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2739_FM_i-xxii 29/08/12 2:40 PM Page i

Nurses
and
Families
A Guide to Family Assessment
and Intervention

EDITION

6

2739_FM_i-xxii 29/08/12 2:40 PM Page ii

2739_FM_i-xxii 29/08/12 2:41 PM Page iii

Lorraine M. Wright and Maureen Leahey

Nurses
and
Families
A Guide to Family Assessment
and Intervention

Lorraine M. Wright, RN, PhD
International Lecturer, Blogger, Author, and Clinician
Professor Emeritus of Nursing
University of Calgary
Calgary, Alberta, Canada
Maureen Leahey, RN, PhD
Consultant, Author, Educator, and Clinician
Pugwash, Nova Scotia, Canada

EDITION

6

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F. A. Davis Company
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As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher
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Library of Congress Cataloging-in-Publication Data
Wright, Lorraine M., 1944Nurses and families : a guide to family assessment and intervention / Lorraine M. Wright,
Maureen Leahey. — 6th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8036-2739-0 (pbk. : alk. paper)
I. Leahey, Maureen, 1944- II. Title.
[DNLM: 1. Nursing Assessment. 2. Family Health. 3. Interviews as Topic—methods.
WY 100.4]
616.07'5—dc23
2012021678
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2739_FM_i-xxii 29/08/12 2:41 PM Page v

After collaborating on our book Nurses and Families for over 30 years, we
thought the time was right to dedicate this Sixth Edition to each other!
Through stimulating conversations, clinical consultations, and a passionate
exchange of ideas, we have experienced a constant synergy and sustained
admiration for each other’s knowledge and expertise. We greatly appreciate
and thank one another for our deep collegiality and friendship on this
incredible journey.
Lorraine M Wright
Maureen Leahey

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REVIEWERS
Michele D’Arcy-Evans, PhD, CNM

Krista Lussier, RN, MSN

Professor
Lewis-Clarke State College
Lewiston, Idaho

Senior Lecturer
Thompson Rivers University
Kamloops, British Columbia, Canada

Faith Johnson,
RN, BA, BSN, MA, CNE

M. Star Mahara, RN, BSN, MSN

Nurse Educator/Faculty
Ridgewater College
Willmar, Minnesota

Jamie Kane, MS, RN, CNE
Evening/Weekend Program Coordinator
Ellis School of Nursing
Schenectady, New York

Kara E. Keyes, MS, RNC
Instructor/Clinical Coordinator
Department of Nursing
Le Moyne College
Syracuse, New York

Stephanie Langford, RN,
BScN, MEd
Professor
University of Ottawa
Faculty of Health Sciences
School of Nursing
Ottawa, Ontario, Canada

Associate Professor
Thompson Rivers University
Kamloops, British Columbia, Canada

Janet McCabe, PhD, MEd, RN
Assistant Professor
University of Saskatchewan
Prince Albert, Saskatchewan, Canada

Carol Murphy Moore, MSN, CRNP
Assistant Professor of Nursing
Bloomsburg University
Bloomsburg, Pennsylvania

Judith Quaranta, MS, RN, CPN,
AE-C, Doctoral candidate
Clinical Associate Professor
Decker School of Nursing/Binghamton
University
Binghamton, New York

vii

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viii Reviewers

Helena Schaefer, RN, MN, NP

Sharon E. Thompson, MSN, RN

Faculty Lecturer
University of Alberta
Edmonton, Alberta, Canada

Assistant Clinical Professor
Northern Arizona University
Flagstaff, Arizona

Gisele Thibodeau, BScN, RN
Faculty/Clinical Instructor
Dalhousie School of Nursing—
Yarmouth Site
Yarmouth, Nova Scotia, Canada

