have happen?” The idea of noticing exceptions to problems is one that we have used frequently in our clinical work, and we are indebted to de Shazer (1991) and White (1991) for emphasizing it.
Future
By focusing on the future and how the family would like things to be, nurses instill hope for more adaptive interaction regarding the presenting concern. They also co-construct a reality between family members and themselves for a system in which the problem has dissolved. Example questions nurses could ask include the following:
Differences:
• “How would it be different if your grandfather did not side with your mother against your father in managing Paola’s Crohn disease?”
Agreement/Disagreement:
• “Do you think your mother would agree that if your grandfather stayed out of the discussions, things would be better?”
Explanation/Meaning:
• “John, if your wife stopped phoning her father for advice about Paola’s Crohn disease, what would that mean to you?”
We believe it is especially important to ask future-oriented questions when working with families dealing with a new diagnosis or a change in health status because the changed expectations and possibilities for the future may be disrupting to family life transitions.
During this stage of the interview, the nurse does the following:
• Attempts to gain a systemic view of the situation and a description of the cycle of repeated interactions. Interactions may be between family members or between family members and the nurse. The nurse does not have to understand or agree with the problem but instead be curious about the family’s description of its positive and negative impact. Appreciative inquiry is questioning that elicits and builds on appreciated practices and engages family members in discussion with each other about what works for them. In this way, families can take a “both/and” position.
• Describes the sequence of the problem’s development over time, the current contextual problem interaction, whether the family believes it has some control over the problem, the times when the problem does not show itself, and what the family members appreciate about their personal and cooperative efforts to work together.
What happens with clients who don’t see themselves as having a problem and yet are referred to the nurse? They may be mandated for treatment or present under duress. In situations where individuals and families have different agendas for a meeting and different definitions of the problem, we believe it is important for the nurse not to rigidify the interaction, however inadvertently. By insisting too early that it is definitely a problem, the nurse can invite a rigid no-problem response from the client. We do not use the word denial because this generally fosters an antagonistic relationship over the question of who is “right.” Although we sometimes find ourselves tempted to give advice and confront the situation head-on, we have found that this typically invites defensiveness and promotes shame. (Additional ideas on how not to give advice prematurely are given in Chapter 11.)
Attempted Solutions for Solving Problems
During the next phase of the assessment, the nurse explores the family’s attempted solutions to the problem. The process can begin with general questions related to the problem. For example, “What improvements have you noticed since you first contacted our clinic?” This type of question conveys the idea to families that they have the strengths and resources to change, and it assumes that changes have already occurred, which can help set in motion a positive self-fulfilling prophecy for them. Another example might be, “How have you tried to obtain information from physicians and nurses about Mandy’s condition in previous hospitalizations?”
Box 7-7 lists some factors to consider when exploring the family’s attempted solutions.
More specific questions should then be used to identify the least and most effective solutions for achieving what the family desires. The nurse can ask when these solutions were used. For example, “What was least helpful in trying to get information from the nurses about Surjit’s resuscitation? What was most effective?” The nurse can ask if any successful elements in the solutions are still being used, and if not, why. Similar types of sequences of interaction questions that focus on difference, agreement or disagreement, and explanation or meaning can be used to explore the family’s attempted solutions to the presenting concerns.
When nurses are told that no solutions have been attempted or that “nothing has worked,” it is useful to ask the following questions:
• “How come things aren’t worse?”
• “What are you doing to keep this situation from getting worse?”
The nurse can then amplify these problem-solving strategies by asking about their frequency, effectiveness, and so forth. The nurse should also try to expand the family’s view of typical solutions to include complementary and alternative medical and health approaches.
Box 7-7 Factors to Consider in Exploring the Family’s Attempted Solution
• How has the family tried to resolve the problem
• Who tried
• With whom
• What were the results
• What were the events precipitating the search for professional help
• Who is most in favor of agency help? Most opposed
• What are the client’s thoughts about the nurse’s role in the change process
• What was the sequence of events resulting in actual contact with the agency
Adapted from Family Nursing Unit records, Faculty of Nursing, University of Calgary.
We also find it useful to draw on the concept of resilience in these situations. In talking with families about their resilience, we use such terms as endurance, withstanding, adaptation, coping, and survival and try to draw forth other qualities surfacing in the face of hardship or adversity. We talk about the ability to “bounce back” or make up for losses. We believe resilience is forged through adversity, not despite it. Bouncing back is not the same as “breezing through” a crisis. Resilience involves multiple recursive processes over time. It is this layering and recursiveness that we inquire about when we ask families about their coping and attempted solutions.
In working with families dealing with life-threatening or chronic illness, the nurse should also be aware of additional “helping agencies” involved in health-care delivery. A nurse may ask questions such as the following:
• “Have any other agencies attempted to help you with this problem?”
• “What has been the most useful advice that you have received?” “Did you follow this advice?”
• “What has been the least helpful advice?”
It is useful to explore the differing ideas espoused by the helping systems. If there is unclear leadership or a confused hierarchy within the helping systems, the family can be placed in a conflictual situation that is similar to that of a child whose parents continually disagree. Confusion among helping agencies can exacerbate the family’s concerns. In this way, the attempted solution (assistance by helping agencies) can become an entirely new problem for both the family and other agencies. It is important for the nurse to be aware of whether this situation exists before attempting to intervene.
Having consolidated a shared view of the problem and elicited some relevant solutions, it can simply be stated to the family that the nurse would like to work with them to achieve their goals. This small but profound acknowledgment is an opportunity for the nurse to show compassion to the client and enter into a deeper relationship and collaboration.
Goal Exploration
At some point during the interview, the nurse and family establish what goals or outcomes the family expects as a result of change. Families are pragmatic: They are seeking practical results when they come to a healthcare provider; they are “in pain” or “suffering,” and their desire is to get rid of a problem. The problem may be between themselves as family members or between the family and the nurse (e.g., the family desires practical information about the acceptable level of physical activity after a myocardial infarction [MI], and the nurse has not provided such concrete information). Family members may expect a large change (e.g., “My brother Sheldon will be able to walk without the aid of a cane”) or a small but significant change (e.g., “We will be able to leave our handicapped daughter, Kayla, with a babysitter for 1 hour a week”). In many cases, a small change is sufficient. We believe that a small change in a person’s behavior can have profound and far-reaching effects on the behavior of all persons involved. Experienced nurses are aware that small changes lead to further progress. Box 7-8 lists some factors for nurses to consider when exploring goals.
Goals describe what will be present or what will be happening when the complaint or concern is absent. We believe that unidimensional behavioral goal statements such as “I will be eating less” are not as desirable as multidimensional, interactional, and situational goal statements that describe the “who, what, when, where, and how” of the solution. Such a multidimensional goal statement might be, “I will be eating a small, balanced meal in the evening at the dinner table with my partner and our children; the television and computer will be off, and we will be talking to each other.” Examples of future-orientated questions nurses could ask to clarify family goals include the following:
Difference:
• “What would your parents do differently if they did not stay at home every evening with Sanna?”
• “How would your parents’ relationship be different if your dad allowed your uncle to take care of Sanna one evening a week?”
Agreement/Disagreement:
• “Do you think your dad would agree that your parents would probably have little to talk about if they went out one evening a week?”
Exploration/Meaning:
• “Tell me more about why you believe your parents would have a lot to talk about when they went out that one evening a week.”
• “What would that mean to you?”
Box 7-8 Factors to Consider When Exploring Goals
• What general changes does the family believe would improve the problem?
• What specific changes?
• What are the expectations of how the agency may facilitate change in the problem?
Adapted from Family Nursing Unit records, Faculty of Nursing, University of Calgary.
We sometimes find it useful to combine past and future questions. For example, “If you were to tell me next week (or month or year) that you had done X, what could I find in your past history that would have allowed me to predict that you would have done X?” The questions capitalize on the “possibility to probability” phenomenon while also inviting a richer account of the history of the new/old story.
Another useful strategy that has been shown to be beneficial in eliciting family goals is the “miracle question” that de Shazer (1988) describes this way:
Suppose that one night there is a miracle and while you are sleeping the problem … is solved: How would you know? What would be different?
What will you notice different the next morning that will tell you there has been a miracle? What will your spouse notice? (de Shazer, 1991, p. 113)
The miracle question elicits interactional information. The person is asked to imagine someone else’s ideas as well as his or her own. The framework of the miracle question (and others of this type) allows family members to bypass their causal explanations. They do not have to imagine how they will get rid of the problem but instead can focus on results. Thus, the goals developed from the miracle question are not limited to just getting rid of the problem or complaint. Clients often are able to construct answers to this “miracle question” quite concretely and specifically. For example, “Easy, I’ll be able to say no to cocaine,” or “She’ll see me smile more and come home from work with less tension.”
KEY CONCEPT DEFINED
Miracle Question
A question asked by a nurse during a family interview that elicits interactional information; a person is asked to imagine someone else’s ideas as well as his or her own; allows family members to bypass their causal explanations.
McConkey (2002) suggests strategies for solution-focused meetings that we believe are particularly useful if a family is angry and the nurse is feeling defensive. The nurse can shift the meeting from the problem picture to the future solution picture by engaging in conversation (p. 192). Here is an example of the nurse’s strategies in such a dialogue:
• “Obviously, you want things to be better for your child, and so do I.”
Purpose: Validating the parent
• “In order to make the most of this meeting, I’m going to ask you an unusual question.”
Purpose: Bridging statement
• “How will you know, by the time you leave here today, that this meeting has been helpful?”
Purpose: Shifting to the future
• “When things are better, what will your son be doing? What will I be doing? What will you be doing?”
Purpose: Including all the stakeholders in the solution picture
Nurses working with families of a patient who has a chronic or life-threatening illness commonly find family members vague about the changes they expect. For example, parents might say, “We would like Attila to feel good about himself even though he has a colostomy.” Experienced clinical nurses know that “feeling good about oneself” is very difficult to describe or measure. In this example, we recommend that the nurse ask the family members to describe the smallest concrete change that Attila could make to show that he “feels good about himself.” By asking for this degree of specificity about desired change early in the nurse-family relationship, we believe it is more likely that the family and nurse can accomplish the desired change.
Planning and Dealing With Complexity
After an initial assessment is completed, a beginning nurse interviewer frequently worries about whether to intervene with a family. The following questions often arise: “Am I the appropriate person to offer intervention? Is the situation too complex? Do I have sufficient skills, or should another professional, such as a social worker, psychologist, or family therapist, be called in? Does every family that is assessed need further intervention?” This is not to say that interventions begin only at the intervention stage. Rather, they are part of the total interview process from engagement to closure. For example, just by asking the family to come together for an interview, the nurse has intervened. Each time the nurse asks a circular question, the nurse influences the family, generates new information, and intervenes. For nurses, the decision to offer interventions, refer the family to others, or discharge them is a complex one. Several factors need to be examined before making the choice: the level of the family’s functioning, the level of the nurse’s competence, and the work context.
KEY CONCEPT DEFINED
Intervention Stage
The stage during a family interview in which the nurse and the family collaborate on areas for desired change.
Level of the Family’s Functioning
The nurse should recognize the complexity of the family situation and the family’s level of functioning. Some clinicians have advocated that treatment begin if the referring problem has been detected early and clearly defined procedures for management have been published. Most nurses would agree with this position but would find it very idealistic.
Desire to Work on Issues
Nurses need to carefully assess the family’s level of functioning and its desire to work on specific issues, such as management of hemiplegia after a stroke, impact of cystic fibrosis on the family, negotiation of services for elderly family members, or caring for a child with special needs. If the family is at all amenable to working on an issue, it is incumbent on the nurse either to offer intervention or to help them get appropriate assistance by referring them to others. (Guidelines for the referral process are provided in Chapter 12.)
Ethical Decisions
Nurses must consider ethical issues in deciding who should be treated and weigh two opposing positions when they decide to intervene with, refer, or discharge a family (potentially dangerous to self or others). They must also have the knowledge and skills of ethical principles, such as autonomy and beneficence, and adhere to their code of ethics and standards of practice.
Values and Beliefs
Nurses need to be aware of the values and beliefs held by the family and its members as well as their own and be cognizant not to impose personal values and beliefs.
Nurse’s Level of Competence
Nurses need to consider their personal and professional capacity prior to making the decision to intervene with a family. It is important to note that we believe that a nurse does not have to personally have dealt with a situation (e.g., raising teenagers) to help a family.
Personal Capacity
• Personal Experiences: Nurses need to be aware of how their life experiences may impact their ability to intervene appropriately and effectively with families (recent loss, new diagnosis, life transition).
• Values and Beliefs: Nurses need to be aware of their own values, beliefs, assumptions, and judgments.
Professional Capacity
• Competence Level: Nurses need to evaluate their competence by asking self-reflective questions, such as the following:
• “Am I at the beginning or the advanced level of family interviewing skill?”
• “Can I obtain supervision to aid in dealing with families who present with complex issues?”
• Scope of Practice: Nurses need to be aware of their roles and responsibilities and provide interventions that they are authorized, educated, and competent to perform, including legal obligations.
• Evidence Informed: Nurses need to be well informed, with up-to-date information and resources, and not just offer advice that might or might not be helpful.
Work Context
• Workplace Structure: Considerable controversy is sometimes raised about the issue of who is competent to assist clients when working in an interdisciplinary team. This controversy involves issues of definition and professionalism. How a “family problem” and a “medical problem” are defined in a particular work setting can fuel the controversy. Nurses often work as mediators, advocates, case managers, and navigators as a way to manage these controversies.
• Health-care System: Changes in health-care reimbursement have required all nurses and health-care providers to examine and adapt their practices to account for the provision of timely, efficient, and cost-effective services. Managed care in its many varieties, health insurance reform, increased focus on primary care, and other complex issues have changed the face of nursing practice.
The increase in the consumer movement, health economics, and technology has huge implications for practice that are more apparent than ever. Nurses must consider these practice implications when they decide to provide interventions. Nurses have to do more than just heal their patients. Day after day, they must also attend to the socioeconomic and political context of health care and to the survival of their careers. We believe that it is vital for nurses to find ways to thrive professionally and for families to receive optimal care.
Intervention Stage
Once a family intervention has been decided on, we recommend that the nurse review the Calgary Family Intervention Model (CFIM; see Chapter 4). This model, which stimulates ideas about change, can help the nurse design interventions to work with the family to address the particular domain of family functioning affected: cognitive, affective, or behavioral. Helpful hints about interventions are offered in Box 7-9.
In choosing interventions, we encourage nurses to attend to several factors to enhance the likelihood that the interventions will focus on change in the desired domain of family functioning. Interventions, offered within a collaborative relationship, are not a demand but rather an invitation to change. Factors to consider when devising interventions include the following:
• What is the agreed-upon problem to change?
• At what domain of family functioning is the intervention aimed?
• How does the intervention match the family’s style of relating?
• How is the intervention linked to the family’s strengths and previous useful solution strategies?
• How is the intervention consistent with the family’s ethnic/cultural/religious beliefs?
• How is the intervention new or different for the family?
Box 7-9 Helpful Hints About Interventions
• They are the core of clinical work with families.
• They should be devised with sensitivity to the family’s ethnic/cultural/religious background.
• They can only be offered to families; the nurse cannot direct change but can create a context for change to occur.
• They are offered in the context of collaborative conversations; nurse and family together devise solutions to find the most useful fit.
• When the nurse’s ideas are not a good fit for the family, the nurse should be open to offering other ideas rather than becoming blameful of self or the family.
Levac, A. M. C., Wright, L. M., & Leahey, M. (2002). Children and families: Models for assessment and intervention. In J. A. Fox (Ed.), Primary health care of infants, children, and adolescents (2nd ed., p. 18). St. Louis, MO: Mosby. Copyright 2002. Adapted with permission.
We do not believe that there is one “right” intervention. Rather, there are only “useful” or “effective” interventions. In our experience, we have found that a nurse sometimes reaches an impasse, with a family not changing, when the nurse persists in either using the same intervention repeatedly or switching interventions too rapidly. Sometimes we find that clients fail to notice responses containing possible solutions. The same can be said of nurses. Interventions are successful when constraints are lifted and important aspects of life change are noticed. The result is a clearer image of how things can be different in the future.
We have also found that sometimes the nurse is too constrained and fails to consider alternate system levels for intervention. For example, if a family does not want to hear or discuss the possibility of older adults having sexual activity at a residential care center, then the nurse may design an intervention not with the family but rather with the care center. Such an intervention with a residential care center could be to plan an in-service around the topic of HIV and older adults. The outcome may be that condoms are available in the center and clients have the information they need to keep themselves safe.
With the availability of computers, smartphones, tablets, e-readers, instant messaging, Twitter, and Facebook, we believe that nurses have become increasingly creative in finding electronic means to facilitate intervention. Just as the use of computers, e-mail, chat rooms, Listservs, blogs, and smartphones for business and education has had dramatic effects on family interaction, we believe their use in health care has also profoundly affected nurse-family interaction. The following list highlights examples of the use of technology as an intervention:
TITLE AUTHOR
Study Protocol: Pragmatic Randomized Control Trial of an Internet-Based Intervention (My Tools 4 Care) for Family Carers (2017) Williams et al
The Use of Information and Communication Technologies to Support Working Carers of Older People—A Qualitative Secondary Analysis (2016) Andersson, Magnusson, & Hanson
The Effectiveness of an Internet Support Forum for Carers of People With Dementia: A Pre-Post Cohort Study (2014) McKechnie, Barker, & Stott
The Provision of Social Support to Single, Low-Income, African-American Mothers via E-mail Messages (2009) Campbell-Grossman, Hudson, Keating-Lefler, & Heusinkvelt
Note: Full citations can be found in the Reference list.
Once an intervention has been devised, the nurse must attend to the executive skills (see Chapters 5 and 10) required to deliver it. Part of the success of any intervention is the manner in which it is offered. The family must feel confident that the intervention will promote change. The nurse also needs to show confidence in the intervention or task requested and believe that it will benefit the family.
However, interventions need to be tailored to each family; therefore, the preamble or preface to the actual intervention will vary. For example, if family members are feeling very hopeless and frustrated with a particular problem, the nurse may say: “I know this might seem like a hard thing that I’m going to ask you to do, but I know your family is capable of …”
On the other hand, if the nurse is making a request of family members who tend to be quite formal with one another, then the nurse might preface it with: “What I’m going to ask you to do may make you feel a little foolish or silly at first, but you’ll notice that, as you do it a few times, you will become more comfortable.”
A good example of a generic intervention is the “What are you prepared to do?” question. The term prepared suggests a voluntary decision to participate in the change process.
When giving a particular assignment for a family to do between meetings, the nurse should try to include all family members. The nurse must review the particular assignment with family members to ensure they understand what is being requested. Reviewing the assignment is a good idea, whether it is carried out within the interview or between interviews. If assignments or experiments are given between sessions, the nurse should always ask for a report at the next interview. If the family has not completed or only partially completed the assignment, the reason should be explored.
We do not subscribe to the view that families are noncompliant or resistant if they do not follow our requests. Rather, we become curious about their decision to choose an alternate course and try to learn from their response. We believe that family interviewing is a circular process. The nurse intervenes, and the family responds in its unique way. The nurse then responds to this response, and the process continues. See Chapter 2 for more ideas about circularity.
During the intervention stage, the nurse must be aware of the element of time. How useful or effective an intervention is can be evaluated only after the intervention has been implemented. With some interventions, change may be noted immediately. However, more commonly, changes will not be noticed for a lengthy period. Just as most problems occur over time, problems also need an appropriate length of time to be resolved. It is impossible to state how long one should wait to ascertain if a particular intervention has been effective, but changes within family systems need to filter through the various system levels. Families themselves offer useful observations and feedback about what interventions are most useful. Robinson and Wright (1995), identified interventions within two stages of the therapeutic change process that they thought were critical to healing: (1) creating the circumstances for change and (2) moving beyond and overcoming problems. (For further elaboration on these stages, see Chapter 1.) More information about devising interventions is provided in Chapters 4, 8, 9, 10, and 12.
Termination Stage
The last stage of the interviewing process is known as termination or closure. It is critically important for the nurse to conceptualize how to end treatment with the family to enhance the likelihood that changes will be maintained. In Chapter 5, we outline the conceptual, perceptual, and executive skills useful for the termination stage. In Chapter 12, we address in depth the process of termination and focus on how to evaluate outcomes.
KEY CONCEPT DEFINED
Termination Stage
The stage during the family interview when the therapeutic relationship between the nurse and the family is ended.
CLINICAL EXAMPLE
The following is an example of how a nurse conducted interviews with a family using the guidelines we have given in this chapter and in Chapter 6. An example of a 15-minute interview is given in Chapter 9.
Pre-Interview
Heinz Auerswald, 51, is a paraplegic and in a wheelchair because of a multiple trauma suffered in an industrial accident. He is unemployed. Eva Auerswald, 49, a homemaker, is the primary caregiver. She is reported to be depressed. A home health agency has received a referral on the Auerswald family for home nursing services, physiotherapy, nutrition counseling, and mental health counseling.
Developing Hypotheses
The home-care nurse hypothesized that Mrs. Auerswald’s depression could be related to feeling overly responsible for caring for her husband. The nurse wondered if the husband’s role and beliefs might be perpetuating this. She was also curious to know what other social and professional support systems were involved and what their beliefs were about the family’s health problems. During the course of the family interview, the nurse gained much evidence from both the husband and wife to confirm the usefulness of her initial hypothesis. She used this hypothesis to provide a framework for her conversation with the couple.
Relation to the CFAM
The nurse generated her hypothesis based on knowledge of and clinical experience with other families in similar situations in addition to the following categories of the Calgary Family Assessment Model (CFAM):
• Structural: Internal and external family structure, ethnicity, gender
• Developmental: Middle-aged families
• Functional: Roles, power or influence, circular communication, beliefs
Arranging the Interview
Mrs. Auerswald stated that she did not want to discuss her depression with the nurse while her husband was awake. For the first home visit, the nurse requested that the husband and wife be interviewed together. The couple agreed to this.
Relation to the CFAM
The nurse thought about family roles and gender and speculated that Eva may be protecting her husband, Heinz, from her problem. The nurse considered the following category of the CFAM:
• Functional: Verbal communication (clear and direct communication between Heinz and Eva might be absent or infrequent)
Interview
Engagement
The genogram data revealed the following:
• Heinz and Eva are alone in the city; extended families and children live in other cities and visit infrequently.
• Eva had been married previously and had stayed with her first husband for 18 years, although he physically abused her. She thought it was her responsibility to protect her children.
• This is Heinz’s first marriage.
Relation to the CFAM
The preceding information added some support for the nurse’s initial hypothesis in terms of Eva’s beliefs about responsibility and an isolated family structure.
Assessment
Problem Definition
• Eva: “Heinz has had such a hard tragedy, but now I’m the one who is depressed. It doesn’t make sense.”
• Heinz: “Eva is worrying too much.”
Relationship Between Family Interaction and Health Problem
The nurse asked circular questions and discovered the following:
• Eva had not allowed herself a break from caregiving for 2 years.
• Heinz encouraged her to “go out and meet people,” but she stated that she was fearful he might be too lonely if she met other people.
• Heinz stated that this would not be a problem for him.
• They both reported that Eva had recently become depressed. She cried frequently and had difficulty sleeping.
• Eva takes excellent physical care of Heinz and bathes him daily.
• Heinz is appreciative of all her nursing care.
• Eva feels guilty about asking for help from Heinz’s parents.
Attempted Solutions
• Eva had recently visited her family doctor and was prescribed an antidepressant.
• Eva had requested home-care services once before, but she discontinued treatment with the nurses because their schedule was unreliable and she never knew when they were coming.
• On the advice of her physician, Eva agreed to try home care again.
Relation to the CFAM
• Functional: Problem solving
The Auerswalds’ problem-solving approaches involved either self-sufficiency or professional resources outside the family. They sought help from the family doctor and from the home-care agency only infrequently, and they were reluctant to call on extended family for assistance.
Goals
• Eva: To not feel depressed and feel good about herself; to be able to go out one afternoon a week without feeling guilty
• Heinz: In agreement with Eva’s goals
Intervention
Consideration of the CFIM
Having developed a collaborative relationship with the couple and a workable hypothesis that fit the data from the family assessment, the nurse began to consider interventions with Eva and Heinz in the cognitive, affective, and behavioral domains of family functioning. The focus of intervention was Eva’s depression. Table 7-4 shows the interventions the nurse used with Eva and Heinz and their outcomes.
TABLE 7-4 Interventions and Outcomes
INTERVENTIONS OUTCOMES
The nurse did the following:
■ Asked questions about beliefs and feelings of responsibility
■ Encouraged change in Eva’s beliefs by asking both husband and wife behavioral effect, triadic, and hypothetical questions about responsibility
■ Asked the couple to engage in behavioral experiments to try new ways of being self-responsible Both Eva and Heinz challenged their own beliefs about depression being a solely biological problem and began to take more responsibility for their own lives.
■ Eva requested caregiving help from her mother-in-law; this was arranged in addition to help from a home-care agency. Eva was able to leave her husband alone for 2 hours, three times per week, while she played cards with friends. The couple reported significant improvement in Eva’s depression.
■ The home-care agency continued to provide nursing and physical therapy services for the family.
■ The nurse and home health aide focused on supporting the couple’s new beliefs about responsibility. The couple reported significant improvement in her depression.
CASE SCENARIO: JULIA
The primary care clinic nurse meets Julia for the first time when she attends the clinic for her annual well-woman check. Julia is 31 years old and married to Kate. She has a very demanding, high-stress job as a second-year medical resident in a large hospital. During her physical assessment, Julia mentions that she has been feeling defeated lately. When the nurse questions her about these feelings, she explains that she has always been a high achiever and graduated with top honors in both university and medical school. She says that she has very high standards for herself and can be very self-critical when she fails to meet them. Lately, she has struggled with significant feelings of worthlessness and shame due to her inability to perform as well as she always has in the past. For the past few weeks, she has felt unusually fatigued and found it increasingly difficult to concentrate at work. Julia’s wife, Kate, is in the waiting room. Kate has driven Julia to the clinic today because Julia says that she felt too tired to drive.
Reflective Questions
Engagement Phase

1. What strategies can the nurse use to establish a relationship with Julia?
   Assessment Phase
2. What questions can the nurse ask Julia and Kate to explore the following issues?
   a. Problem identification
   b. Relationship between family interaction and health problem
   c. Attempted solutions to solving problems
   d. Goals
   CRITICAL THINKING QUESTIONS
3. Identify a situation from your clinical practice and reflect on how you completed the following stages of a family interview:
   a. Engagement
   b. Assessment
   • Problem identification
   • Relationship between family interaction and health problem
   • Attempted solutions
   • Goal exploration
   c. Intervention
   d. Termination
4. What worked well, and what did not? What would you do differently based on your experience?

Chapter 8
How to Use Questions in Family Interviewing
Learning Objectives
• Compare the difference between linear and circular questions, and explain when to use them.
• Describe how to apply questions to achieve the following:
• Engage all family members and focus the meeting.
• Assess the impact of the problem or illness on the family.
• Elicit problem-solving skills, coping strategies, and strengths.
• Intervene and invite change.
• Request feedback about the meeting.
Key Concepts
Assessment questions
Interventive questions
One-question question
Throughout our book, we have discussed the usefulness of asking questions in family interviewing. We believe questions are useful for family assessment, and they are one of the most helpful family interventions nurses can offer. We have found the research of Healing and Bavelas (2011) to be encouraging in this regard. Their “controlled experiment confirmed that interview questions on the same topic but with a different focus can affect the interviewee, producing different attributions and even different behaviors” (p. 43). This is an important finding for clinical work. Through the use of examples of clinical interviews in this text, we demonstrate and reveal how questions are used in relational practice.
KEY CONCEPT DEFINED
Assessment Questions
Types of questions that inform the nurse; often investigative questions, such as asking a family member to describe the illness experience or problem.
QUESTIONS IN CONTEXT
First, we discuss a few ideas about asking questions in the context of clinical practice, specifically in the context of a therapeutic conversation between a nurse and a family. We believe that useful or helpful questions have the potential to provide information to both the family and the nurse, invite family members to reflect on their illness experience, and can be potentially healing when the nurse asks them in a manner of sincere inquiry or curiosity. Questions are not effective in and of themselves; rather, it is only through a therapeutic conversation that questions help nurses be effective. (See Chapter 7 for more ideas about therapeutic conversation.) Questions also enhance a nurse’s understanding of family members’ experiences with a particular illness or problem. Answers to questions can help the nurse and the family appreciate the family’s coping strategies, unique strengths, and resources. These types of conversations are very different from ones that a family may have with an intake worker or data clerk. We frequently have found that just telling the story can be therapeutic.
KEY CONCEPT DEFINED
Interventive Questions
Questions asked by the nurse during a family interview that invite reflection and effect change; questions may encourage family members to see their problems in a new way and subsequently to discover new solutions.
There are numerous and various types of questions, such as difference questions, triadic questions, hypothetical questions, and behavioral-effect questions (see Chapter 4). In this chapter, we offer a simple dichotomy of questions that a nurse can ask: assessment and interventive questions.
• Assessment (linear) questions: The purpose is to inform the nurse; these are often investigative questions, such as asking a family member to describe the illness experience or problem.
• Interventive (circular) questions: The purpose is to invite a reflection and effect change; these questions may encourage family members to see their problems in a new way and subsequently to see new solutions.
The important difference between these two categories of questions is in their intent. Thus, as the family’s answers provide information for both the family and the nurse, the nurse’s questions may provide information for the family.
At the start of the family meeting, it can be helpful for the nurse to explain to the family members that various kinds of questions will be asked in order to obtain a thorough understanding of their situation. Also, this gives the family an opportunity to familiarize themselves with the nurse. In a social conversation, it is often considered rude to interrupt someone to ask a question while that person is speaking. However, in a time-limited family interview, it could be considered rude not to obtain each family member’s perception of the health concern. Sometimes interrupting one family member to include the perspective of another is most appropriate.
It is also appropriate in therapeutic conversation for nurses to understand that they are not invading a family’s privacy by asking questions. In training our students to overcome such a mental barrier, we have found it helpful to teach them to say to clients or patients, “I don’t know you very well, so can I trust that if I ask you something too sensitive, or something you would prefer not to talk about, that you will let me know?” In this way, the nurse obtains the family’s permission to have a wide-ranging discussion. If conflict among family members erupts as a result of the nurse’s questions, we encourage our students not to be frightened or intimidated by this. Rather, the nurse could say, for example, “Is this typically what happens when the two of you do not agree on an issue?” The nurse’s tone is also important when asking questions so as not to convey judgment or criticism but rather to convey a message of the nurse’s desire to seek a sincere understanding of the illness or issue and invite the family to a reflection that may result in a new perspective and new behaviors. (See Chapter 7 for additional ideas about engagement and assessment.)
Useful, effective, and time-efficient questions are part of relational practice in that they aid in relationship building and collaboration between nurses and families. Most important, questions can be very effective in creating a safe context for the family to describe their illness experience and, hopefully, glean ideas for how to soften or diminish their suffering. Through the asking of interventive questions as well as other useful interventions, the nurse can invite, encourage, and support families to change.
Example 1: Engage All Family Members and Focus the Meeting
In this first example, Dr. Lorraine Wright is meeting with a couple, Nicholas and Bev. Nicholas had a heart attack recently, and this is a follow-up clinic visit. Dr. Wright asks the “one-question question”: “What one question would you most like to have answered during our meeting together?” The one-question question is a term that Dr. Wright coined (Wright, 1989), and themes of answers to this question have been explored in a study by Duhamel, Dupuis, and Wright (2009). This question emphasizes a specific concern and also asks the couple to prioritize their concerns; she asks what they would most like to have answered. The question also includes a time frame (i.e., “during our meeting together”).
KEY CONCEPT DEFINED
One-Question Question
A question asked by the nurse during a family interview that emphasizes a specific concern and helps family members to prioritize their concerns.
When Dr. Wright asks the one-question question of both Nicholas and Bev, she does not ask Bev to comment on Nicholas’s answer. Rather, she engages each family member and elicits their primary concern. Dr. Wright paraphrases and clarifies each person’s response so that both she and the person are in agreement about what has been said. In this example, the nurse and the client collaborate to set the focus for the meeting. Notice how the nurse, Dr. Wright, persists in obtaining an answer from Bev. Gentle persistence can be an important skill in establishing a meeting’s focus.
Dr. Wright: I’m wondering, then, in the brief time we have, is there any particular question you would most like to have answered during our meeting today?
Nicholas: I’d like for her (looking at his wife) to deal differently with her anxiety. Me … I’m fine.
Bev: Hmm … Oh yes, he wants me to go on tranquilizers. So … sure … (Turning away)
Dr. Wright: (Looking at the husband) So you want to know how to help your wife deal with her anxiety?
Nicholas: Oh yeah…
Dr. Wright: And for you, Bev, what is the one question you would most like to get answered?
Bev: I would like to get him to start exercising more, watch his diet, spend some time with the family, and stop worrying so much about work…
Nicholas: (Looking down)
Dr. Wright: Is there one question you’d like answered, Bev?
Bev: Well, how can we get him to change his lifestyle?
Dr. Wright: Okay …
We want to emphasize that there is no single, “correct” question to ask. Rather, by engaging in purposeful conversation with patients and their families, nurses will choose and select the most helpful questions in the context of each particular family along with their unique concerns and issues.
Example 2: Use Questions to Assess the Impact of the Problem/Illness on the Family
Asking questions about the impact of the illness or problem is essential to understanding the effect, impact, and changes caused by illness in family members’ lives and relationships. By inquiring in this manner, we are giving the family an opportunity to talk about their illness experience or illness story. Families have reported to us that telling their illness story or narrative was helpful in their emotional, physical, or spiritual healing because the illness is understood, listened to, acknowledged, and witnessed. Too often, families have not been given this opportunity to tell their illness story through useful and skillful questions posed by a caring nurse.
In the next example, Dr. Leahey is meeting with a middle-aged couple that is experiencing multiple chronic illnesses. In particular, Phyllis is coping with osteoarthritis and uses a scooter for mobility. Both Ken and Phyllis are 59 years old. They have two sons: the elder, age 26, is married, while the younger, age 22, lives in the family home.
Dr. Leahey explores the impact of osteoarthritis on the couple. Notice how initially, the husband says it has not had an impact on them but then does talk about the impact of his wife’s pain upon him. Phyllis commends her husband for his support and assistance with household chores but then offers, with sadness, her decision to leave the teaching profession, which she loved, because her energy is being depleted by her illness. Phyllis believes she needs to save her energy for her family but openly admits that it is a huge adjustment to being a full-time homemaker. This one question about the impact of the illness upon them as a couple opened up a very useful discussion about how osteoarthritis has dramatically changed their lives, careers, and relationships and offered a window into their suffering, coping, and healing experiences. These types of questions address the suffering the family may be enduring and the systemic effects of that suffering.
Dr. Leahey: What has been the impact of these illnesses on the two of you?
Ken: I don’t know if there has really been an impact … I know that I feel at times … I wish I could take some of the pain away. It is very hard on me to see … especially someone I love so much, suffering with pain.
Phyllis: (Looking at husband)
Dr. Leahey: (Nodding)
Ken: And it’s a continual, chronic pain…
Dr. Leahey: Yes. (Nodding)
Ken: But I try to be as supportive as I possibly can, but…
Phyllis: He is just so helpful and so wonderful … When I think about the impact … I was a teacher, an elementary teacher, and when my arthritis got to bother me so badly, I decided to take a leave of absence because at school, I had to be cheerful and bubbly. I had to put myself forward, but when I came home I was not (turning toward husband and laughing) quite as bubbly. I thought this is not really fair to my own children. So I thought if I am at home, I will be able to do more for them with less effort. So actually, it did impact our lives because I stopped teaching … and when I was teaching, I was really quite independent, I think…
Ken: (Nodding) You were … It took you a long time to adjust…
Phyllis: It did. Away from school, from being a teacher at school to just being at home, it was really difficult for me, but Ken adjusted really quickly with helping me with things I needed help with. Also, our boys, I think, were very aware of the change in our family … how things changed, because truly they were different.
Dr. Leahey: It sounds like the two of you made tremendous changes.
It is helpful to remember that talking can be healing, and these kinds of questions have the potential for simultaneously assessing and intervening. If Ken and Phyllis expressed a desire to work on changing or modifying a particular coping strategy, Dr. Leahey could then have asked them a variety of other questions to foster change.
Example 3: Use Questions to Elicit Problem-Solving Skills, Coping Strategies, and Strengths
Families coping with chronic or life-threatening illness or psychosocial problems can commonly feel defeated, hopeless, or failing in their efforts to overcome the illness or live alongside it. Asking questions about the family’s problem-solving abilities and their coping strategies and strengths not only serves as assessment but also can be considered interventive. Exploring these areas of problem-solving skills and coping strategies can often remind families of forgotten or suppressed skills and strengths. Through interventive questioning, families can rediscover and reclaim their own abilities to solve problems and bring back to their hearts and minds their inherent strengths. McGoldrick, Carter, and Garcia-Preto (2011, p. 451) offer some questions to help clients look beyond the stress of their current situations and access the strengths of their heritage. For example, the nurse could ask:
• How might your grandfather, who dreamed of your immigration but never made it himself, think about the problem you are having with your children?