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ACKNOWLEDGMENTS
We are grateful to our many colleagues, local, national, and international,
for their continued support, interest, and positive comments about our book
over these 30 years as we continue to evolve our ideas of how to best involve
and assist families experiencing illness, loss, and/or disability. It continues to
amaze and gratify us that, since 1984 when the First Edition was published,
so many practicing nurses, students, and faculty have joined us in promoting
family nursing worldwide.
We are especially grateful to:
■ Joanne DaCunha, Publisher, Nursing Department, F.A. Davis, for her
unfailing support, promptness, helpfulness, competence, and good
nature as we worked on this Sixth Edition.
■ Bob Martone, Publisher, Nursing Department, F.A. Davis, for his vision
and support of our work, starting with the First Edition in 1984.
■ Christina C. Burns, Senior Project Editor, Nursing, for her initial work
on this Sixth Edition.
■ Victoria White, Project Editor, Nursing, for her care in readying the
manuscript for publication.
■ Echo Gerhart, Project Editor, Nursing, who cheerfully walked us
through the final miles of preparing the manuscript. Her attention to
detail and speed in finding solutions to issues helped keep the book on
track.
Finally, we are grateful to each other . . . for enduring friendship/
collegiality over some 37 years, for Caffe Beano Saturday morning conversations, fabulous restaurant experiences, and wonderful trips traveling together in Provence, Germany, Thailand, Iceland, Inle Lake, Luang Prabang,
Lake O’Hara, Pugwash, Nova Scotia . . . and more adventures await!
Lorraine M. Wright
Maureen Leahey

ix

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CONTENTS
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11

Introduction
Family Assessment and Intervention:
An Overview
Theoretical Foundations of the Calgary
Family Assessment and Intervention Models
The Calgary Family Assessment Model
The Calgary Family Intervention Model
Family Nursing Interviews: Stages and Skills
How to Prepare for Family Interviews
How to Conduct Family Interviews
How to Use Questions in Family
Interviewing
How to Do a 15-Minute (or Shorter)
Family Interview
How to Move Beyond Basic Family
Nursing Skills
How to Avoid the Three Most Common
Errors in Family Nursing
How to Terminate With Families

Chapter 12
Index
The “How To” Family Nursing DVD Series

xiii
1
23
51
151
179
193
219
249
263
281
309
321
339
349

xi

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INTRODUCTION
REFLECTIONS ON THE FIRST TO SIXTH EDITIONS
We welcome you to the Sixth Edition of Nurses and Families. Whether you are
a nursing student, practicing nurse, or nurse educator, this book is for you. We
believe our book will benefit you whether you desire more relevant knowledge
and essential skills for relational practice with families dealing with complex
issues; information about teaching practices for family nursing; and/or the most
pertinent research regarding family interaction. Our text breaches the boundaries of practice, education, and research. Research evidence and clinical narratives of families experiencing illness make it mandatory and a moral
imperative for nurses to treat families with care and competence in whatever
nursing context nurses find themselves. The development and evolution of
family nursing have moved beyond the debate of whether families should be
included in health care to a more important focus and emphasis on how to
involve families. Therefore, the main emphasis and thrust of our Sixth Edition
is to offer ideas of how to include families in nursing practice with the specific
knowledge and skills to accomplish that. Yes, this is a “how to” book.
The First Edition of Nurses and Families was published in 1984, the
second in 1994, the third in 2000, the fourth 2005, the fifth in 2009, and
now the sixth in 2013.
Some of the changes and developments in family nursing, as well as the
influence of larger societal differences in the past 30 years, are obvious and
apparent to us and are discussed in our text, whereas others are more subtle
and perhaps tenuous.
One example of the globalization of family nursing is our text having been
translated into French, German, Icelandic, Japanese, Korean, Portuguese,
Spanish, and Swedish. As well, we have developed a Web site www.family
nursingresources.com for educational resources. We have written and
produced eight educational DVDs (Wright & Leahey 2000, 2001, 2002,
2003, 2006, and 2010). See the section following the Index for additional
information. These programs are also available in streaming video (.mov files
and Quicktime and Windows Media Player). The programs are:
■ How to Do a 15-Minute (or Less) Family Interview (2000)
■ Calgary Family Assessment Model: How to Apply in Clinical Practice
(2001)
xiii

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xiv Introduction
■
■
■
■
■
■