• Your great-grandmother immigrated at age 21 and became a pieceworker in a sweatshop but managed to support her six children and had great strength. What do you think were her dreams for you, her daughter’s daughter? What do you think she would want you to do now about your current problem?
In this next example, Dr. Wright is meeting with a family with young children: Chris, age 36; Carleen, age 28; Reuben, age 5; Mariah, age 2; and Rebecca, age 9 months. Chris, an immigrant from Zimbabwe, is employed full-time; Carleen, who grew up in a small, rural town in western Canada, is the resident manager in their building. The health concern for this family is Carleen’s thyroid condition.
In the first section of the example, Chris comments on the many changes in his life with three preschoolers, in addition to his working full-time and taking evening courses. Notice how Dr. Wright empathizes with the many demands upon Chris but then asks the couple an interventive question: “What have you learned that works to assist you with all of these demands?” This interventive question invites Carleen to talk about how things are more organized for her family when she mobilizes resources such as friends to assist them. This solution gives her an opportunity to do her own work as resident manager plus gives her husband more time for his studies. Notice that after Carleen shared her thoughts about “what works” in the family to assist with all of their demands, Dr. Wright commended the couple for their very good idea of friends taking turns caring for each other’s children.
Chris: The accounting program is very demanding time-wise … and then the kids … I’m finding it … I am having a hard time finding time to study because we have three of them … to feed them, get them ready for bed sometimes and then to help clean up the house. By the time … I am so tired…
Carleen: (Looking over at him)
Dr. Wright: Well, sure … you are pooped yourself.
Chris: I do not put in as much time as I should into studying. This has been one of the biggest changes from my point of view.
Dr. Wright: So many demands upon yourself … and so what have you learned to handle this? What have you learned that works or does not work?
Chris: Mmm…
Carleen: If I can get things ready, have them all fed, have the place cleaned, have my work done … ‘cause often when he comes home, I have to go out and do some of my work. I have friends who help me out and I help them out. We babysit for each other.
Dr. Wright: Oh really … that is good…
Carleen: That allows me to get work done during the day.
Dr. Wright: That’s a good idea … a good arrangement.
Carleen: It gives me more time in the evening.
In this next section of the example, Dr. Wright normalizes the difficulty of time pressures for mothers and fathers; she asks if Carleen has been able to work out finding any time for herself. An important conversation unfolds with Carleen illustrating her problem-solving skills. She talks about involving her son to watch the youngest child while she does yoga in their home. This sparks Chris to remember how he gives his wife some time for herself when he takes all three children to the park. Once again, Dr. Wright is able to commend the family for these efforts.
Dr. Wright: (To Carleen) Have you been able to find any time for yourself?
Carleen: Yeah, I have. I try to get up before the kids … that does not always work, though. This one (turning toward 5-year-old Reuben) gets up, and then the baby is up … I’ll go downstairs and I’ll do yoga, and Reuben will just watch me. Or I’ll do aerobics…
Dr. Wright: (Looking at Reuben) So you watch Mommy do yoga … Do you ever join in and do it with her?
Reuben: (Looking at Dr. Wright) … when the baby’s awake … watching her…
Carleen: He watches the baby.
Dr. Wright: Very nice.
Chris: Sometimes what I do is take the kids out to the park so she can have the day to herself. I still try to do it, but some days she’d rather be doing her work.
Asking about a family’s problem-solving skills, coping, and strengths can set the stage for further interventions, if needed. For example, if Carleen had stated she wanted to increase her problem-solving skills, Dr. Wright could have pursued this with her. For instance, they could have discussed possible playgroups in the area, available community resources, and so forth.
Example 4: Use Questions as Interventions and to Invite Change
The intervention process represents the core of clinical practice with families. Myriad interventions are possible, but nurses need to tailor their interventions to each family they encounter. Openness to certain interventions is profoundly influenced by the relationship between the nurse and the family and the nurse’s ability to help the family reflect on their health problems.
Questions in and of themselves can provide new information and answers for the family; thus, they become interventions. Interventive questions can encourage family members to view their problems or illness experience in a new way or to change their beliefs and subsequently discover new solutions. Some clinicians and authors recognize how questions can introduce alternative possibilities, theories, beliefs, and views, simply in their posing (Bell, 2016; McGee, Del Vento, & Bavelas, 2005; Östlund, Bäckström, Saveman, Lindh, & Sundin, 2016; Wright & Bell, 2009).
The next example is with a couple, Al and Benz. This is Benz’s first marriage and Al’s second marriage. Benz is close to being discharged from the hospital following surgery for breast cancer. The first interventive question in this example is, “And who would you say, between the two of you, was the most upset with this diagnosis and news when you got it?” This leads to a very poignant therapeutic conversation about Benz’s future. In this therapeutic conversation, Benz is very concerned about her prognosis. Dr. Wright asks about Benz’s beliefs about her prognosis when she says to Benz, “What are your thoughts about your future?”
Dr. Wright: (Looking at Benz) Have there been any other kinds of cancer in your family?
Benz: No … we are all pretty healthy.
Dr. Wright: (Looking at Al) … and what about for you, Al—has there been any history of cancer in your family?
Al: No … I cannot think of any … I had an aunt and uncle who got lung cancer. Both were heavy smokers.
Dr. Wright: So this was something very new for both of you, dealing with cancer. And who would you say, between the two of you, was most upset about this diagnosis and news when you got it?
Al: Oh, Benz was, I think.
Benz: I would say so, too. I cried and cried. I just could not handle it.
Dr. Wright: Yes…
Al: … and I just don’t see what a lot of crying accomplishes. I think you have to really think positively and know in your heart that you can beat this thing.
Dr. Wright: That’s how you’ve been trying to encourage Benz?
Benz: Yeah, he kept telling me that. I just felt I needed to cry. That’s the only thing I needed to do…
Dr. Wright: Yes…
Al: Well, a certain amount of this is understandable, and I have tried to be sympathetic, but you have got to get onto the positive-thinking path and really believe you’re going to beat this thing.
Dr. Wright: (Nodding)
Al: I really do believe that. I really do believe that.
Dr. Wright: (Looking at Al) … You do. (Looking at Benz) And what are your thoughts for the future? Because I’ve met other women with breast cancer who worry … What are your thoughts?
Benz: Some days I am pretty good about it. I am in good hands; my doctor is good. And some days, I just do not know. It fluctuates. Some days are good and some are bad.
Dr. Wright: So some days you are more optimistic about your future and other days you…
Benz: I think the worst.
Dr. Wright: And what do you think about when you think the worst?
Benz: That Al and our child, Bryan, would be alone without me. I care about them so much.
Al: And this is the kind of thinking I try to discourage. I do not think it is good.
Dr. Wright: So when you hear your wife talking this way and I am not here, do you try to cheer her up and get her off of this topic?
Al: Oh yeah. I allow her a little bit of it. She has to express herself and express her feelings, but once she has got that out, she has to get back to being hopeful.
Dr. Wright: (Looking to Benz) And do you like that approach Al takes? He tries to get you off of this topic and to think optimistically. Or do you want to be able to say more about the other side, the “worry side”?
Benz: Well, I know he is being kind and wants me to do well. But sometimes, that is just the way I feel. Maybe if he would just listen to me…
These are not easy conversations when a nurse “speaks the unspeakable” by introducing a conversation about a family’s beliefs about prognosis (Wright & Bell, 2009). Knowing the family’s beliefs about various aspects of their illness assists the nurse in knowing if their beliefs are constraining or facilitating. We believe that nurses have a socially sanctioned role and thus can talk about such delicate and intimate topics with families. In our clinical experience, we have found that families rarely mind any question if it is asked in a kind, nonjudgmental, purposeful, and thoughtful manner. We have encouraged our students to be curious and pursue hard topics with families. If the nurse working with the family cannot address potentially difficult areas with them, then we encourage the nurse to transfer the family to another nurse, if possible, or request that another nurse continue the conversation.
Dr. Wright’s question invited a very useful disclosure about this couple’s differences in beliefs about how to cope with worries and face the future. Benz wanted to talk about her fears for the future, whereas Al preferred to deal with worry by being optimistic. Instead of Dr. Wright taking sides with either Al or Benz about the best way to handle fears, she asked Benz, “And do you like that approach Al takes (her husband’s optimism)? Or do you want to say more about the other side, the ‘worry side’?”
This simple, but powerful, interventive question had the potential for inviting healing change in one or both spouses. Benz offered very clearly that she would prefer that her husband listen to her. It is very understandable that Al wanted to cheer her up, but it was not Benz’s preferred way for her husband to comfort her.
In this example, interventive questions invited family members to explore and reflect on their beliefs about the illness experience, the prognosis, and how best to manage their illness. Reflections are invited through very deliberate, thoughtful, and purposeful interventive questions.
Example 5: Use Questions to Request Feedback About the Family Meeting
We seek to ask questions that are in keeping with our philosophy of fostering collaborative relationships between nurses and families. These kinds of questions imply to family members that their satisfaction with the meeting, or lack thereof, matters and that we want to improve our care to families. Collaborative questions also give the family the chance to voice concerns about what specifically was helpful to them.
In the following example, at the end of the meeting with Al and Benz, Dr. Wright asks if the conversation has been helpful to them. Benz gives a short answer and comments on the relationship with Dr. Wright by saying, “You are kind.” Notice how Dr. Wright’s question invites much more pondering from Al. He reflects back on Benz’s suggestion about wanting him to listen more. This is a lovely example of how an interventive question invited a reflection and how Al decides on his own that he could make a behavioral change that would be more in tune with his wife’s preferred way to be comforted. This is always the most desirable and sustaining kind of change—that is, when a family member initiates the change rather than being instructed to do so.
Dr. Wright: (Looking at the couple) Well, just before we end, was there anything about this conversation that has been useful or helpful for you or not helpful?
Benz: … I think you are very kind.
Dr. Wright: (Nodding to Benz and then looking to Al) Anything that was helpful for you, Al?
Al: Yeah … it made me think. It made me think. Perhaps I need to listen a little bit more and not be so free with the advice.
Dr. Wright: (Looking at Benz) I think it is wonderful to have a husband who wants to cheer you up and make you feel better…
Benz: I’m lucky.
Dr. Wright: But there are times when you want him to hear you out about what you are thinking and feeling.
Of course, families do not always convey positive feelings about the meeting with the nurse. If the family members express dissatisfaction or discontent, we encourage the nurse to explore their reasons for being dissatisfied and accept the feedback nondefensively. The nurse can thank the family members for their insights and ask for their suggestions for how she could be more helpful to other families. If the nurse takes a sincere “one-down” position when receiving feedback, it encourages the family to maintain a collaborative relationship. It also permits the nurse to reflect on her practice and potentially alter her actions for future family meetings.
CASE SCENARIO: MEHRZA, ZOYA, AND SHAILA
Mehrza and Zoya moved from Afghanistan to Canada in 1991 with their two children, Ali and Rahmaan. Mehrza worked hard in retail while completing his studies in accounting. Zoya stayed home for the first 10 years and then went back to work to provide additional financial support for the family. Both of their children are now young adults attending university. Mehrza recently sponsored his younger sister, Shaila, who is a trained physician, and her two young children, Akbar (26 months old) and Zeeya (6 months old), to come to Canada. They are currently living with Mehrza and Zoya.
Shaila’s childhood was very difficult; her family was always moving from one area to another due to conflict and safety concerns in Afghanistan. She is struggling with the transition to living in the West and speaks very little English. She feels overwhelmed and is always worried about her children’s safety. Mehrza and Zoya take Shaila to the nearest walk-in clinic because she does not have a family doctor and they are concerned about her. When the nurse begins to ask Shaila questions, she is hesitant to answer and begins to get teary. Mehrza and Zoya are very vocal regarding their concerns about Shaila and her children, and they wonder if she is experiencing posttraumatic stress disorder.
Reflective Questions

1. What types of questions could the nurse ask to assess the impact of the problem on the family?
2. What types of questions could the nurse ask to elicit the problem-solving skills, coping strategies, and strengths of the family?
3. What questions can the nurse ask to assess the family’s emotional and verbal communication?
   CRITICAL THINKING QUESTIONS
4. What are some questions that a nurse could use to engage all family members and focus the conversation?
5. Reflecting on your own clinical practice, what questions could you ask that foster change in relation to the impact of an illness or problem with a family?
6. Consider your clinical practice and reflect on the conversations you have had with patients and families. What questions have you asked about problem-solving skills, coping strategies, and strengths?
7. What questions can invite feedback about the usefulness of the therapeutic conversations that nurses have with families?

Chapter 9
How to Do a 15-Minute (or Shorter) Family Interview
Learning Objectives
• Discuss the purpose of completing a 15-minute interview.
• Summarize the key ingredients of a 15-minute family interview.
• Identify possible constraining beliefs nurses might have for not including family members in their practice.
• Explain how to provide a brief family interview without family members present.
Key Concepts
15-minute family interview
Art of listening
Commendations
Genogram
Manners
Therapeutic conversation
Therapeutic questions
Therapeutic relationships
Family nursing can be effectively, skillfully, and meaningfully practiced in just 15 minutes or less. We have listened to and read in professional journals the many stories and reports by nurses of how these ideas have been implemented in their practice and thus how their practice with patients and families has changed in rewarding ways (Duhamel, 2010; Duhamel, Dupuis, Turcotte, Martinez, & Goudreau, 2015; Goudreau, Duhamel, & Ricard, 2006; LeGrow & Rossen, 2005; Moules, Bell, Paton, & Morck, 2012; Moules & Johnstone, 2010). Bell (2012) offered the compelling thought that the 15-minute family interview is one of the most “sticky” ideas in family nursing. By “sticky,” she is referring to ideas that are unexpectedly introduced, credible, efficient, and subsequently have had an enthusiastic worldwide implementation in family nursing teaching, research, and practice.
One of our goals in developing these ideas was to address head-on the perception among nurses that they lack the time to involve families in their practice, and this effort seemed to resonate with many nurses. “I don’t have time to do family interviews” is the most common reason nurses offer for not routinely involving families in their practice. In numerous undergraduate and graduate nursing courses, professional workshops, and presentations, we have encountered this statement as the resounding reason for the exclusion of family members from health care. With major changes in the delivery of health-care services through managed care, emphasis on providing more care in the community, budgetary constraints, increased acuity, and staff cutbacks, time is of the essence in nursing practice. However, it is our belief that families need not be banned or marginalized from health care. To involve families, and especially in a time-limited conversation, nurses need to possess sound knowledge of family assessment and intervention models, interviewing skills, and questions. We have witnessed and conducted enough interviews to know that family nursing knowledge can be applied effectively even in very brief family meetings. We also claim that a 15-minute family interview, or even a shorter family interview, can be purposeful, effective, informative, and even healing. Any involvement of family members, regardless of the length of time, is better than no involvement.
KEY CONCEPT DEFINED
15-Minute Family Interview
A condensed version of the core elements of conducting family interviews that is based on the theoretical underpinnings of the Calgary Family Assessment Model (CFAM) and the Calgary Family Intervention Model (CFIM).
But what is time? And what exactly can be accomplished in 15 minutes or less with a family? We have noticed that much of nursing practice time is socially and culturally coordinated, highly ritualized, and therefore honored. Nurses clearly articulate the start and end of their shifts, their schedules, and so forth. We propose that ritualizing and coordinating meeting time with families, even if it is only 15 minutes, can also become part of nursing practice.
However, for nurses’ behaviors to change, they must first alter or modify their beliefs about involving families in health care. We have discovered that when nurses do not include family members in their practice, some very constraining beliefs usually exist (Wright & Bell, 2009). Some of these beliefs are as follows:
• If I talk to family members, I will not have time to complete my other nursing responsibilities.
• If I talk to family members, I may open up a can of worms, and I will have no time to deal with it.
• It is not my job to talk with families; that is for social workers and psychologists.
• I cannot possibly help families in the brief time I will be caring for them.
• If the family becomes angry, what would I do?
• What if they ask me a question and I do not have the answer? What would I do? It is better not to start a conversation.
Another constraining belief that nurses and other health-care professionals often have is that nothing meaningful can be accomplished in one meeting with a client. Slive and Bobele (2018) challenge this belief in their landmark book documenting clinical success with clients who use walk-in single-session therapy. The significance of having an opportunity to converse with a professional at the time most meaningful to the family cannot be overestimated. Research on time-effective single-session therapy has demonstrated its effectiveness and client satisfaction with the outcome (Green et al, 2011; Harper-Jacques & Leahey, 2011; Hopkins, Lee, McGrane, & Barbara-May, 2017). See Research Highlight: Single-Session Family Therapy in Youth Mental Health.
Research Highlight
Single-Session Family Therapy in Youth Mental Health
This research used quantitative analysis to assess the effectiveness of single-session therapy in young people and their families when presenting to a mental health service. Data were collected using self- and family-member-reported outcome rating scales. Findings indicated young people and their families found that single-session therapy intervention improved the mental health and well-being of the young people.
Source: Hopkins, L., Lee, S., McGrane, T., & Barbara-May, R. (2017). Single session family therapy in youth mental health: Can it help? Australasian Psychiatry, 25(2), 108–111.
Uncovering these constraining beliefs makes it more comprehensible why nurses may shy away from routinely involving families in nursing practice. We postulate that if nurses were to embrace only one belief, that “illness is a family affair” (Wright & Bell, 2009), it would change the face of nursing practice. Nurses would then be more eager to know how to involve and assist family members in the care of loved ones. They would appreciate that everyone in a family experiences an illness and that no one family member has diabetes, multiple sclerosis, or cancer. By embracing this belief, they would realize that, from initial symptoms through diagnosis and treatment, all family members are influenced by and influence the illness. They would also come to realize that our privileged conversations with patients and their families about their illness experiences can contribute dramatically to healing and the softening or alleviation of suffering (Wright, 2015, 2017; Wright & Bell, 2009). Our evidence for this belief comes from our clinical and personal conversations as well as from reading numerous blogs and books about illness narratives.
We also believe that nurses will increase their caring for and involvement of families in their practice, regardless of the practice context, if such behavior is strongly supported and advocated by health-care administrators (Leahey & Harper-Jaques, 2010; Leahey & Svavarsdottir, 2009). One powerful and visual way for health-care administrators to show their commitment to family-centered care is to involve nurses in the creation, development, and implementation of family-friendly policies and services (International Council of Nurses, 2002). Table 9-1 offers some examples of family-friendly policies and actions at various levels.
TABLE 9-1 Implementation of Family-Friendly Policies and Services
SYSTEM LEVEL DEPARTMENT/UNIT LEVEL
■ Including family members as advisory-board or task-force members
■ Having family members as focus-group participants
■ Inviting family members to be program evaluators
■ Making family members participants in quality and safety initiatives
■ Providing parking at healthcare facilities for families with limited income ■ Providing family-friendly visiting hours
■ Providing family-friendly spaces such as a play area for children or offering a quiet room for retreat or for family discussion of difficult situations or moments
■ Lobbying for routine provision of family nursing therapeutic conversations when families are suffering
■ Inviting family members to participate in new staff orientation
■ Volunteering to orient new families to the inpatient unit and mentor other families
■ Inviting families to patient conferences
■ Accompanying patients to tests
■ Supporting patients during procedures
■ Assisting patients with personal care
The following are some specific ideas for conducting a 15-minute (or shorter) family interview. These ideas are the condensed version of the core elements previously presented in Chapters 5 through 7 about conducting family interviews. The ideas honor the theoretical underpinnings of the Calgary Family Assessment Model (CFAM; see Chapter 3) and the Calgary Family Intervention Model (CFIM; see Chapter 4) and highlight some of the most critical elements of these models.
KEY INGREDIENTS
The key ingredients of a healing, productive, and effective 15-minute family interview are presented in Figure 9-1.
The overall framework for ritualizing a 15-minute (or shorter) family interview consists of the following:
• Begin a therapeutic conversation with a particular purpose in mind that can be accomplished in 15 minutes or less.
• Use manners to engage or reengage. Introduce yourself by offering your name and role. Orient family members to the purpose of a brief family interview.
KEY CONCEPT DEFINED
Manners
A way of behaving toward others.

Figure 9-1 Key ingredients of a 15-minute interview.
• Assess key areas of internal and external structure and function—obtain genogram information and key external support data.
• Ask three key questions of family members.
• Commend the family on one or two strengths.
• Evaluate usefulness and conclude.
All of these elements can be involved only within the context of a therapeutic relationship between the nurse and family.
KEY CONCEPT DEFINED
Genogram
A structural assessment tool that shows a diagram of the family constellation.
Holtslander (2005) described how the 15-minute family interview was successfully applied to the needs of families in a postpartum unit. Martinez, D’Artois, and Rennick (2007) conducted research to explore nurses’ perceptions of the impact of the 15-minute interview on the hospital admission process and on their family nursing practice. They found that practicing pediatric hospital nurses perceived the genogram, therapeutic questions, and commendations as having a positive impact on their ability to conduct family assessments and family interventions. These nurses concluded that a 15-minute interview should be routinely incorporated into practice at the time of a child’s admission. More recently, Silva, Moules, Silva, and Boussa (2013) investigated the use of the 15-minute family interview with nurses completing postpartum home visits in Sao Paulo, Brazil. The nurses found the 15-minute interview useful in providing a broad range of information and identified their experiences using it as having a significant impact on their relationships with the families.
KEY CONCEPT DEFINED
Commendations
Comments by the nurse during family interviews and counseling that emphasize observed positive patterns of behavior, such as family and individual strengths, competencies, and resources.
Key Ingredient 1: Therapeutic Conversations
All human interaction takes place in conversations. Each conversation in which nurses participate effects change in their own and in patients’ and family members’ biopsychosocial-spiritual structures. No conversation that a nurse has with a patient or family member is trivial (Wright & Bell, 2009). Nurses are always engaged in therapeutic conversations with their clients without perhaps thinking of them as such.
KEY CONCEPT DEFINED
Therapeutic Conversation
Conversation in which nurses’ participation effects change in their own and in patients’ and family members’ biopsychosocial-spiritual structures. Such conversations are purposeful and time-limited and have the potential for healing through the very act of bringing the family together.
The conversation in a brief family interview is therapeutic because, from the start, it is purposeful and time-limited, as is the relationship between the nurse and the family. Therapeutic conversations between a nurse and a family can be as short as one sentence or as long as time allows. All conversations between nurses and families, regardless of time, have the potential for healing through the very act of bringing the family together (Hougher Limacher & Wright, 2003, 2006; McLeod, 2003; Robinson & Wright, 1995; Svavarsdottir & Sigurdardottir, 2013; Sigurdardottir, Svavarsdottir, Rayens, & Adkins, 2013; Wright & Bell, 2009). One study evaluated the usefulness of short therapeutic conversations with families (15 to 50 minutes, with an average of 30 minutes) with a child/adolescent experiencing chronic illness. The study yielded both expected and unexpected results (Svavarsdottir, Tryggvadottir, & Sigurdardottir, 2012). A positive, expected result was that parents in the experimental group perceived significantly higher family support after the intervention compared with the parents in the control group. An unexpected result was that these same parents in the experimental group perceived significantly lower expressive family functioning (e.g., emotional communication, collaboration, problem solving, and verbal communication) after the intervention of a short therapeutic conversation.
Svavarsdottir and colleagues (2012) offer possible explanations for the lower expressive family functioning following the therapeutic conversation intervention. One might be that parents with children with acute illnesses were generally younger and may not have had the instrumental or emotional resources to adequately cope with this illness crisis. Another explanation might be that the parents may have trusted the nurse more during and after receiving the therapeutic conversation intervention and therefore offered more of their “real” experience of family functioning in the context of illness. These results point the direction that additional studies will need to examine further what happens “inside” the intervention and in the nurse-family relationship.
It is not only the length of the conversation or time that makes the most difference but also the opportunity for patients and family members to be acknowledged and affirmed in their illness experience that has tremendous healing potential (Bell & Wright, 2011; Hougher Limacher, 2003; Hougher Limacher & Wright, 2003, 2006; Moules, 2002; Moules & Johnstone, 2010; Wright & Bell, 2009). Nurses are socially empowered and privileged to bring forth either health or pathology in their conversations with families.
Another pretest/posttest research study that illustrates the possibility of healing within families was conducted in four acute psychiatric units with patients and family members (Sveinbjarnardottir, Svavarsdottir, & Wright, 2013). The experimental group received two to five short therapeutic conversations. A control group of patients and families received traditional nursing care. The family members in the group who received the short therapeutic conversations intervention perceived higher cognitive and emotional support than those receiving traditional care. As more research studies examine the short therapeutic family interviews, they will add to the knowledge base about the effectiveness of short interviews and thus what needs to be implemented into practice.
The art of listening is also paramount. The need to communicate what it is like to live in our individual, separate worlds of experience, particularly within the world of illness, is a powerful need in human relationships (Wright, 2017). Frank (1998) suggests that listening to families’ illness stories is not only an art but also an ethical practice. Nurses commonly believe that listening also entails an obligation to do something to “fix” whatever concerns or problems are raised. However, in many cases, the most therapeutic move, intervention, or action the nurse can perform is showing compassion and offering commendations (Bell, 2016; Bell & Wright, 2011, 2015; Bohn, Wright, & Moules, 2003; Hougher Limacher, 2003, 2008; Hougher Limacher & Wright, 2003; Moules, 2002; Moules & Johnstone, 2010; Wright & Bell, 2009).
KEY CONCEPT DEFINED
Art of Listening
Listening to families’ illness stories while showing compassion and offering commendations.
It is the integration of task-oriented patient care with interactive, purposeful conversation that distinguishes a time-effective 15-minute (or shorter) interview. The nurse makes information giving and patient involvement in decision making integral parts of the delivery process. He or she takes advantage of opportunities and searches for ways to engage in purposeful, healing conversations with families. These practices differ from social conversations and can include basic ideas such as the following:
• Families are routinely invited to accompany the patient to the unit, clinic, or hospital.
• Families are routinely included in the admission procedure.
• Families are routinely invited to ask questions during the patient orientation.
• Nurses acknowledge the patient’s and family’s expertise in managing health problems by asking about routines at home.
• Nurses encourage patients to practice how they will handle different interactions in the future, such as telling family members and others that they cannot eat certain foods.
• Nurses routinely consult families and patients about their ideas for treatment and discharge.
Key Ingredient 2: Manners
Good manners have always been the core of common, everyday social behavior and interaction. However, in the last several decades in North America, social behavior has dramatically shifted from formal to casual social interaction. Style of dress has been altered from “Sunday best” to “casual Friday.” Martin’s (2011) Miss Manners’ Guide to Excruciatingly Correct Behavior offers her perspective and humor on manners. Miss Manners, as Martin is known, comments on what is missing in social interactions and thus what is missing in society. Manners are simple acts of courtesy, politeness, respect, and kindness. Culture as a whole seems to be undergoing an erosion of manners and thus civility. This erosion has spilled over into the nursing profession.
Nursing has not been immune to the changes in social behavior. In some situations, we can argue that formal nursing behaviors (such as dressing in starched uniforms and caps) perhaps inhibited our relations with clients and families. Countless nurses still maintain respectful, polite, and thoughtful relations with their clients. However, we have witnessed and listened to far too many professional and personal encounters between nurses, patients, and families in which manners were absent.
One of the most glaring examples of the absence of manners in nursing is in the basic social act of an introduction. Numerous stories have been told of nurses who do not introduce themselves to their patients, let alone the patients’ family members. For example, Pablo, a 23-year-old man, was seen in an outpatient clinic in a large metropolitan hospital after open-heart surgery. He reported that the nurse did not introduce herself but began touching his body and adjusting his intravenous peripherally inserted central catheter (PICC) line without telling him what she was doing or why. He found this experience very invasive, frightening, and rude.
This clinical anecdote is consistent with what nurses have told us about nurse-family relationships in the intensive care unit. We believe that one of the nursing strategies that inhibit the establishment of therapeutic relationships is the depersonalization of the patient and family. Examples include not referring to the patient by name, labeling the patient or family difficult, providing care without encouraging participation by the patient or family, and not talking or making eye contact.
KEY CONCEPT DEFINED
Therapeutic Relationships
Helping relationships based on mutual trust and respect, the nurturing of faith and hope, and being sensitive to self and others; assisting with the gratification of patients’ physical, emotional, and spiritual needs through the nurse’s knowledge and skills.
Therefore, introduction is obviously an essential ingredient of a successful family interview and relational family nursing practice. However, introductions by nurses have changed from overly formal to overly casual. Just a few years ago, a nurse might introduce herself as “Miss Garcia,” whereas now a more typical introduction is “Hello, my name is Sasha, and I’m your nurse today.” Any introduction is better than no introduction, but as one client remarked to us, “Nurses don’t introduce themselves any differently from a server who says, ‘Hi, my name is Josh, and I’m your server tonight.’” We encourage nurses always to introduce themselves by their full names, except in unique circumstances when there might be concerns about safety.
An equally serious omission is the lack of introduction by nurses to their patients’ family members. What inhibits or prevents nurses in hospitals, community health clinics, and home care from introducing themselves to the people at a patient’s bedside or to those accompanying the patient at a clinic? What prevents nurses from inquiring about their relationships to the patient? Worse yet, what precludes nurses from making eye contact with family members or friends, one of the most expected social norms in our North American culture? We have discussed this phenomenon with our nursing students and professional nurses. It has been revealed to us that the belief of “lack of time” constrains many nurses from talking with anyone but their patients for fear that family members or close friends may “ask questions” or “require time from me that I just don’t have.” We would like to counter this belief by suggesting that, in the end, nurses would save time if they would use a few manners with family members or friends. Nurses who did so would not be pursued at even more inopportune times by family members or friends inquiring about their loved ones. Nurses who have involved family members in their practice have reported that they have enjoyed greater rather than less job satisfaction (Leahey, Harper-Jaques, Stout, & Levac, 1995). Nurses who practice good manners also instill trust in family members. Box 9-1 provides some examples of manners.
Box 9-1 Examples of Manners
• Always call patients and family members by name.
• Always tell the patient and family members your name.
• Explain your role for that shift or meeting or any encounter with the patient and/or family.
• Explain a procedure before coming into the room with the equipment to do it.
• If you tell the patient or a family member that you will be back at a certain time, attempt to keep to that time or provide an explanation about why it didn’t occur.
Key Ingredient 3: Family Genograms and Ecomaps
Nurses need to make it a priority to draw a quick genogram (and sometimes, if indicated, an ecomap) for all families but particularly for families who will likely be part of their care for more than a day. Extensive details for the collection of genogram and ecomap information are given in Chapter 3 in the discussion of the “structural assessment” category of the CFAM. In a brief interview, the collection of genogram and ecomap information needs to be brief also. This information can be gleaned from family members in a couple of minutes.
The most essential information to obtain includes data about the age, occupation or school grade, religion, ethnic background, immigration date, and current health status of each family member. Begin by asking “easy” questions (e.g., ages, current health) of the household family members. Drawing out information relating to, for example, siblings’ divorces or grandchildren is not necessary or time-efficient unless this information immediately relates to the family and health problem. Once the genogram information is obtained, if indicated, expand the data collection to obtain external family structure information in the form of an ecomap. It may be useful to ask questions such as, “Who outside of your immediate family is an important resource to you or is a stress for you?” and “How many professionals are involved in treating your husband’s current heart problems?” Obtaining structural assessment data through the genogram and ecomap also serves as a quick engagement strategy because families are usually very pleased that a nurse is asking about their entire family rather than just the person experiencing the illness. It quickly acknowledges to the family the nurse’s underlying belief that illness is a family affair.
Ideally, the genogram should become part of any documentation about the family and patient. In one cardiac unit, genogram information is collected on admission, and the genogram is hung at the patient’s bedside. Emergency telephone numbers for family members are listed on the genogram. In this way, the genogram acts as a continuous visual reminder for all health-care professionals involved with the patient to “think family.”
Key Ingredient 4: Therapeutic Questions
Therapeutic questions are a key, defining element in a therapeutic conversation. Many ideas about and examples of linear, circular, and interventive questions were given in the presentation of the CFIM (see Chapter 4), in the discussion of family nursing skills (see Chapter 5), and in the vignettes demonstrating the use of questions (see Chapter 8). When nurses attempt to have a very brief family meeting, they can ask key questions of family members to involve them in family health care. We encourage nurses to think of at least three key questions that they will routinely ask all families.
KEY CONCEPT DEFINED
Therapeutic Questions
Questions that focus on the key, defining element in a therapeutic conversation and include linear, circular, and interventive questions.
Of course, these questions need to fit the context in which the nurse encounters families. For example, the questions that a nurse may ask family members in an emergency or oncology unit in a hospital might differ from the questions that a nurse might routinely ask family members in an outpatient diabetic clinic for children or in primary care. However, some basic themes need to be addressed, such as the sharing of information, expectations of hospitalization, clinic or home-care visits, challenges, sufferings, and the most pressing concerns or problems. Table 9-2 provides examples of questions that address these particular topics.
Key Ingredient 5: Commending Family and Individual Strengths
The important intervention of offering commendations (Bell, 2016; Bell & Wright, 2011, 2015; Hougher Limacher, 2003, 2008; Hougher Limacher & Wright, 2003, 2006; Moules & Johnstone, 2010; Wright, 2017; Wright & Bell, 2009) is fully discussed in the presentation of the CFIM (see Chapter 4). In each session, we routinely commend families on the strengths observed during the interview. In a brief family interview of 15 minutes or less, we endorse the practice of offering at least one or two commendations to family members on individual or family strengths, resources, or competencies that the nurse directly observed or gathered from another source. Remember that commendations are observations of behavior that occur across time. Therefore, the nurse is looking for patterns rather than a one-time occurrence that is more likely going to elicit only a compliment. An example of a commendation is “Your family is showing much courage in living with your wife’s cancer for 5 years.” A compliment would be “Your son is so gentle despite feeling so ill today.”
TABLE 9-2 Therapeutic Questions
QUESTIONS PURPOSE
How can we be most helpful to you and your family (or friends) during your hospitalization? Clarifies expectations and increases collaboration
What has been most and least helpful to you in past hospitalizations or clinic visits? Identifies past strengths and problems to avoid and successes to repeat
What is the greatest challenge facing your family during this hospitalization, discharge, or clinic visit? Indicates actual or potential suffering, roles, and beliefs
With which of your family members or friends would you like us to share information? With which ones would you like us not to share information? Indicates alliances, resources, and possible conflictual relationships
What do you need to best prepare you or your family member for discharge? Assists with early discharge planning
Who do you believe is suffering the most in your family during this hospitalization, clinic visit, or home-care visit? Identifies the family member who has the greatest need for support and intervention (Wright, 2017)
What is the one question you would most like to have answered during our meeting right now? I may not be able to answer this question at the moment, but I will do my best or will try to find the answer for you. Identifies most pressing issue or concern (Duhamel, Dupuis, & Wright, 2009; Wright, 1989)
How have I been most helpful to you in this family meeting? How could we improve? Shows a willingness to learn from families and to work collaboratively
Families coping with chronic, life-threatening, or psychosocial problems commonly feel defeated, hopeless, or failing in their efforts to overcome the illnesses or live with them. In our clinical experience, we have found that most families who are experiencing illness, disability, or trauma also suffer from “commendation-deficit disorder.” Therefore, nurses can never offer too many commendations.
Immediate and long-term positive reactions to commendations indicate that they are powerful, effective, and enduring therapeutic interventions (Bell, 2016; Bell & Wright, 2011, 2015; Bohn, Wright, & Moules, 2003; Hougher Limacher, 2003, 2008; Hougher Limacher & Wright, 2003, 2006; Moules, 2002; Moules & Johnstone, 2010; Wright & Bell, 2009). Benzies (2016) identified implementing relational communication strategies, including the use of commendations, as a useful tool for negotiating role boundaries and shared decision making for nurses in their day-to-day practice in neonatal intensive care units (p. 233). Hougher Limacher’s 2003 study, which specifically focused on understanding more about the intervention of commendations, lends even further validation to the power of commendations. Families who internalize commendations offered by nurses appear more receptive to and trusting of the nurse-family relationship and tend to readily take up ideas, opinions, and advice that are offered.
By commending families’ resources, competencies, and strengths, nurses offer family members a new view of themselves. When nurses change the view families have of themselves, families are commonly able to look at their health problem differently and thus move toward more effective solutions to reduce any potential or actual suffering.
PERSONAL EXAMPLE OF INVOLVING FAMILY IN NURSING PRACTICE
To illustrate how involving family members in health care can be effective and healing—or ineffective and resulting in a needless increase of suffering—Dr. Wright offers a personal story to illustrate the best and worst of family nursing. These experiences occurred during two very brief interactions with nurses in the emergency unit of a large city hospital while accompanying her mother for a possible admission.