Family Nursing Interviewing Skills: How to Engage, Assess, Intervene,
and Terminate With Families (2002)
How to Intervene With Families With Health Concerns (2003)
How to Use Questions in Family Interviewing (2006)
Common Errors in Family Interviewing: How to Avoid and Correct
(2010)
Tips and Microskills for Interviewing Families of the Elderly (2010)
Interviewing an Individual to Gain a Family Perspective With Chronic
Illness: A Clinical Demonstration (2010)

We are delighted that these eight DVDs are being utilized by faculties,
schools of nursing, and hospitals worldwide. These educational programs
complement this text, Nurses and Families. They demonstrate family interviewing skills in action that have either been substantiated with practicebased evidence or evidence-based practice or both.
Further evidence of the expansion of family nursing assessment models
worldwide is the fact that the Calgary Family Assessment Model (CFAM) continues to be widely adopted in undergraduate and graduate nursing curricula
and by practicing nurses. The CFAM is utilized in nursing curricula throughout
North America, Australia, Brazil, Chile, China, Denmark, England, Finland,
Germany, Hong Kong, Iceland, Japan, Korea, Norway, Portugal, Qatar,
Scotland, Singapore, Spain, Sweden, Switzerland, Taiwan, Thailand, and
Vietnam. With this expansion, we have had to revisit and revise our thinking
about the CFAM in order to acknowledge, recognize, and embrace the evolving
importance of certain dimensions of family life that influence health and illness,
such as class, gender, ethnicity, race, family development, and illness beliefs.
A significant amplification in our text was the development of a framework and model for interventions, namely the CFIM, which was introduced
in the Second Edition. This was done in recognition of the need to give as
much emphasis to intervention as there had been on assessment of families
and to provide a framework within which to capture family interventions.
This change was clearly influenced by the advances in family nursing
research, education, and practice from a primary emphasis on assessment to
an expanding and equal emphasis on intervention.
Perhaps a more subtle but equally significant development is our everchanging and evolving relationship with the families with whom we work.
This change is reflected in our choice of language to describe the nurse-family
relationship that we deem most desirable. Our preferred stance/posture with
families has evolved into a more collaborative, consultative, relational, and
nonhierarchical relationship over the past 30 years. When we adopt this
stance, we notice greater equality, respectfulness, nonjudgmentalness, and
status given to the family’s expertise. Therefore, the combined expertise
of both the nurse and the family forms a new and effective synergy in the
context of therapeutic conversations that otherwise did not and could
not exist.

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Introduction xv

Another subtle development evolving throughout our six editions has been
the movement toward a postmodernist worldview. We embrace the notion
that there are multiple realities in and of “the world,” that each family member and nurse see a world that he or she brings forth through interacting
with themselves and with others through language. We encourage an openness in ourselves, our students, and the families with whom we work to the
many “worlds”, differences, and diversity between and among family members and health-care providers. For this reason we have included a diversity
of client names representing various cultures to remind everyone of the many
different “worlds” we and our clients inhabit.
We have also been influenced by dramatic restructuring in health care that
has occurred over the past 20 years in Canada and the United States. With
massive restructuring in health-care institutions and community clinics,
budgetary constraints, and managed care, many nurses believe they cannot
afford the opportunity to get involved in or attend to the needs of families
in health-care settings. Nurses, particularly those in acute-care hospital settings, have expressed their frustration about the substantially reduced time
to attend to families’ needs and concerns because of increased caseloads,
heightened acuity of patients, and short-term stays. To respect and respond
to this change, we developed ideas about how to conduct a 15-minute (or
less) family interview and introduced them in the Third Edition.
We have been gratified by how these ideas have been enthusiastically accepted in both our text and when presenting them at nursing workshops or
conferences. More important, based on anecdotal reports, the implementation of these ideas has shown great promise. We have been encouraged by
nurses’ reports of softened suffering by family members and enhanced health
promotion with families in their care. Equally gratifying are reports of
increased job satisfaction by practicing nurses when collaborating with
families, even if only for 15 minutes or less.
We consider it a privilege to collaborate and consult with families for health
promotion and/or to diminish or soften emotional, physical, or spiritual suffering from illness. We are also grateful for opportunities to teach professional
nurses and undergraduate and graduate nursing students about involving,
caring for, and learning from families in health care. Through our own clinical
practice and teaching of health professionals for over 40 years and personal
family experiences with illness, we recognize the extreme importance of
nurses’ possessing sound family assessment and intervention knowledge,
skills, and compassion in order to assist families. We also acknowledge the
profound influence that families have upon our own lives and relationships.