Over the last 5 years of my mother’s life, she experienced several major exacerbations of multiple sclerosis (MS), with frequent hospitalizations. Each exacerbation left my mother more physically disabled. The extreme exacerbations of the last year of her life left her a quadriplegic. With each exacerbation, she never returned to the level of either physical or cognitive functioning that she previously enjoyed. Despite all of these setbacks, there was tremendous courage on the part of both my mother and my father. Amazingly, my mother’s moments of complaining, sadness, or grief were minimal, which of course buffered other family members’ suffering. I saw my father become a very caring caregiver and “nurse” while his own life became very constrained.
On one of my mother’s admissions to the hospital, I encountered two very brief but powerful conversations with nurses in the emergency department (ED). One I prefer to call “Naughty Nurse” and the other “Angel Nurse.” Both of these nurses had a profound impact on my emotional suffering. Both of these nurses interacted with me for a very brief time, not more than 5 minutes each.
Before our arrival at the hospital ED, I spent a few very exhausting hours with my mother. My father, mother, and I were enjoying a day at our cottage about an hour out of the city. As the afternoon unfolded, it became apparent that my mother was becoming more wobbly when walking (at that time she was still able to walk a few steps with assistance). As we were packing to leave, she became unable to bear weight. With great difficulty, my father and I lifted her into her wheelchair and headed down the ramp of our cottage to the car. The greater challenge lay ahead of us: to get her from the wheelchair into the car. It took all of our strength and ingenuity to accomplish this task, with my mother, of course, frightened that we would drop her. After some 30 minutes and lots of perspiration, we realized our goal, with my mother safely in the car. On the way into the city, we made a mutual decision to take her to the hospital where she had been admitted on previous occasions to have her assessed for possible admission. We all believed that she was having another severe exacerbation.
When we arrived at the ED, I was very relieved. It had been a very worrisome and arduous few hours. I now looked forward to my mother’s receiving nursing and medical assessment and treatment to assist her and us. My father waited with her in the car at the curb of the ED while I entered to seek assistance to lift my mother out of the car. On arriving at the nursing station, I encountered Naughty Nurse. I explained the current situation to her and requested assistance to lift my mother out of the car and into the ED. Naughty Nurse responded in a curt, mistrusting tone by saying, “How did you get her into the car?” This initial brief interaction was shocking to me; it was accusatory, blaming, and mistrusting of one another. No therapeutic relationship was being developed. This nurse’s response invited me to counter with an equally rude, impolite response. I said, “With great [difficulty], so we will need help to lift her out of the car.” Our conversation now escalated in terms of accusations and recriminations as Naughty Nurse retorted, “Well, I can’t lift her out of the car.” I suggested that perhaps one of her male colleagues could assist us. As Naughty Nurse and a male colleague approached the car to assist my mother, they did not introduce themselves to my mother nor did they discontinue their conversation with each other. This was an extreme example of what family nursing should not be. By now, I was very distressed and upset about our treatment by this particular nurse. Of course, she was completely unaware that, in my professional life, I teach, practice, research, and write about family nursing.
However, all was not lost. Within a short while, we were placed in a room in the ED, and after a brief wait, “Angel Nurse” appeared. First, she introduced herself to my mother, explained that she would be taking her blood pressure and temperature and that blood work had been ordered. Angel Nurse competently and kindly attended to my mother, inquiring about both her medical history and her illness experiences with MS. In a very impressive manner, she reassured my mother that she would probably be admitted for another round of intravenous steroids and that everything would be done to keep her comfortable.
Then she came to me, reached out her hand to shake mine, introduced herself, and warmly inquired about the nature of my relationship to the patient. I was softened by this nurse’s kind and competent approach. I offered the information that I was the patient’s daughter and that I was visiting from another city. Then the nurse offered a possible hypothesis in the form of a statement: “This must be very upsetting for you.” In that one sentence, this nurse assessed and acknowledged my suffering. Angel Nurse provided comfort and understanding through her very brief interaction with me in probably less than 2 minutes. However, in just those 2 minutes, she had involved me in her practice and some of my emotional suffering had healed.
Later, on reflection, I realized that my reaction to this nurse’s encounter with me was to make every effort to assist her in caring for my mother because I could see that she was overloaded with patients in the ED. Angel Nurse’s particular nursing approach had encouraged me to want to be more helpful to her. Kindness invites kindness; accusations invite accusations. In this very brief interaction, Angel Nurse had entered into a therapeutic conversation with me, my mother, and my father. She also showed good manners by shaking my hand, introducing herself, eliciting some genogram information, and validating my suffering. Perhaps not all the key ingredients that we have suggested for a brief family interview are evident in this interaction with Angel Nurse; however, it exemplifies how the context and the appropriateness of the situation determine how much family members can be involved. This nurse beautifully demonstrated that family nursing can be done, even in busy EDs, in just 2 minutes and still effect healing.
CASE SCENARIO: KAREN NELSON
Karen Nelson is a 68-year-old woman who lives with her 70-year-old husband, Vern, in a small town 20 minutes outside of the city. Karen is at a hospital waiting to see an orthopedic surgeon; a few hours earlier, she fell in her apartment, broke her upper arm, and was transferred to the emergency department (ED) in the city. Presently, her son, Andrew, and daughter-in-law, Louise, are with her at the bedside in the ED. Karen tells Andrew and Louise that she is concerned about how Vern is managing at home alone and what they will do if she needs to stay in the hospital overnight or for a few days.
After 5 hours of waiting for the surgeon with Karen, Andrew and Louise decide to go home; they have left their 2-year-old son with Louise’s parents, and Karen is becoming very tired and would like to sleep since it is 1 o’clock in the morning. Karen has not yet been seen by the orthopedic surgeon, and Louise and Andrew are very uncertain about whether Karen will have to stay in the hospital and how they will manage everything with Vern at home alone. As they begin to leave, they realize that they have had very minimal interaction with the nurse who came in and out of the room in the ED all evening, and they are not sure of the nurse’s name. Louise rings the call bell and asks for the nurse to come to their room. When the nurse arrives, Louise asks the nurse to write down Andrew’s cell phone number in Karen’s chart in case of an emergency or if Vern does not answer the phone during the night. The following conversation ensues:
Nurse: “Well, who are you, anyway, and why would we need this number?”
Louise: “I am Louise, Karen’s daughter-in-law, and this is her son, Andrew. We live close to the hospital, and Karen’s husband, Vern, lives 20 minutes outside of town and has very poor mobility.”
Reflective Questions

1. What would be the benefits of the nurse conducting a 15-minute family interview with Karen, Andrew, and Louise?
2. How could the nurse use therapeutic conversation to provide Karen, Andrew, and Louise with the opportunity to share their feelings about their current situation?
3. What are three key therapeutic questions the nurse could ask Karen, Andrew, and Louise to gain an understating of their expectations during their time in the emergency department and the most pressing concerns or problems they currently have?
   CRITICAL THINKING QUESTIONS
4. Identify barriers to involving family in your nursing practice area. What are potential solutions to these barriers?
5. Consider how you would complete a 15-minute family interview in your practice area. What are the benefits? What are the challenges?
6. Consider the key ingredients of therapeutic questions and commendations. Can you provide an example of how you would apply each of these specifically to your nursing practice?
7. What influences the manners of individuals or families? Consider values, beliefs, culture, age, society, and technology. How might this impact your therapeutic relationship?

Chapter 10
How to Move Beyond Basic Family Nursing Skills
Learning Objectives
• Compare the difference between basic and advanced skills in family nursing.
• Summarize the distinguishing features of advanced skills in family nursing.
• Describe advanced skills used when interviewing families of the elderly at times of transition.
• Describe advanced skills used for interviewing an individual to gain a family perspective on chronic illness.
Key Concepts
Advanced family nursing skills
Basic family nursing skills
Relative influence questioning
Moving beyond basic family nursing skills requires increased knowledge, increased clinical practice, and greater attention to the uniqueness of each practice context. It also involves an appreciation of the circularity between knowledge and practice.
Entering into therapeutic conversations with families can increase our understanding of and knowledge about families while simultaneously offering interventions to promote health and/or to address concerns or ease suffering. Our research efforts can augment the efficacy of our interventions with families, and this new knowledge is extended back into practice. Thus, both clinical practice and research operate in a continuous feedback loop for one another, with promising benefits for both families and nurses. Experienced nurses realize that it is always an interactional process of “evidence-based practice” and “practice-based evidence” that enhances the care offered to families.
KEY CONCEPT DEFINED
Basic Family Nursing Skills
Generalist-level nursing skills used when caring for families.
A major challenge in determining core competencies for family work is to distinguish what can be called “general skills and knowledge”—which are needed by all nurses working with clients or patients—from unique, advanced practice skills and knowledge, particularly those of family nurses. Another challenge is to delineate sufficient competencies to cover the range of practice settings and yet not specify so many that the practitioner is overwhelmed.
In Chapter 5 we discuss basic essential skills and stages in family nursing interviews. In this chapter we discuss the more advanced family nursing skills that we have identified and labeled as vital in interviewing families in various settings. Two clinical vignettes are offered to highlight advanced practice skills. In particular, we present sample skills for interviewing families of the elderly at times of transition and advanced skills for interviewing an individual to gain a family perspective on chronic illness. We also offer tips for advanced practice with these populations and delineate advanced micro-skills. Ideas for how to integrate family nursing into various practice contexts are also offered.
KEY CONCEPT DEFINED
Advanced Family Nursing Skills
An expanded range of nursing skills that improve health outcomes for patients and families in the larger discipline of nursing; these skills require increased knowledge, increased clinical practice, and greater attention to the uniqueness of each practice context.
FAMILY NURSING SKILLS IN CONTEXT
The importance of specifically tailoring family nursing interviewing skills to the relational practice context cannot be overstressed. We have found in our review of the literature that the contextual and clinical competence application is often overlooked. Leahey and Svavarsdottir (2009) advocate that knowledge translation and exchange are a shared responsibility requiring the involvement of researchers with potential knowledge users such as practicing nurses. Astedt-Kurki and Kaunonen (2011) recommend making family nursing more visible through intervention studies involving skilled nurses.
However, awareness of research findings does not necessarily mean adoption. Rather, interventions must be adapted to local settings that are inevitably varied, complex, and idiosyncratic. Duhamel (2010), who developed a Center of Excellence in Family Nursing at the University of Montreal, advocates “engaged scholarship” to create knowledge and application into practice in unique clinical settings. Svavarsdottir and Sigurdardottir (2011) have provided excellent examples of knowledge exchange in pediatric settings. In an ambitious and innovative project, Moules, Laing, Morck, and Toner (2011) have undertaken a program connecting family research in pediatric oncology to practice; they are devising interventions in an effort to reduce family suffering in the experience of childhood cancer.
The new knowledge created must be useful for nurses and families in the unique relational practice setting. McLeod, Tapp, Moules, and Campbell (2010) found that the skill of addressing specific family concerns in the oncology unit was particularly helpful. Gathering family members and opening space for conversation allowed the nurse to feel he or she “knew” the families. Coming to know the families as individuals with histories was an important skill identified by the researchers. Vandall-Walker, Jensen, and Oberle (2007) found that in the intensive care unit (ICU), skills identified as important in this setting included engaging with family members, sustaining them, and disengaging from them.
Leahey and Harper-Jaques (2010) created a method for integrating family nursing into practice settings and used a mental health urgent care context in a Canadian community health center as an example (Southern et al, 2007). Leahey and Harper-Jaques (2010) developed a grid and listed the main four elements of clinical practice in the setting: mental health/psychiatric assessment, physical health assessment, family nursing, and integrated behavioral health care. Alongside these practice framework elements, they listed Benner’s (2001) skill levels from novice to advanced beginner to competent to proficient to expert. See Table 10-1 for mental health urgent care practice framework elements and ladders.
Staff had identified the need for a practice framework specific to their setting and participated in generating the skills relevant for each section of the grid. Through team discussion, observation of clinical work, reviews of the literature, clinical documentation audits, supervision, and feedback from clients and families, family nursing practice took hold in the setting. Family nursing grew to be seen as an integral part of practice rather than as an “add-on” or “one more thing to do.” The value of this tool is that it can be adapted to various settings by tailoring the practice framework elements and specifying the unique family nursing skills for the context.
TABLE 10-1 Mental Health Urgent Care Practice Framework Elements and Ladders
LADDERS MENTAL HEALTH/PSYCHIATRIC ASSESSMENT PHYSICAL NURSING ASSESSMENT FAMILY NURSING INTEGRATED BEHAVIORAL HEALTH
1
Novice
2
Advanced/Beginner
3
Competent
4
Proficient
5
Expert
Leahey, M., & Harper-Jaques, S. (2010). Integrating family nursing into a mental health urgent care practice framework: Ladders for learning. Journal of Family Nursing, 16(2), 200. Copyright 2010 by Maureen Leahey and Sandy Harper-Jaques. Reprinted by permission of SAGE Publications.
Duhamel and Dupuis (2011) believe that utilizing family systems nursing knowledge in clinical practice requires more administrative and educational support than is usually offered. They advocate a circular process among education, research, and practice, especially favoring the idea of having facilitators or coaches in the clinical setting to advance practice skills and implementation. The work of Litchfield (2011) in New Zealand similarly supports the value of a mentor and the inclusivity of stakeholders.
Nevertheless, Svavarsdottir et al (2015) identify the need for further research at an institutional level focusing on effective strategies to implement family systems nursing into practice.
BEYOND BASIC SKILLS
Differentiating basic and advanced skills in family nursing is a challenge. We believe that education, experience, practice time, and deliberate practice are considered to be distinguishing features between basic and advanced skills in family nursing.
Education
Education can be thought of as a differentiation point, with higher nursing education implying advanced skill level. Moules, Bell, Paton, and Morck (2012) stress that “teaching graduate family nursing students the important and delicate practice of entering into and mitigating families’ illness suffering signifies an educational practice that is rigorous, intense, and contextual, yet not articulated as expounded knowledge” (p. 1). More conceptual knowledge aims to lead to a more advanced skill level, but as Chesla (2008) points out, awareness of information does not necessarily lead to implementation or executive skills.
Experience
Experience can be another delineator of levels. For example, the novice interviewer typically talks with the family to obtain information for the nurse, whereas the more experienced nurse invites the family to ask questions and designs interventions for the family’s needs. This is an important distinction. The more proficient nurse demonstrates curiosity about the family’s needs, styles of coping, and so forth, in an effort to maximize the family’s and nurse’s ability to care for their loved one. In this situation, the nurse and family collaborate on a plan of care instead of the nurse controlling and directing the interview process with less regard for the needs and concerns of the family.
Practice Time
Another way to conceptualize expert or advanced practice skills is the “10,000-hour rule” popularized by social science commentator Malcolm Gladwell (2008). He claims that to be an expert and successful in any field requires 10,000 hours of deliberate practice. The 10,000-hour rule is usually attributed to the research done by Anders Ericsson (2006). He and his team divided students into three groups ranked by excellence at the Berlin Academy of Music and then correlated achievement with hours of practice. They discovered that the elite had all put in about 10,000 hours of practice, the good 8,000 hours, and the average 4,000 hours. This rule was then applied to other disciplines, and Ericsson found that it proved valid.
Deliberate Practice
More recently, Ericsson’s work on deliberate practice has been geared toward application in established domains of expertise, such as nursing and medicine (Ericsson, Whyte, & Ward, 2007). It is our belief that the 10,000-hour rule could be one useful guideline to determine when nurses have become expert in their clinical skills when working with families.
Recognition and the ability to make relevant observations are factors in increasing perceptual skill development. Benner’s ladders (2001) are another way of differentiating various skills by the changes in familiarity, integration, flexibility, and efficiency that accompany each skill level. We believe that whatever method one chooses to differentiate basic and advanced skills is less important than the compassionate application of these skills with unique families in specific relational practice contexts.
CLINICAL EXAMPLE 1: INTERVIEWING FAMILIES OF THE ELDERLY AT TIME OF TRANSITION
Setting, Family Composition, and Purpose of the Interview
Ross, age 72, and Myrna, age 70, are siblings whose mother has recently moved into a long-term care facility. They have two younger sisters, ages 69 and 60, who live in different cities. Ross is retired and separated from his wife. He has four children and four grandchildren. Myrna is a widow with two sons and four grandchildren, and she continues to work 3 days a week. Ross and Myrna’s father died 15 years ago. Myrna and Ross have a photo of their mother at her 99th birthday party.
The purpose of this example is to offer tips for collaborating with senior children at the time of their elderly parents’ transition to a care facility and to demonstrate the advanced micro-skills for quickly engaging with family members, obtaining a brief relevant history, discussing caregiver impact and burden, and responding to senior children’s suggestions about their parents’ care. The necessary clinical skill or skills are listed before each example.
Clinical Skills:
• Engagement
• Creating welcoming context for collaboration
• Involving all family members
• Obtaining brief relevant history by co-constructing an illness narrative versus a medical narrative
Dr. Leahey: First of all, let me introduce myself. I’m Maureen. Glad to meet you. Myrna, is it?
Myrna: Yes, it is.
Dr. Leahey: And Ross? Glad to meet you, hi. So thanks very much for coming in this afternoon. I understand that this is the third facility that your mom has been in. And so one of the routine practices that we have here is that when our patients have been in other facilities, we like to meet with the family as soon as possible.
Maybe one way we could start is for me to ask you, how did it come to be that your mom came to this facility?
Ross: Do you want to start, Myrna?
Myrna: Mom has lived at home until this year. She’s been very independent, and she feels independent, but that’s partly because the family’s protecting her. But she was getting to a point where she really couldn’t look after herself. She was getting quite forgetful, and we had several caretakers at different times in the home, but they didn’t seem to work out. Things would go fine for a little while, and then Mom would not like something they did. So we went through a succession of those people but decided that we just really couldn’t keep Mom in her home. So we have talked about it for years and finally really encouraged her last year that we just had to find a place for her and started looking.
Dr. Leahey: So what…
Ross: And it was trying because she’s so independent. She’s a tough old Norwegian, and independence is most important to her, so she was very resistant. We eventually did get her to look at two or three facilities, and she kind of gave in to it in a way. She was in her own home, multilevel, a lot of steps and preparing her own meals. She was not eating properly. We had to do something, so we did find a seniors’ living residence. That was the first place that she moved into.
Dr. Leahey: Yes.
Ross: And she was … started to have some falls, so they … at one point they thought she had broken some bones and she had to be admitted to the hospital. In the hospital, she was assessed and told that she could not go back to her…
Myrna: Assisted living.
Ross: Her assisted living.
Dr. Leahey: Okay. So this has been a long haul for your family in getting your mom to this facility.