A SNAPSHOT OF 30 YEARS OF PROGRESS AND
PARADIGM EVENTS IN FAMILY NURSING
Over these 30 years since the publication of the First Edition of Nurses and
Families, there have been paradigm events in family nursing worthy of celebration. There has been progress, and yet there are other areas where nursing

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xvi Introduction

still needs to put its “shoulder to the wheel.” We believe one of the most farreaching paradigm events in family nursing has been the publication of the
Journal of Family Nursing in 1995. Since its inception, it has been under the
able and competent editorship of Dr. Janice M. Bell. The establishment provided a central place, for the first time, for the uniting of family nurses and
the dissemination of family nursing knowledge. Another paradigm event was
the offering of the First International Family Nursing Conference in 1988, in
Calgary, Canada. Without any formal organization or association, eight
International Family Nursing Conferences (IFNCs) have been held in
North America, South America (Chile), and (in 2007 for the first time) Asia
(specifically, Bangkok, Thailand). Conferences in Chile, Iceland, Thailand,
and Japan have enabled a further appreciation of family nursing’s global
expansion beyond the boundaries of North America. In 2009, the Ninth
IFNC was held for the first time in Europe at Reykjavik, Iceland, and in 2011,
the Tenth IFNC was held in Kyoto, Japan. The Eleventh IFNC returns to
North America in 2013 in Minneapolis, Minnesota.
With each international family nursing conference, there is confirmation of clear, steady progress in the development and expansion of family
nursing. It is evident in the presentations, workshops, and keynotes; in the
advancement of knowledge in theory, research, assessment, and interventions in family work. There exists a solid commitment to focus on knowledge transfer and implementation to improve and sustain family care in
actual clinical practice. The community of family nurses has expanded to
be a true global force and phenomenon with enduring colleagueships and
friendships.
Another momentous development occurred at the Ninth IFNC in Iceland
when the International Family Nursing Association (IFNA) was created.
With a formal organization, even more opportunities are now available for
nurses to network and share knowledge and expertise outside of the conference format (www. internationalfamilynursing.org). One of the most exciting
new developments in advancing family nursing has been the endowment of
seven million dollars in 2008 to establish the Glen Taylor Nursing Institute
for Family and Society (http://ahn.mnsu.edu/nursing/institute/) at the School
of Nursing at Minnesota State University, Mankato. The university’s vision
is to create landmark innovations in the scholarship of family and society
nursing practice.
The face of families has dramatically changed over the past 30 years as
demographics in North America indicate an ever-increasing aging population; Baby Boomers are moving into retirement with significantly reduced
numbers of Generation Xers to care for them. Marriages are being delayed
or are nonexistent, as are pregnancies. Diversity in North American populations is clearly evident, demanding ever-increasing respect for a wide array
of cultural, religious, and sexual orientation differences in the health-care
system. Increased globalization invites the possibility for better health-care
practices worldwide but also allows for the universal transmission of