Ross: Very, very long.
Clinical Skill:
• Eliciting impact of illness on family members
Dr. Leahey: What do you think has been the impact of that on you, Ross?
Ross: Oh, the impact? I went through 14 years of always being there and available, and it just got more intense as time went on. The impact? By the time when we finally got her into a facility last August until December, I lost 18 pounds. I mean, my weight was dropping. It was really, really a big thing because when she was in the assisted living, I’d be getting phone calls every day. What do you want to do about this? What are you going to do about that?
Dr. Leahey: You look sad just talking about it. It’s okay with me if you cry.
Ross: Oh, I’m not going to cry.
Dr. Leahey: Okay.
Ross: It’s … but it is a fact of life, and this is—
Dr. Leahey: Yes.
Ross: Unfortunately, the way it went.
Dr. Leahey: And what do you think the impact has been on Myrna of looking after your mom?
Ross: She’ll have to answer that. (Smiles and nods)
Myrna: I think it’s … there’s been much less impact on me partly because Ross has taken the major role. Having worked and not being available has made me less accessible to care.
Ross: It’s that, but the other fact is that Mother is from a…
Myrna: A patriarchal viewpoint.
Ross: She has a patriarchal viewpoint that the girls cannot do the job as well as a man, and that’s unfortunate because they can do better than I could probably. But it always has to be me who makes the final decision.
Clinical Skills:
• Demonstrating curiosity
• Inquiring about the biopsychosocial-spiritual factors when asking about the impact of stress on family members.
Dr. Leahey: Do you have some health problems, Myrna?
Myrna: I do. I was diagnosed with Parkinson’s almost 7 years ago, and one of my main symptoms is tiredness. So I just find it hard to cope with any extra requests or demands of Mom. I think it’s kind of settled down now. We’ve each got kind of our own jobs, and that’s what we do.
Dr. Leahey: And how did you manage as a group of siblings to figure out your own jobs?
Ross: It just fell into place.
Dr. Leahey: Fell into place?
Ross: I mean, we each have our own strengths.
Dr. Leahey: Yes.
Ross: And we are close and we just … we back each other up, and if we need help in an area, we ask the others for help or thoughts. It’s cooperation. That’s the big thing.
Dr. Leahey: And how about for you, Ross? Do you have any health problems?
Ross: No, my health is pretty good, basically.
Myrna: Although your blood pressure has—
Ross: Well, that was the other thing. My blood pressure shot up last fall, too, because of all the extreme stress that we were going through. But it’s under control.
Clinical Skill:
• Asking for other family members’ noticings or ideas
Dr. Leahey: What impact would you say your sons would have noticed, Myrna, on you?
Myrna: I think they’re aware that it creates a strain for me, but day to day I don’t think it really affects our relationship. I think they are more concerned about me than they are about their grandmother.
Dr. Leahey: And what do you think they’re most concerned with about you?
Myrna: Tiring out. Just, you know, the Parkinson symptoms increasing, but I think they feel that Grandma is now in place.
Ross: She’s being looked after.
Dr. Leahey: She’s being looked after?
Myrna: Yeah.
Ross: It’s not a concern.
Myrna: Yeah.
Clinical Skills:
• Summarizing
• Using the patient’s language
• Commending
• Asking for other’s advice to patient
Dr. Leahey: It sounds like your mother has been very fortunate to have the two of you and your sisters who have looked after her as well as you have. And sometimes it sounds like at the expense of your own health. I mean, your blood pressure, your weight loss, the tiredness and stress on your Parkinson’s. And if your boys were here, what advice might they want to give to you, Myrna, about your health?
Myrna: That I shouldn’t stress myself. I should take it easy. They really are very sensitive about it.
Dr. Leahey: And would you take their advice?
Myrna: I think I do. Yeah.
Dr. Leahey: What do you think? Does she take it enough?
Ross: I don’t know.
Myrna: They don’t put a lot of demands on me.
Clinical Skill:
• Inviting conversation about various family members’ beliefs and coping styles
Dr. Leahey: One of the things I did want to ask you is, if your mom were here with us today, what might she say has been the most challenging part of coming into this facility?
Myrna: I think leaving her home.
Dr. Leahey: Leaving her home. And what do you think, Ross?
Ross: Well, leaving her home is a very big thing to her. I’d say it was her anchor. Also leaving her cat.
Myrna: Yeah.
Dr. Leahey: Oh.
Ross: And her pet was a very big thing in her life.
Myrna: And actually, that was one of the ways we were able to move her initially because they allowed pets where she moved, so she could take her cat.
Dr. Leahey: I see. And is her cat still alive?
Ross: It was this morning. (Laughs)
Dr. Leahey: Okay, good. (Smiles)
Myrna: Ross inherited the cat.
Dr. Leahey: And you know that you can bring the cat into the facility here?
Ross: Yes, we’re aware, and we have plans to do that. We also realize that the shots have to be up to date, and that’s taken care of.
Dr. Leahey: Good, and your mom, does your mom know that the cat can come and visit her?
Ross: Yes.
Dr. Leahey: Okay.
Myrna: She asks about the cat all the time.
Dr. Leahey: Okay.
Myrna: More so than the family members.
Dr. Leahey: And how’s that for the family members?
Myrna: It’s fine.
Ross: We understand. She’s focused on certain things, more things that have immediate meaning to her.
Clinical Skill:
• Asking patients what others might appreciate about them
Dr. Leahey: So if your mom were here with us now, what might she say that she most appreciates about the two of you?
Ross: I don’t know. Probably looking after her affairs.
Dr. Leahey: Looking after her affairs.
Ross: Yeah. Being the house and her monetary things.
Myrna: Well, it’s an interesting question because sometimes I wonder if Mom appreciates what we’re doing for her, really truly appreciates. There’s not a lot of, well, she’ll say thank you for doing this or that, but there’s … to me, there’s not a sense of real appreciation.
Ross: I don’t think she grasps the amount of effort that is involved, and to her, well, it’s just you do it, and that’s the way it is.
Myrna: She knows. She gets upset if we don’t visit every day, but she doesn’t appreciate what that does to our lives.
Ross: She’s become quite self-centered.
Myrna: Which I think is normal.
Dr. Leahey: So that can be very hard when you’re caregiving as much as you have been to feel like your mom, although appreciative, is not really aware of the impact that it has on your lives. How do you both cope with that?
Ross: Well, I understand that her health is deteriorating. Her mental abilities are deteriorating, and that just goes with age. We’ll all reach that point and just try and understand that this is not the person you knew, and they can’t help it.
Dr. Leahey: So that’s your belief … she can’t help it and…
Ross: For the most part. Sometimes she uses it, but for the most part, yeah.
Dr. Leahey: And how about for you, Myrna?
Myrna: I think I have the same attitude. It really hurts when she uses it or goes off into a tantrum, which is unfair, really.
Dr. Leahey: Yes.
Myrna: But you very quickly come around to the realization that’s how she’s feeling, and that’s the only way she can demonstrate it. I mean, I try to put myself in her place, and it must be horrible. I don’t know what you wake up every morning looking forward to, so I can certainly understand some of her comments and criticisms. But I think she’s getting much better.
Clinical Skill:
• Eliciting “unspoken” information
Dr. Leahey: Would there be anything that we should know about your mom that maybe she wouldn’t tell us that would make it easier for us to care for her or to be helpful to her?
Ross: I can’t think of anything. Well, maybe one thing is that she still insists on her independence. She doesn’t like people doing everything for her. I think she would still like to make more choices than are available to her, such as seating at meals, choice in meals, times for bathing, things like that. And, you know, how much help does she need dressing, or how much does she want to do herself?
Dr. Leahey: Thank you, and I’ll make sure to put that with a big star on her care plan.
Clinical Skill:
• Eliciting family expectations for collaborative care and responding to expectations
Dr. Leahey: When you think about what we could do in this facility to both help your mom and help the two of you and your sister, Linda, what comes to mind?
Ross: Well, I think I feel our major role is to advocate and be aware of what’s going on and to work with the staff to try and work around problems that might occur or give suggestions for how they could better help her and just interaction between the staff and ourselves.
Dr. Leahey: We do welcome people’s ideas, and it sounds like you’ve been through a hard time, particularly in the last year.
Ross: We have.
Dr. Leahey: Yes. You’re obviously very caring and think about your mom in many different ways like her privacy, her independence, her socialization, her food. Nice. Is there anything else you can think of how we could work with you to make your mom’s last years as comfortable as possible?
Myrna: I think the open communication is the most important thing, that we feel comfortable being able to make suggestions.
Dr. Leahey: Okay.
Myrna: And that works the other way … that you’re keeping us up to date on changes in Mom.
Dr. Leahey: So some reciprocity there that you would tell us things you notice and that we would tell you. Some people like to have periodic meetings.
Ross: That was my next point.
Dr. Leahey: Do you like that? Some other families say “no news is good news.” What’s your preference?
Ross: No, I don’t take that attitude at all. I would welcome periodic meetings.
Dr. Leahey: Okay.
Ross: Not just for the sake of having a meeting but because there’s purpose in it that it will be beneficial for all those involved.
Dr. Leahey: Okay, good.
Clinical Skills Summary
Tips and micro-skills for working with elderly persons and their families include the following:
• Draw forth the family’s illness experience.
• Ask difference questions, such as, “What do you think your sons are most concerned with about you?”
• Inquire what absent family members might say about the situation being discussed.
• Ask about the biopsychosocial-spiritual domains, and identify family and individual strengths.
In the preceding case example, the following clinical skills were demonstrated:
• Empathized with the siblings about the stress of the last year
• Commended their caring for their mother
• Pursued with them what they would find most helpful
• Asked open-ended questions to elicit their desires
• Offered practical, concrete suggestions such as family meetings
• Wove commendations throughout the interview
All these are more advanced micro-skills that a nurse interviewer can compress and use in a thoughtful, purposeful, time-effective interview. Two interventions have shown to be particularly powerful in promoting hope. Weaving commendations throughout the interview, we have found, is a very helpful and healing practice. Inviting reflections about what family members appreciate about each other can also be a powerful intervention that invites more confidence and competence in the family and thus leaves the family more hopeful about their abilities to manage in the future.
CLINICAL EXAMPLE 2: INTERVIEWING AN INDIVIDUAL TO GAIN A FAMILY PERSPECTIVE ON CHRONIC ILLNESS
Setting, Family Composition, and Purpose of the Interview
Ralph, age 55, came to the outpatient clinic looking for more coping strategies to deal with his longstanding chronic pain related to his disability. Ralph has been married for 37 years and has two children, ages 31 and 29. Ralph is self-employed in a mobile knife-sharpening business, and his wife is the bookkeeper in the family business. She is also employed full-time as a paralegal.
In these excerpts, Dr. Wright explores how a chronic illness impacts a middle-aged man’s life and relationships. The interview is brief, time-limited, and effective. The purpose is to recognize that illness is a family affair and that all family members are affected by and can influence an illness, demonstrate the skills for gaining a family perspective when interviewing an individual, assess the impact of chronic illness on one’s life and relationships, assess solutions and coping strategies, and intervene by offering commendations and planning a ritual. What do health professionals do if family members cannot or will not attend a meeting so that a family perspective can be obtained? What if the context in which the health professional works does not lend itself to involving other family members? Yes, it is possible to “bring family members into the room” even if only meeting with an individual.
In the first excerpt of the therapeutic conversation, Dr. Wright asks, “What are you most hoping can happen at the Center and during our meeting together?” This is an example of a collaborative interaction in which Ralph and Dr. Wright jointly set the goals.
Clinical Skills:
• Recognize that illness is a family affair and that all family members are affected by and can influence an illness.
• Gain a family perspective when interviewing an individual.
• Assess the impact of chronic illness on one’s life and relationships.
• Assess solutions and coping strategies.
• Intervene by offering commendations.
• Plan a ritual.
Dr. Wright: I’m wondering, what are you most hoping can happen at the Center and during our meeting together? What are you most interested in?
Ralph: Basically, coping mechanisms.
Dr. Wright: Coping mechanisms.
Ralph: To help cope with the pain.
Dr. Wright: To cope with pain, yes?
Ralph: Right. Because of the fact that I have some permanent spinal cord damage.
Dr. Wright: Yes.
Ralph: From my accident.
In this next segment, Dr. Wright inquires about the family’s problem-solving strategies.
Clinical Skill:
• Exploring usefulness/not usefulness of other helpers
Dr. Wright: And so your wife went to the pain clinic?
Ralph: Yes, she went to see the pain psychologist.
Dr. Wright: Right, and was that helpful to her?
Ralph: It was because it helped to direct our conversations. If I was having a bad day and started to react to everybody around me because I was having a bad day, then it helped her because then she was able to look at me and say, “Is this the pain talking or are you having other issues?”
Dr. Wright: Oh, okay.
Ralph: A lot of times when people are arguing or people are short with their kids or whatever, it’s because they’re in pain and it’s a reaction to the action.
Dr. Wright: Do you ever find, though, that it’s useful to use your pain as an excuse or an out if you are…
Ralph: Actually…
Dr. Wright: … getting into trouble with your wife or your kids?
Ralph: No, I don’t.
Dr. Wright: No? Just say, “Oh, that’s the pain talking. It’s not really me”? Or …?
Ralph: Actually, I don’t personally know.
Dr. Wright: Okay, and so have you and your wife been seen now together as a couple or did she just go?
Ralph: No, we went together, and she also went to private sessions. I went to private sessions, too, and then we were seen by the pain psychologist together.
Clinical Skill:
• Inquiring about the best/worst advice the client received
Dr. Wright: Okay, and what was the best and worst advice that was offered to you?
Ralph: The world doesn’t stop just because you’re in pain.
Dr. Wright: That was the best advice? Yes?
Ralph: That was the best advice.
Dr. Wright: Okay. And the worst advice?
Ralph: One of the other best advices was if you don’t control it, it will control you. That was the second part of that.
Dr. Wright: Okay. So if you don’t control it…
Ralph: It will control you.
Dr. Wright: Will control you. And what was the worst advice you received?
Ralph: Don’t worry. Things will get better.
Dr. Wright: Ah.
Ralph: Because by expecting things to get better when a person is in chronic pain … It is far better for them to learn how to deal with the situation they’re in rather than hoping that it’s going to get better or expecting it to get better.
Clinical Skill:
• Inquiring about the impact of illness on family members
• Asking difference questions
Dr. Wright: Right. So who do you think the pain has been a bigger problem for over the years? You or your wife?
Ralph: Oh, it’s definitely been a larger problem for me.
Dr. Wright: A larger problem for you. And what’s your wife…
Ralph: But it definitely has had an impact. It’s had an impact on not only my wife but my children as well. For instance…
Dr. Wright: Yes. Tell me about that.
Ralph: They were 5 and 7 years old when I broke my neck. So I wasn’t able to have them sit on my knee.
Dr. Wright: Okay.
Ralph: It took me a long time to learn how to walk. So…
Dr. Wright: So they only really remember you as a dad with pain or…
Ralph: Yes.
Dr. Wright: … disabilities or problems, challenges all the time.
Comments
Throughout the interview, did you notice how Dr. Wright explored Ralph’s understanding of the effect of chronic pain on his wife and children? And then how she was curious about the best and worst advice he had been offered? This is very helpful in being able to sidestep errors or mistakes that Dr. Wright could make by offering similar recommendations that were not found to be helpful in the past.
Clinical Skills:
• Naming the illness
• Using the client’s language
Dr. Wright: What do you call it? Do you call it a disability? Do you call it an accident? How do you refer to it?
Ralph: It’s … I just … I have a permanent disability.
Dr. Wright: Permanent disability.
Ralph: I consider it to be a permanent disability.
Dr. Wright: That’s how you refer to it?
Ralph: And that’s it.
Dr. Wright: Okay.
Ralph: But it is, actually. It’s helped me put life into perspective in that I control how I react to things. And it has helped me by all of the different reading that I’ve done.
Dr. Wright: Okay.
Comments
In this next section of the case example, Dr. Wright explores the influence of chronic pain on Ralph’s life and the pain’s influence on him. This line of questioning is called relative influence questioning, and we wish to credit the late and brilliant Michael White (1989) of Australia for this very useful way of questioning.
KEY CONCEPT DEFINED
Relative Influence Questioning
Questioning that allows clients to think of themselves not as problems but as individuals who have a relationship with a problem.
Clinical Skill:
• Relative influence questioning
Dr. Wright: What, at this moment today, what percent of the time does pain rule your life, and what percent of the time do you think that you have control over the pain?
Ralph: I…
Dr. Wright: What percent do you control now?
Ralph: I have to be able to control the pain at least 75% of the time.
Dr. Wright: Seventy-five, okay.
Ralph: Because of the permanent spinal cord damage, I have problems in that I spasm.
Dr. Wright: Okay.
Ralph: I have to take an antispasmodic, and there are problems with having permanent spinal cord damage. I’ve taken a lot of medication, and now the medications have created different problems.
Dr. Wright: Like?
Ralph: Like problems with my liver, problems with my kidneys.
Dr. Wright: Oh, dear.
Ralph: And so consequently, there are other things to deal with.
Dr. Wright: So 25% of the time the pain controls you.
Ralph: Yes, which is why I have to get up and I have to actually do things in order to control the pain so that I can continue on with my life.
Dr. Wright: So when you say today that you’ve come to this pain center and you are wanting to have more coping strategies, what percent are you trying to get to manage?
Like, what would be your ideal percent that you would say, wow.
Ralph: It would be nice to be 90%.
Dr. Wright: 90%.
Ralph: I mean, I am not looking for a fairy godmother or some … I don’t expect…
Dr. Wright: Okay, to wave her magic wand over you and…
Ralph: A magic wand and everything is going to be fine.
Dr. Wright: And the pain is gone forever, yeah.
Ralph: Coping strategies so that I can learn more about how to cope so that I don’t … so I can get on more with a normal life, whatever that might be.
Dr. Wright: Okay. So you really are only asking to have coping strategies for 15% more?
Ralph: That’s right.
Dr. Wright: That’s amazing. So you’re willing to live with at least 10% pain 24/7. Yes?
Ralph: I have to be realistic.
Clinical Skill:
• Asking the “one-question question”
Dr. Wright: Okay. So in our meeting together today, if there was just one question that you could have answered today, what would that one question be around your situation? What you’ve been dealing with?
Ralph: Actually, I would say that it’s how to help me help myself.
Dr. Wright: How can you help yourself?
Ralph: Is there something that could be pointed out or something that could be better? Because everybody has a different perspective.
Dr. Wright: Yes.
Ralph: Sometimes I don’t see certain things because I’m too close to it.