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Introduction xvii

diseases, making it much more difficult for health-care providers to isolate,
control, and segregate the origins of disease.
Amidst all the changes in demographics, technology, health-care delivery,
and diversity, there are also profound changes occurring in worldviews, from
modernism to postmodernism, from secularism to spiritualism. Family nursing has not been immune to these changes, nor have we.
Numerous other paradigm events have influenced families and the development of family nursing. Massive health-care restructuring and downsizing
in North America, the growth of managed care in the United States, and the
movements to reduce the length of stay in hospitals and to increase patient
satisfaction have expanded and enlarged community-based nursing practice
in the United States, Canada, and other countries. These movements have
directly and indirectly placed more responsibility on families for the care of
their ill members. Perhaps as a result of these dramatic changes, there is an
expanded consumer movement and more collaboration with families about
their health-care needs. Adding to this consumer movement is the increased
technology, particularly the use of computers, personal digital assistants, instant messaging, e-mails, texting, and cellular phones. Access to the Internet
and the explosion of health information through social networking such as
blogs, Twitter, Facebook, Linkedin, and YouTube enable family members to
be more proactive and knowledgeable about their health problems. Internet
health sites and social media open doors never before possible for families
to obtain current knowledge about their health problems, options for treatments, and traditional and alternative health-care resources.

THE SIXTH EDITION: WHAT IT IS, WHAT IS NEW
This revised Sixth Edition of Nurses and Families continues to be a “howto” basic text for undergraduate, graduate, and practicing nurses. It is the
only textbook, of which we are aware, that provides specific how-to guidelines for family assessment and intervention and actual skills for implementation in clinical practice with numerous clinical examples. This practical
how-to guide for clinical work offers the opportunity for nursing students,
practitioners, and educators to deliver better health care to families. Students
and practitioners of community and public health nursing, maternal child
nursing, pediatric nursing, mental health nursing, geriatric nursing, palliative
care nursing, and those specializing in family systems nursing will find it
most useful. Nurse educators who currently teach a family-centered approach and/or those who will be introducing the concept of the “family as
the client” will find it a valuable resource. Educators involved in continuing
education courses or nurse practitioner programs, especially family nurse
practitioner programs, will be able to use this book to update and substantially enhance nurses’ clinical knowledge and skills in family-centered care.
Our text provides specific guidelines and skills for nurses to consider when
preparing for and conducting family meetings, from the first interview

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xviii Introduction

through to discharge or termination. Actual clinical case examples are given
throughout the book. These case examples reflect ethnic, cultural, racial, and
sexual orientation diversity in conjunction with various family developmental
life-cycle stages and transitions. Special attention is given to the variety of
family forms and structures prevalent in today’s society. Issues in a variety
of practice settings, including hospital, primary care, school, community,
outpatient, and the home, are addressed. Innovative ideas to increase critical
thinking are offered.
The clinical practice ideas are based on solid theory, research, and our
own 40 years of clinical work with families. The ideas are current best practices. Due to our extensive clinical experience, both in our own practice and
in the teaching and supervision of nursing and interdisciplinary students, we
have been able to adapt the theoretical and clinical ideas so they can be useful. How to Do a 15-Minute (or Shorter) Family Interview (Chapter 9) remains one of the most popular, well-received, and useful chapters in the book
as reported by numerous practicing nurses and nursing students. It assists
nurses working in time-pressured environments to offer valuable assistance
to families.
The major purposes of this book are to (1) provide nurses with a sound
theoretical foundation for family assessment and intervention; (2) provide
nurses with clear, concise, and comprehensive evidence-based family assessment and intervention models, namely the Calgary Family Assessment and Intervention Models, for current best practice; (3) provide guidelines for family
interviewing skills; (4) offer detailed ideas and suggestions with clinical examples of how to prepare, conduct, use questions in, and terminate family interviews; and (5) provide nurses with an appreciation of the powerful influence
of nurse-family collaboration to diminish, soften, or alleviate illness suffering.
In this Sixth Edition, the following features are new:
■ A new chapter (Chapter 10) has been added: How to Move Beyond
Basic Family Nursing Skills. We hope that this chapter will give nurses
a clear idea how they can enhance their knowledge and skills, especially
those nurses who have been familiar for a number of years with the
skills that we discuss. This chapter offers more advanced skills in interviewing families in various settings and presents two clinical vignettes.
Sample skills for interviewing families of the elderly at times of transition are highlighted as well as skills for interviewing an individual to
gain a family perspective on chronic illness. Tips are offered, and microskills are delineated. Ideas for how to integrate family nursing into
various practice contexts are offered.
■ The Calgary Family Assessment Model (CFAM) has been thoroughly
updated and expanded to include many new references to the most
current research, theory, and U.S. statistics about families. These will
enhance evidence-based practice. Increased attention is given to diversity issues, including ethnicity, race, culture, sexual orientation, gender,
and class. CFAM is an easy-to-apply, practical, and relevant model for

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Introduction xix

■

■

■

■

■

■

busy nurses working with a wide variety of complex issues and family
structures and encountering various developmental stages.
More complex genograms have been added. Recommendations for how
to draw genograms for blended families with multiple parents and siblings, lesbian and gay families with children, and other family structures
will enable nurses to increase their interviewing skills and take proactive
steps to help families.
The Calgary Family Intervention Model (CFIM) has been updated and
revised to continue to make it more user-friendly and evidence-based.
It remains, to our knowledge, the only family intervention model for
nurses by nurses. It offers clear and specific family nursing interventions
to assist with improving and/or sustaining family functioning and
coping with illness.
Increased complex family situations and key intervention skills will foster nurses’ competence in dealing with multifaceted clinical issues, such
as genetic testing, obesity, intergenerational adoption, and the impact
of war and terrorism.
Elements of the Internet, such as health networks, social networking,
pornography, cybertherapy, cyberbullying, and their effects on families
have been integrated into information-rich content.
Specific suggestions for fostering collaborative nurse-family relationships are given throughout this text. Sample questions for nurses to ask
themselves and the family are also offered.
New clinical examples, vignettes, and boxes including questions used
in practice are a fast and easy reference tool for busy practicing nurses.

TOUR OF THE CHAPTERS
The first five chapters provide the conceptual base for collaborating and consulting with families. To be able to interview families, identify strengths and
concerns, and intervene to soften suffering, it is first necessary to have a
sound conceptual framework. The specific how-to section of the book is included in Chapters 6 through 12 with numerous clinical examples in a variety
of practice settings.
Chapter 1 establishes a rationale for family assessment and intervention.
It describes the conceptual shift required in considering the family system,
rather than the individual, as the unit of health care. It outlines the indications and contraindications for family assessment and intervention.
Chapter 2 addresses the major concepts of systems, cybernetics, communication, biology of knowing, and change theory that underpin the two
models offered in this text: the CFAM and CFIM. The chapter also presents
a brief description of some of the major worldviews that influence our models, such as postmodernism and gender sensitivity. Clinical examples of the
application of these concepts are offered.

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xx Introduction

Chapter 3 presents the updated and revised CFAM, a comprehensive,
three-pronged structural, developmental, and functional family assessment
framework. This model has been thoroughly updated and expanded to reflect the current range of family forms in North American society, and it
has increased emphasis on diversity issues such as ethnicity, race, culture,
sexual orientation, gender, and class. Specific questions that the nurse may
ask the family are provided. Two structural assessment tools—the genogram
and ecomap—are described, and instructions and helpful hints are given for
using them when interviewing families. Excerpts from actual family interviews are presented to illustrate how to use the model and tools in clinical
practice.
Chapter 4 describes the updated and revised CFIM. The revisions enable
nurses to move beyond assessment and to have available a repertoire of
family interventions that will effect or sustain changes in family functioning
in cognition, affect, and/or behavior. Actual clinical examples of family
work are presented, and a variety of interventions are offered for consideration. Nurses traditionally have primarily focused on family assessment
because there have been no family nursing intervention models within nursing to draw on.
Chapter 5 describes the family interviewing skills and competencies necessary in family-centered care. Perceptual, conceptual, and executive skills
necessary for family assessment and intervention are presented. The skills
are written in the form of training objectives, and clinical examples are given
to help broaden the nurse’s understanding of how to use these skills. Nurse
educators, in particular, may find this chapter useful in focusing their evaluation of students’ family interviewing skills. Ethical considerations in family
interviewing are addressed.
Chapter 6 focuses on the importance of the nurse-family relationship. It
presents clinical guidelines useful when preparing for family interviews. Ideas
are given for developing hypotheses, choosing an appropriate interview setting, and making the first telephone contact with the family.
Chapter 7 delineates the various stages of the first interview and the remaining stages of the entire interviewing process: engagement, assessment,
intervention, and termination. Actual clinical case examples in a variety of
health-care settings illustrate the practice of conducting interviews.
Chapter 8 emphasizes that questions are one of the most helpful interventions nurses offer to families. Questions to engage, assess, elicit problemsolving skills, intervene, and request feedback are recommended for
relational practice in various clinical settings.
Chapter 9 offers specific suggestions on how to conduct 15-minute (or
less) family interviews in a manner that enhances the possibilities for healing
or health promotion. These ideas respond to the realities facing many nurses
in this era of managed care and health restructuring. The chapter also encourages nurses to adopt the belief that any time spent with families is better
than no time.