Comments
In this segment, Ralph’s response to Dr. Wright’s question again demonstrated his openness to new ideas for problem solving. In this next excerpt, Dr. Wright asks about Ralph’s family and the influence of his beliefs on his situation.
Clinical Skill:
• Asking a difference question to bring family members into the room
Dr. Wright: And is there anything that your family could be doing differently to help you to do more of or less of?
Ralph: Actually, I’m very fortunate.
Dr. Wright: Yes.
Ralph: I think that my family has learned to cope very well. It’s made them more forgiving, made them more open to dealing with their problems and dealing with other people’s problems.
Dr. Wright: Okay. So there’s been some good, it sounds like, that’s come out of this.
Ralph: Oh, definitely a lot of good that’s come out of it.
Clinical Skill:
• Asking about the influence of spirituality and beliefs
Dr. Wright: And what about for you personally? What good has come out of it?
Ralph: There has been a lot of good that’s come out of it.
Dr. Wright: Really. Can you give me a couple of examples?
Ralph: Well, when I broke my neck, I was 245 pounds. I had a 21-inch neck and 56 inches across the shoulders and a 52-inch chest. And I used to throw around quarters of beef that weighed up to 300 pounds.
Dr. Wright: My.
Ralph: And I thought that I was invincible. And then God stepped in and said, “Oops.”
Dr. Wright: So you have some beliefs about faith or God that had…
Ralph: Yes.
Dr. Wright: … a part in all of this?
Ralph: Actually, God does not make junk. What you do with it after that is up to you.
Dr. Wright: So did you pray about your situation when…
Ralph: Oh, many times.
Dr. Wright: Yes? And what did you pray for when you were injured like that?
Ralph: Help.
Dr. Wright: Help.
Ralph: Actually, that’s all a person can do.
Dr. Wright: So, Ralph, I just wanted to follow up a little bit more about your faith and your beliefs. Was that helpful to you in being able to cope with the pain or not?
Ralph: Actually, I think that I had an uncle once tell me that God doesn’t give you any more than you cannot handle with his help.
Dr. Wright: And did you adopt that belief?
Ralph: And the largest obstacle to that?
Dr. Wright: Yes.
Ralph: Is asking for that help.
Dr. Wright: Okay.
Ralph: People have to actually ask. And that’s…
Dr. Wright: And were you able to come to that point?
Ralph: Oh, definitely. Yes.
Dr. Wright: Okay.
Ralph: And that’s God no matter how you perceive him to be. Anybody who doesn’t believe that there isn’t a higher being really should look within themselves.
Clinical Skill:
• Inquiring about the client’s ideas about family members’ beliefs about the client
Dr. Wright: Well, I love that you’ve touched on your beliefs just now, and I’m wondering if your children were here, what do you think they would tell me about you and how you’ve managed this disability all these years? What do you think their comment would be?
Ralph: Actually, I really and truly think that my daughter became a paramedic to help others.
Dr. Wright: Is that right? That’s been one of the influences on her?
Ralph: Yes, because she realized that people do get hurt and need help. And my son is very … he’s a gentle giant. He’s 6 foot 1, 230 pounds, and very kind.
Dr. Wright: Oh. So you think the influence of your disability has been that it’s invited kindness in your son and your daughter’s desire to help people?
Ralph: Yes. I really do.
Dr. Wright: Okay.
Ralph: I think they realize that things happen to people.
Dr. Wright: Yes. And what would they say about you, how you’ve managed it?
Ralph: They probably think that I’ve done very well.
Dr. Wright: Okay. So they’d give you a pretty good grade, would they?
Ralph: I would hope so.
Dr. Wright: Yes?
Ralph: Yes.
Dr. Wright: What kind of grade do you think they would give you?
Ralph: I think it would be pretty high.
Dr. Wright: Wow, okay. And your wife, if she was here, what would she say the biggest influence upon her has been?
Ralph: I think it’s made us closer, a lot closer.
Dr. Wright: It’s made you closer?
Ralph: Yes.
Dr. Wright: Okay. Emotionally close or physically close?
Ralph: Emotionally and physically.
Dr. Wright: And physically? ‘Cause one…
Ralph: Emotionally, definitely, because of the fact that we’ve had to deal with so much.
Dr. Wright: Okay, ‘cause one very personal thing I was going to ask you, because of all your surgeries and back problems and pain, has that interfered with your being able to enjoy sexual relations?
Ralph: It has.
Dr. Wright: Yes?
Ralph: To a certain degree. A lot of the medications I have to be on, anti-inflammatories and muscle relaxants…
Dr. Wright: Yes.
Ralph: And when you’re dealing with muscle relaxants … (Smiles)
Dr. Wright: Yes, but you found a way?
Ralph: Oh, definitely.
Dr. Wright: Yes.
Ralph: Yeah, it’s a very important part.
Dr. Wright: Yes, absolutely.
Ralph: And not only that, I … we … believe that a good marriage doesn’t just happen.
Dr. Wright: How would your wife say that you have evolved over these 20 years, or what do you think her description of you would be?
Ralph: Actually, probably sometimes she thinks I’m a little bit too positive.
Dr. Wright: Too positive, oh? Okay. So she and I might share some of that because that was a bit of my worry earlier.
Ralph: Yeah.
Dr. Wright: Okay. So just to go back to your wife for a moment, what did you say was the biggest influence on her, the biggest challenge for her with your chronic pain?
Ralph: Actually, I would say probably in the early years it was staying positive.
Dr. Wright: Staying positive about what aspect?
Ralph: About the situation. For instance…
Dr. Wright: That you were going to get better or that you would … what?
Ralph: Well, I mean it was not an easy path. She had to take on the major breadwinner. There were a lot of things that happened.
Clinical Skill:
• Demonstrating curiosity
Dr. Wright: Okay. Wow, so it impacted every area of your life, it sounds like.
Ralph: It did.
Dr. Wright: Financially?
Ralph: Financially, emotionally, physically.
Dr. Wright: So your wife had to become the breadwinner?
Ralph: Mmm-hmm.
Dr. Wright: Changed the roles in your family?
Ralph: Definitely.
Dr. Wright: Wow, so it didn’t leave any aspect of your life…
Ralph: Everything has changed.
Dr. Wright: … untouched.
Ralph: Everything has changed.
Dr. Wright: So for your wife in those early years, when you’re saying staying positive, I’m still trying to understand staying positive about …?
Ralph: That things were going to work out.
Dr. Wright: That things would work out.
Ralph: That eventually, that things would eventually get better.
Dr. Wright: Okay, and is she…
Ralph: And staying positive for me because she didn’t want to drag me down because she figured that I already had enough…
Dr. Wright: Yes.
Ralph: … to deal with.
Comments
Let us review what we have just read. Dr. Wright asked the “one-question question” to help identify where the greatest concerns, problems, or suffering lie (Duhamel, Dupuis, & Wright, 2009; Wright, 1989). Dr. Wright then explored Ralph’s religious and spiritual beliefs after he spontaneously told her about the influence of God in his life. Dr. Wright used this opening in the therapeutic conversation about spirituality to also explore if Ralph has prayed about his condition and, if so, what he prays for. In our experience, persons with illness often reach out for comfort, hope, and/or guidance in their lives, and prayer is one alternative for fulfilling that need. Following this, Dr. Wright again brought the family into the meeting by asking, if present, what family members would say about Ralph’s progress throughout the years. These questions were to assess the influence the family members have had on the ill person.
Clinical Skill:
• Offering interventions of prescribing a ritual and giving commendations
Dr. Wright: I’ve … not extensively, but I have worked with a number of people who have experienced chronic pain for a variety of things—accidents, illnesses. And it is one of the most difficult things to deal with in terms of how it affects your life and often demoralizes a person and can invite depression. It can invite such terrible suffering. And when you were answering me earlier when I was asking you about what’s one question that you might want to have answered today, you said learn more coping strategies. I’d just like to throw out one idea that I have utilized with some patients and families.
Ralph: Okay.
Dr. Wright: You’ve been at this so long. You only want to improve 15% more. You’ve already done 75%. Maybe you’ve done some of these strategies, but one of the ones that some couples and individuals have told me that has worked for them is to have moments when they refuse to talk about pain. So they take a holiday from talking about pain. So if somebody asks them, “How are you doing?” even if they’re having pain, they say, “No, this is my time when I don’t talk about it.”
It’s the knowing when I can talk about it and when I don’t have to discuss it that’s important. Some people say if I could just talk about it to my wife or to my husband for 15 or 20 minutes a day and just say what kind of a day it has been, that would be good. And then to take a holiday from pain.
Ralph: Give yourself permission to do that.
Dr. Wright: Permission to do it.
Ralph: Give yourself permission to do that. That’s right, yeah.
Dr. Wright: Exactly, to be able to choose when to talk about it and when not to talk. To have moments when you absolutely put a moratorium on talking about pain because pain has a way of…
Ralph: And when somebody asks how you’re feeling, you tell them, “With my hands like everybody else.”
Dr. Wright: Yeah, yes. So I don’t know. That’s just one little tip.
Ralph: Yes. I appreciate that.
Dr. Wright: One little hot tip for you. And so I just want to say to you, I just think your own wisdom in all of this is so marvelous! It is your own willingness to learn, your willingness to be open to so many ideas from improving your marriage, to improving your health and trying to cope with this disability that is so impressive to me. Now you’re at this pain center. You’ve got a remarkable story.
Ralph: Literally, if you do not control it, it will control you. And that’s all I try to do is to have the ability to control it better and that’s all.
Dr. Wright: Well, I think that the fact you are controlling it 75% is just really remarkable and really incredible.
Ralph: Thank you.
Dr. Wright: Because there are many things in our lives, say, that people struggle with, whether it is diabetes or whatever health problems they may have that they wish they could be at 75%, especially with people experiencing chronic pain. I have met many people, like I said, and some of them would just be thrilled if they could get to 30% that they could control, and you’re up to 75%.
Ralph: I’m working on it.
Dr. Wright: So…
Ralph: But you have to work at it.
Dr. Wright: But I think you are very clever not to expect to be 100% pain-free, that you—
Ralph: That’s never going to happen.
Dr. Wright: No, that you always will allow the pain to be in your life about 10%. Because if you wanted to be pain-free and you always worked toward that, it can be a great disappointment when you are not reaching that goal all the time.
Ralph: And I think realistically, you have to look at the fact that it is not going to happen.
Dr. Wright: Yeah.
Ralph: And be happy where you are.
Comments
Dr. Wright concludes the session with some very specific interventions. First, she offers Ralph commendations about his strengths and resources that he has utilized to cope with and heal from his condition, such as his wisdom, his positive approach, and the success he has had on influencing his chronic pain. Finally, she offers a very specific intervention in the form of a prescribed ritual. She suggests taking a holiday from pain talk.
CASE SCENARIO: GRETA
Greta, a 32-year-old woman, is admitted to a medical unit with a questionable diagnosis of influenza. Her weight has dropped to 82 pounds, a loss of 10 pounds in the week before admission.
Greta also has a genetic disease involving weakness and wasting of skeletal muscles. She lives with her two younger brothers and their mother, all of whom have what Greta calls “the disease” (wasting of the muscles). She is the only family member who is able to drive. The nursing staff perceives her to be angry and abrupt; they also wonder what the medical problem is. They feel sorry for Greta and think of her as “very dependent.” The charge nurse suggests that a brief family interview would be helpful to explore Greta’s expectations, beliefs, and resources. Her family is invited to the meeting, which is held on the unit, but they do not attend. During the brief interview, the primary nurse working with Greta asks Greta about her expectations for the hospitalization and how the nurses could be most helpful. Greta responds by saying that she would know how the staff would care for her “by how they talk with me and other patients, show me respect and trust, and treat me independently.” She states that she needs to be strong to care for her brothers and mother, “who depend on me.”
Reflective Questions

1. What clinical skills can the nurse use to move beyond basic family nursing skills and demonstrate advanced family nursing skills?
2. How can the nurse use relative influence questioning as an intervention with Greta?
3. How can the nurse collaborate with Greta to develop a plan of care for her during her hospitalization?
   CRITICAL THINKING QUESTIONS
4. Reflect on your own nursing practice with families; how do you identify your skill level (basic or advanced)? What is your rationale for this?
5. If you identify as having advanced skills in family nursing, what did you do to achieve this?
6. If you identify as having basic skills in family nursing, what do you require to move beyond basics skills toward advanced skills?
7. Reflect on your practice setting to answer the following questions:
   a. Are there distinct roles for nurses with basic and advanced family nursing skills?
   b. What are the supports and/or barriers to applying family nursing skills?

Chapter 11
How to Avoid the Three Most Common Errors in Family Nursing
Learning Objectives
• Identify the three most common errors in family nursing.
• Describe strategies to avoid failing to create a context for change.
• Summarize strategies to avoid taking sides.
• Describe strategies to avoid giving too much advice prematurely.
Key Concepts
Context for change
Curiosity
Premature advice
Taking sides
Nurses working with families want to be helpful and to ease or alleviate emotional, physical, or spiritual suffering whenever possible (Wright, 2017). However, despite nurses’ best efforts, sometimes errors, mistakes, and/or misjudgments occur. Whether nurses are beginners or experienced clinicians in family nursing, they can benefit from knowing the most common errors and how they might avoid or sidestep them. We have identified three errors that we believe occur most frequently in relational family nursing practice. They are as follows:

1. Failing to create a context for change
2. Taking sides
3. Giving too much advice prematurely
   Although we are experienced family nurses, we have committed, experienced, or witnessed these errors in our own practices and in the supervision of our students. But the most important aspect is to learn from these errors and to correct them immediately, if at all possible.
   For each error, we will explain in what way we believe it is a mistake and how it can negatively impact the family. We also suggest practical ways for avoiding these errors and offer a clinical example for each error. It is our hope that by sidestepping the most prevalent mistakes, nurses can sustain and improve their nursing care of families.
   Nurses will have more confidence and competence in their nursing practice if they can offer a context for clinical work that is more likely to be helpful and healing.
   ERROR 1: FAILING TO CREATE A CONTEXT FOR CHANGE
   Every nurse in every encounter and experience with a family, whether for 5 minutes or over 5 years, has the responsibility to create a context for healing and learning. Creating a context for change is the central and enduring foundation of the therapeutic process. It is key to the relationship between the clinician and family. It is not just a necessary prerequisite to the process of therapeutic change; it is therapeutic change in and of itself (Wright & Bell, 2009). In creating this context for change, both the nurse and family undergo change, and the nurse is in a unique position to act as a “relational bridge” (McLeod, Tapp, Moules, & Campbell, 2010, p. 97).
   KEY CONCEPT DEFINED
   Context for Change
   A central and enduring foundation of the therapeutic process in which both the nurse and the family undergo change, and the nurse is in a unique position to act as a “relational bridge.”
   What must happen in order to create a healing context for change? Empathy, mindfulness, and empathic responding are all necessary ingredients for creating a healing context (Block-Lerner, Adair, Plumb, Rhatigan, & Orsillo, 2007). Wright and Bell (2009) suggest that before a context for change can be created, all obstacles to change must be removed. Such obstacles can include a family member who does not want to be present or attends the session under duress, a family member who is dissatisfied with the progress of the clinical sessions, a family that has had previous negative experiences with health-care professionals, or a situation in which there are unclear expectations for the meetings.
   At the Family Nursing Unit, University of Calgary, a hermeneutic research study conducted by Drs. Bell and Wright explored the process of therapeutic change (Bell, 1999). The focus of this study was to analyze the clinical work with three families who reported negative responses. These families suffered from serious illness and were seen in an outpatient clinic by a clinical nursing team of faculty and graduate nursing students.
   The preliminary results of this study provide helpful feedback that can be used to improve family interviews. The most informative learning was that creating a context for change was either ignored or neglected among families that were dissatisfied with the nursing team’s clinical work. Curiosity was absent on the part of the nurse interviewer. For example, the nurse interviewer did not seek clarification of the presenting problem or concern. Also, the nurse interviewer paid no attention to how the intervention “fit” the family’s functioning. The nurse interviewer did not ascertain from the family if the intervention ideas offered were useful.
   KEY CONCEPT DEFINED
   Curiosity
   The desire of the nurse to learn or know about each person’s story of a family’s health concerns or problems; an openness to experiencing an altered view of any family member and/or situation as more information is revealed during a family interview.
   Another example of not creating a context for change was the error of commission of the clinical nursing team becoming too “married” to a particular way of conceptualizing the family’s problems or dynamics that was not in harmony with the family’s conceptualization.
   Blow, Sprenkle, and Davis (2007) argue that the clinician is a key change ingredient in most successful therapy and that it is the “fit” between the model and the clients’ worldviews that is important. According to Miller, Hubble, and Duncan (2007, p. 28), “who provides the therapy is a much more important determinant of success than what treatment approach is provided.” Fife, Whiting, Bradford, and Davis (2014, p. 24), in referring to a therapist’s “way of being,” states that one can be “genuine and open or impersonal and objectifying,” and therefore a “therapist’s way of being will influence a client’s experience.” We believe that these same thoughts can be adapted to nurses providing care to families—that is, who provides the nursing care is a much more important determinant of healing than the particular nursing interventions that are offered.
   The process of developing and maintaining a respectful and collaborative relationship between the clinician and the family is one of the best predictors of success and therapeutic change (Fife et al, 2014; Garfield, 2004; Karam, Sprenkle, & Davis, 2014; Martin, Garske, & Davis, 2000).
   How to Avoid Failing to Create a Context for Change
4. Show interest, concern, and respect for each family member. The most useful way to do this is to invite to a family meeting anyone who is involved with or concerned about the problem or illness or who is suffering as a result of it. After introducing oneself and meeting each family member, the nurse should express the desire to learn from the family how this problem or illness has affected their lives and relationships. This articulation can convey to the family that the nurse is interested and willing to learn about them and their most pressing concerns. This task will be easier to accomplish if the nurse embraces the belief that all families have strengths that are often unrealized or unappreciated (Wright & Bell, 2009).
5. Obtain a clear understanding of the most pressing concern or greatest suffering. Seek each family member’s perspective on the problem/illness and how it affects the family and their relationships. Even if the perspectives vary, each perspective offers the nurse the best understanding of the family’s challenges and sufferings.
6. Validate and acknowledge each member’s experience. Remember that no one view is the correct, right view or the truth about the family’s functioning but is each family member’s unique and genuine experience. Be open to all perspectives about the family’s concerns. To bring understanding to the nurse and family, not only must each member’s perspective be elicited, but each member’s perspective must also be valued, acknowledged, and considered important.