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Introduction xxi

Chapter 10 is a new chapter for this Sixth Edition and focuses on skills
that are beyond the basics. Two in-depth clinical examples are given to
illustrate the kind of skills that are more advanced. Ideas for how to integrate
family nursing into various practice contexts are offered.
Chapter 11 offers ideas on how to avoid the three most common errors
made in family nursing. Each error is defined and discussed. A clinical example is given, followed by specific ideas how each error could have been
avoided. This chapter has proved useful to nurses in improving their care to
families as well as enhancing their satisfaction in collaborating with families.
Chapter 12 highlights how to terminate with families in a therapeutic
manner, whether after only one very short meeting, for example at the bedside, or after several meetings with a family, such as in an outpatient clinic.
Ideas are given for family-initiated and nurse-initiated termination as well
as for discharges determined by the health-care system.
The major difference between this book and other books on family nursing is that this book’s primary emphasis is on how to meet, interview, and
collaborate with families with the ultimate goal to soften suffering and/or
promote health of the families in your care. We wish to emphasize, however,
that this book does not offer a “cookbook” approach to family meetings
and interviews. The real development of skills results from knowledge transfer to actual clinical practice and supervisory feedback.
We envision this book as a springboard for nursing students, nursing educators, nursing researchers, and practicing nurses. With a solid conceptual
base and practical ideas for family assessment and intervention, we hope
that more nurses will gain confidence and a commitment to engage in the
nursing of families. In so doing, they will be reclaiming some aspects of
nursing that have been directly or inadvertently given to other health professionals. In the process, nurses will continue to regain an important and
expected dimension of nursing practice and be instrumental in the health
promotion and healing of families with whom they care for and collaborate.
We appreciate and are grateful for your interest and support of the ideas
we offer in our book.
References
Wright, L.M., & Leahey, M. (Producers). (2000). How to do a 15-minute (or less) family interview. [DVD]. Calgary, Canada: www.familynursingresources.com.
Wright, L.M., & Leahey, M. (Producers). (2001). Calgary Family Assessment Model:
How to apply in clinical practice. [DVD]. Calgary, Canada: www.familynursing
resources.com.
Wright, L.M., & Leahey, M. (Producers). (2002). Family nursing interviewing skills:
How to engage, assess, intervene, and terminate with families. [DVD]. Calgary, Canada:
www.familynursingresources.com.
Wright, L.M., & Leahey, M. (Producers). (2003). How to intervene with families with
health concerns. [DVD]. Calgary, Canada: www.familynursingresources.com.
Wright, L.M., & Leahey, M. (Producer). (2006). How to use questions in family interviewing. [DVD]. Calgary, Canada: www.familynursingresources.com.