7. Acknowledge suffering and the sufferer. Health providers’ acknowledgment of clients’ and patients’ suffering can be a powerful starting point to begin understanding a family’s situation and for healing to occur (Wright, 2017; Wright & Bell, 2009). Through these efforts to understand, the nurse-family relationship is enhanced and strengthened. When nurses acknowledge their clients’ or patients’ suffering and are compassionate and nonjudgmental, families are often more willing to disclose fears and worries. As a result, the potential for healing, growth, and change increases.
   Clinical Example
   Mr. Garcia was an inpatient on a medical unit because of his chronic obstructive pulmonary disease. A woman visited frequently and was usually crying during visits. On one occasion, the primary nurse asked Mr. Garcia, “Do you know why your wife is crying?” He responded, “No, this is not my wife. My wife and I are divorced. This is my sister.” The nurse was somewhat embarrassed but responded, “Oh, I’m sorry. Well, do you know why your sister is crying? She cries on every visit.” Mr. Garcia responded, “I’m not sure.” At that point, his sister stopped crying and looked up but did not speak. The nurse then responded, “Well, I think she is crying because she is worried that you are not going to get better if you don’t stop smoking. Isn’t that right?” The sister shook her head to indicate no. At this point, Mr. Garcia stated, “Well, it’s too late even if I do stop smoking.” The nurse then said she would like to come back at another time to discuss the issue with them more fully, at this point addressing the sister for the first time. The sister replied that she did not want to meet because this was her brother’s problem. The nurse accepted this response and did not have any further discussions with this family. Table 11-1 lists the errors the nurse could have avoided and the missed opportunities in working with the Garcia family.
   ERROR 2: TAKING SIDES
   One of the most common errors in family work is taking sides by the nurse, that is, forming an alliance with one family member or subgroup of the family. Although this is commonly done unintentionally, at times the nurse may do so deliberately, usually with a benevolent intent. However, aligning with one person or subgroup can often result in other family members feeling disrespected, disempowered, and noninfluential as the family pursues its goals with the nurse.
   TABLE 11-1 Errors/Missed Opportunities
   ERRORS/MISSED OPPORTUNITIES RATIONALE
   The nurse did not introduce herself to the woman who was visiting and made the assumption that it was the patient’s wife. Acknowledging the sister at the start may have encouraged the sister to be more forthcoming and more willing to have another meeting.
   The nurse did not ask Mr. Garcia and his sister if they had any questions about his condition, worries, or concerns. This question would provide the nurse the opportunity to validate or acknowledge any concerns or suffering they might have.
   The nurse offered a quick conceptualization of the problem without obtaining the perspective of each family member and assumed that the sister is worried about the brother’s smoking habit and its relationship to his recovery. The sister denied the problem but was not asked any other therapeutic questions to ascertain the nature of her distress.
   KEY CONCEPT DEFINED
   Taking Sides
   When the nurse forms an alliance with one family member or subgroup of the family, commonly done unintentionally.
   How to Avoid Taking Sides
8. Maintain curiosity. Be intensely interested in hearing each person’s story about the health concern or problem. When each family member’s perspective has been revealed, the nurse generally gains an understanding of the multiple forces interacting together to stimulate or trigger the problem. Families are always very complex, and the complexity is increased when an illness or problem emerges. Be open to experiencing an altered view of any family member and/or situation as more information is revealed. This is particularly important when nurses work with the elderly because there can be a temptation to take the side of the 55-year-old son (who is dressed in a suit) and not listen sufficiently to his 83-year-old mother lying passively in a bed in an extended care facility.
9. Remember that the glass can be half full and half empty simultaneously. There are multiple truths and therefore many ways to view a problem or illness. The more all-inclusive the understanding gathered from as many family members as possible, the more possible options for resolution may be derived. However, we wish to emphasize that we do not condone violence, and we do not fail to act in dangerous, illegal, or unethical situations.
10. Ask questions that invite an exploration of both sides of a circular, interactional pattern. Exploring each person’s contribution to circular, interactional communication helps the nurse and family members understand that each person contributes to the problem rather than blaming one family member or taking one family member’s side or position. (See Chapter 3 for more explanations about circular interactional patterns and the Calgary Family Assessment Model [CFAM].)
11. Remember that all family members experience some suffering when there’s a family problem or illness. Invite family members to describe their suffering and the meaning they give to it. The nurse can also ask, “Who in the family is suffering the most?” Often it is surprising to find that the family member suffering the most is not the person with the illness diagnosis but, rather, another family member (Wright, 2017).
12. Give relatively equal “talk time” and interest to each family member. This, of course, may vary with very young children or family members who are only able to minimally contribute verbally, such as those who are disabled or have dementia.
13. Remember that information is, as Bateson (1972) described it, “news of a difference.” Treat all information as a new discovery; maintain a systems or interactional perspective regarding your understanding of the illness and family dynamics.
14. Try not to answer phone calls or have “side conversations” involving one family member “telling on” another family member. Instead, invite the person to bring the issue to the next family meeting. Alternatively, invite one parent to ask the other parent to join in the phone conversation. In this way, the conversation is transparent for all. Sometimes, e-mailing all parties participating in the family interviews also facilitates transparency.
    Clinical Example
    Community health nurses and nurse practitioners are often involved in family discussions about the eating habits of children. A mother, Rose, describes her children’s grandparents’ eating habits as poor and how they encourage her children, Hadley and Jack, to eat high-fat food, including junk food, fried foods, and sugary desserts. Rose describes the situation at home as being hopeless and her husband, Joshua, as not being supportive in changing the children’s eating habits or behaviors. However, listening to Joshua’s viewpoint, the nurse hears an entirely different story about how Rose and his mother both become so incredibly tense and stressed out that they verbally release their anger and frustrations at each other. Joshua explains how Rose is in conflict with the grandparents’ eating habits and how they are influencing the children’s eating habits, but he doesn’t see any harm with what the children are eating as long as the meals are homemade. The nurse then asks herself, “Who should I believe? Who is telling the truth?” If she sides with one parent, she worries she may alienate one parent from the other. She may miss opportunities to work with the entire family in helping them adjust to normal family functioning. This trap is especially easy to fall into if one parent negatively labels the other. For example, Joshua may say, “You know my wife gets hysterical when she has to speak to my mother,” or Rose may say, “My husband is so irresponsible. He struggles with not being able to speak to his mother due to his past childhood anxiety and depression.” Table 11-2 provides strategies the nurse can use in working with this family.
    Clinical Example
    A family with a teenager is dealing with anorexia. Shaheena, age 16, is being seen by the unit nurse, Karin Johnson, age 51, to receive help in developing more appropriate eating habits and to increase her socialization. Shaheena has begun to successfully conquer the grip of anorexia and is very appreciative of Karin’s assistance. She looks forward to individual meetings with Karin and compliments Karin frequently on wearing “cool clothes my mother never would wear.” Karin believes she and Shaheena have an “excellent” working relationship and is pleased that Shaheena likes her taste in clothes.
    TABLE 11-2 Strategies for the Nurse to Avoid Taking Sides
    STRATEGIES RATIONALE
    Ask the mother, “When your husband shows you indifference, what do you find yourself doing?” By asking questions, the nurse is able to explore each person’s contribution to circular, interactional communication, which helps the nurse and the family members understand that each member contributes to the problem rather than blaming one another.
    Ask the father, “When your wife and your mother start to scream at each other, what do you do?” The nurse provides an opportunity for each party to view the problem and to think about how they might find resolutions themselves.
    Invite both parents to a meeting together to talk about the challenges involved in raising children with healthy eating habits and role modeling healthy relationships. The nurse provides an opportunity for family members to each have equal “talk time” and gain awareness and understanding of the issues.
    Karin has agreed to alternate individual meetings with Shaheena with family interviews that include both parents. During a family meeting in which Karin proudly described Shaheena’s recent accomplishments on the unit, Shaheena’s mom starts to downplay her daughter’s successes. She tells Karin of the various “bad behaviors” Shaheena engaged in during a recent pass home. Following this, Shaheena bursts out to her mother, “How come you do not treat me as an adult like Karin does?”
    By inadvertently aligning too much with Shaheena (e.g., around clothes and a special relationship) and not sufficiently aligning with Shaheena’s parents (e.g., never seeing them as a couple alone to appreciate their challenges in raising a daughter who is in the grip of anorexia), Karin has sacrificed her ability and therapeutic leverage to be multipartial in the family meetings. Rather, the nurse is now perceived by the mother and daughter to be on the teen’s side. This makes it difficult for the mother-daughter relationship to flourish and for Shaheena’s mother to acknowledge her daughter’s changes. Rather, Shaheena’s mom may feel inadvertently competitive or usurped by the nurse. Indeed, nurses who take the side of one or more family members most often are not consciously trying to alienate, compete with, or usurp any particular family member. In fact, they are usually unaware of doing so, and thus it comes as a shock when other family members express dissatisfaction or begin to disengage or discontinue family meetings. Table 11-3 provides strategies the nurse might use in working with Shaheena and her family.
    TABLE 11-3 Strategies for the Nurse to Avoid Taking Sides
    STRATEGIES RATIONALE
    Provide time for the mother to respond to her daughter’s comments, give the mother an opportunity to hear Shaheena’s point of view, and then provide Shaheena time to tell her story about the problem or health concern. By being open and maintaining curiosity, the nurse is able to gain an understanding of the multiple forces interacting to stimulate or trigger the problem. Be open to experiencing an altered view of any family member and/or situation as more information is revealed.
    Ask, “Who in this relationship is suffering the most between the two of you?”
    Ask about each family member’s strengths and build on them by asking, “Who would find it easier to believe that the other might change?” Inviting both the mother and daughter to a meeting together to talk about their experience and challenges with the mother-daughter relationship provides an opportunity for each family member to obtain a circular view of the interaction.
    ERROR 3: GIVING TOO MUCH ADVICE PREMATURELY
    Nurses have abundant knowledge to offer families and are in the socially sanctioned position of offering advice, information, and opinions about matters of health promotion, health problems, illness suffering, illness management, and relationship issues. We believe, similar to Couture and Sutherland (2006), that advice can have generative and healing potential when it is offered collaboratively. Families are often keen on and receptive to nurses’ expertise concerning health issues. However, each family is unique, as is each situation. Therefore, timing and judgment are critical for nurses to determine when and how to offer advice.
    How to Avoid Giving Too Much Advice Prematurely
15. Offer advice, opinions, or recommendations only after a thorough assessment has been done and a full understanding of the family’s health concern or suffering has been gained and acknowledged. Otherwise, advice and recommendations can appear too simplistic or patronizing, and the nurse can be seen as lacking an in-depth understanding. Of course, in crisis situations or in a busy emergency or intensive care unit, a full family assessment may not be possible. When families are in shock, numb, or overwhelmed, they can benefit from clear, direct advice from a nurse who, through professional experience and knowledge, can bring calm and structure in a time of crisis.
16. Offer advice without believing that the nurse’s ideas are the “best” or “better” ideas or opinions. “Often there is a tendency and temptation among health-care providers to offer their own understandings, their own ‘better’ or ‘best’ meanings or beliefs for clients’ suffering experiences with serious illness. One way to avoid this trap of prematurely offering explanations or advice to soften suffering is to remain insatiably curious about how clients and their families are managing in the midst of suffering” (Wright, 2017). Specifically, nurses should ask themselves, “What do family members believe, and what meaning do they give to their suffering?” (Wright & Bell, 2009). In working with the elderly, this is particularly important. Nurses should examine their own beliefs about whether they think older adults can change or whether they hold the belief that “the elderly are too old to change their ways.” Health professionals who are insatiably curious put on the armor of prevention against blame, judgment, or the need to be “right.”
17. Ask questions more than offering advice during initial conversations with families. Asking therapeutic or reflexive questions (Tomm, 1987; Wright & Bell, 2009) invites individuals to explore and reflect on their own meanings of their health concerns or suffering, not the nurse’s. Everyone, especially the elderly, has accumulated a vast reservoir of personal local wisdom and knowledge about health and wellness over the years. Hopefully, through reflections that happen in the therapeutic conversations we have with families, healing may be triggered as new thoughts, ideas, or solutions are brought forth about how a family can best live with illness (Wright, 2017).
18. Obtain the family’s response and reaction to the advice. After offering advice, it is essential to obtain family members’ reactions to the information. Specifically, does this information “fit” for the family with their own biopsychosocial-spiritual structures? We believe it is the manner in which advice is delivered, received, interpreted, and refined that is most critical in our clinical work. Relational practices and therapeutic conversations that include advice-giving are ongoing, collaborative, clarifying, and meaningful. There is a forward process to the conversation; advice-giving is not just a prescription of a particular course of action for the family to follow. (See Chapter 4 for an in-depth discussion about “fit,” “meshing,” and matching information offered to families with family functioning.)
    Clinical Example
    Gina is a 39-year-old woman on a postpartum unit following the birth of her first child via emergency cesarean section. Gina’s husband, Leo, is at the bedside. The nurse walks into the room on the morning after the birth and says, “You have to attend the breastfeeding class at 9 this morning, but first you will need to watch a video on manually expressing breastmilk.” Gina is extremely tired, sore, and overwhelmed. She is aware that her baby was given formula during the night due to the baby’s low blood sugars and therefore has not given much thought to breastfeeding at this point. Gina questions what the breastfeeding course is about, then says, “I am not even sure if I want to breastfeed my baby. I am in some pain and exhausted. Do I really need to attend right now?” The nurse responds, “All new moms must attend so that you learn the proper way, and we only have the class this morning.” The nurse leaves the room with the video playing on the computer. When the nurse returns to the room, she hurriedly assists Gina out of bed without further explanation, leaving Leo confused as to what is happening and where Gina is going. He can see that she is teary and frustrated, but he is not sure what he should do to help her. Table 11-4 presents the nurse’s errors and missed opportunities with Gina.
    TABLE 11-4 Errors/Missed Opportunities
    ERRORS/MISSED OPPORTUNITIES RATIONALE
    The nurse offered advice prior to completing a thorough assessment of the family’s health beliefs. Without a thorough assessment, advice and recommendations can appear too simplistic or patronizing, and the nurse can be seen as lacking an in-depth understanding.
    The nurse offered advice based on the nurse’s ideas of “best.” The nurse’s advice and responses did not “fit” with the family, and the opportunity to offer opinions and recommendations that would have been more healing was missed.
    The nurse did not ask Gina or Leo questions. Asking Gina further questions about breastfeeding would support her in exploring and reflecting on her own meaning of her health, possibly bringing forward new thoughts, ideas, or solutions.
    The nurse did not attend to the responses of Gina and Leo. Obtaining Gina and Leo’s reactions to the information provided by the nurse is essential in ensuring that the information they received is a “fit” for them.
    Clinical Example
    The Li family had recently experienced the loss of their 88-year-old father, William, who had lived with them for 10 years. Mr. Li had left Hong Kong after the death of his wife and moved to Canada to live with his son, Shen, and daughter-in-law, Ming-mei. Just 3 weeks after the death of the elderly father, Ming-mei, accompanied by Shen, presented at a walk-in medical clinic with abdominal pain. Upon concluding a medical exam, a doctor determined that there were no physical reasons for her pain. A nurse was asked to meet with the husband and wife. Shen told the story of the recent loss of his father, explaining that his wife had been the primary caregiver and had given up her employment to care for her father-in-law. He then offered his belief that his wife’s pain was due to her extreme grief at the loss of her father-in-law. The nurse, upon hearing this story but without inquiring about the wife’s extreme grief or the meaning of her loss and suffering, offered premature advice to the couple.
    KEY CONCEPT DEFINED
    Premature Advice
    Advice given too soon by the nurse without considering timing and judgment when working with families.
    To the husband, she said, “You need to take your wife on a holiday. She is very tired after caring for your father.” To Ming-mei, she said, “Your father-in-law was an elderly man, and his time had come. And because he was not your father, but your husband’s, you will get over his passing more quickly.” Table 11-5 lists the nurse’s errors and missed opportunities with the Li family.
    TABLE 11-5 Errors/Missed Opportunities
    ERRORS/MISSED OPPORTUNITIES RATIONALE
    The nurse offered premature advice. The nurse’s recommendations did not “fit” with the family, and the nurse missed the opportunity to offer opinions and recommendations that would have been more healing.
    The nurse did not ask questions to complete a thorough assessment of the situation. Asking assessment questions, such as structural assessment questions within the CFAM (see Chapter 3), the nurse would have learned that Shen owns a small coffee shop and is unable to take holidays because he is the sole provider and works 7 days a week. Ming-mei also did not find the nurse’s words healing, particularly because the nurse ignored the very close relationship she had with her father-in-law.
    The nurse did not recognize the Chinese culture of the Li family. The Li family has a strong sense of honoring and caring for their elderly family members. The nurse missed a golden opportunity to commend the daughter-in-law for the care of her father-in-law. (See Chapter 4 for a more in-depth discussion of the intervention of commendations.)
    CASE SCENARIO: NAIM AND SIKEENA
    Naim is a 74-year-old male who was recently diagnosed with a reoccurrence of pneumonia. He lives with his 69-year-old wife, Sikeena, in their own home. Sikeena has no serious health concerns, and she and Naim have been taking care of each other with no assistance. Recently, Sikeena has been noticing Naim struggling at night with his breathing and has called the 24-hour nurse help line twice. Sikeena has voiced her concerns to their family doctor, and he has reassured her that it is due to his pulmonary disease. Naim has recently been started on oxygen at home. Sikeena is always worried about her husband. Both of their children are working abroad, and they have limited conversations with them. The couple has very few friends, and they are not active in their community.
    Naim and Sikeena are attending the pulmonary outpatient clinic for a follow-up appointment regarding Naim’s home oxygen use. Sikeena tells the nurse how worried she is about Naim and how she feels nervous about the home oxygen and managing it. She states, “I don’t understand what is going on; it is all so confusing. I thought Naim would get better once the pneumonia went away.” Naim tells the nurse, “Sikeena worries too much. I am fine; everything will work out how it is meant to be.”
    Reflective Questions
19. How can the nurse avoid giving Naim and Sikeena too much advice prematurely?
20. What questions could the nurse ask Naim and Sikeena to assess the context of their family structure, such as ethnicity, spirituality and/or religion, and environment?
    a. How can the nurse use this information when working with Naim and Sikeena?
21. What questions could the nurse ask Naim and Sikeena to assess the developmental life cycle for their family?
    a. How can the nurse use this information when working with Naim and Sikeena?
    CRITICAL THINKING QUESTIONS
22. Identify a situation from your clinical practice for each of the following common errors in family nursing:
    a. Failing to create a context for change
    b. Taking sides
    c. Giving too much advice prematurely
23. What contributed to each of these outcomes?
24. What strategies could you implement in future situations to avoid the errors?