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xxii Introduction

Wright, L.M & Leahey, M. (Producers). (2010). Common Errors in Family Interviewing:
How to Avoid & Correct. [DVD]. Calgary, Canada: www.FamilyNursingResources.com
Wright, L.M & Leahey, M. (Producers). (2010). Tips and Microskills for Interviewing
Families of the Elderly. [DVD]. Calgary, Canada: www.FamilyNursingResources.com
Wright, L.M & Leahey, M. (Producers). (2010). Interviewing an Individual to Gain a
Family Perspective with Chronic Illness: A Clinical Demonstration. [DVD]. Calgary,
Canada: www.FamilyNursingResources.com

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Chapter

1

Family Assessment and
Intervention: An Overview
Nurses have an ethical and moral obligation to involve families in their
health-care practice. This bold statement is due to evidence that the 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.
A rich tradition of nursing literature about the involvement of families in
nursing care has been evolving over the past 35 years. Some of the classic
and more recent texts on family nursing have enabled a new language to
emerge through naming, describing, and communicating about the involvement of families in health care. Terms such as family interviewing (Wright
& Leahey, 2013), family health promotion nursing (Bomar, 2004), family
health care nursing (Hanson, 2001; Hanson & Boyd, 1996; Kaakinen,
Gedaly-Duff, Coehlo, & Hanson, 2010), family nursing (Bell, Watson, &
Wright, 1990; Broome, et al, 1998; Friedman, Bowden, & Jones, 2003;
Gilliss, 1991; Gilliss, et al, 1989; Svavarsdottir & Jonsdottir, 2011; Wegner
& Alexander, 1993; Wright & Leahey, 1990), family nursing practice and
family systems nursing (Bell, 2009; Wright & Leahey, 1990; Wright, Watson,
& Bell, 1990), nursing of families (Feetham, et al, 1993), and family nursing
as relational inquiry (Doane & Varcoe, 2005) have all helped to bring
forth a vital aspect of nursing practice heretofore overlooked, neglected, or
minimized.
Perhaps the most significant, but not necessarily well-known, publication
about family nursing is the monograph published by the International Council
of Nurses titled The Family Nurse: Frameworks for Practice developed by
Madrean Schober and Fadwa Affara (2001). It is a convincing validation for
an emerging new role and specialty that the influential International Council
of Nurses identifies the “family nurse” and “family nursing” as two of the
important new and ongoing movements in nursing.
1

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2 Nurses and Families: A Guide to Family Assessment and Intervention

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.
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 softening suffering and
enhancing healing.

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.
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; Feetham, et al, 1993; Ford-Gilboe, 2002; Friedman, Bowden, &
Jones, 2003; Gilliss, 1991; Gilliss, et al, 1989; Hartrick, 2000; Kaakinen,
Gedaly-Duff, Coehlo, et al, 2010). These authors have made significant contributions to the advancement of family nursing knowledge.
The evolution, development, and practice of family nursing are well established and are being documented in many countries outside North America,
such as Brazil (Angelo, 2008), Finland (Astedt-Kurki, 2010; Astedt-Kurki &
Kaunonen, 2011), Iceland (Svavarsdottir, 2008; Svavarsdottir & Sigurdardottir,
2011), Hong Kong (Simpson, et al, 2006), Japan (Bell, 1999; Moriyama, 2008;
Sugishita, 1999), Nordic countries (Svavarsdottir, 2006), Nigeria (Irinoye,
Ogunfowokan, & Olaogun, 2006), Scotland (O’Sullivan Buchard, et al,
2004), Sweden (Saveman, 2010; Saveman & Benzein, 2001), and Thailand
(Wacharasin & Theinpichet, 2008), to name a few.
Perhaps the boldest and most ambitious global effort to enhance care to
families by implementing and improving the education and practice of nurses

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Chapter 1: Family Assessment and Intervention: An Overview 3

is the World Health Organization (WHO) Family Health Nurse Multinational
Study (World Health Organization, 2006). Eighteen European countries were
involved in this multinational study whose aim was to implement and evaluate
the concept of family health nurse (FHN) within their various health and educational systems. The inclusion of countries such as Slovenia, Kyrgyzstan,
Tajikistan, Republic of Moldova, and Lithuania indicates the continued global
expansion of family nursing. An FHN was defined as a skilled generalist family/
community nurse who combined illness prevention and management and
other duties determined by family/community needs.
In 2006, there was a final meeting in Berlin, Germany, 6 years after the
start of the study. At this meeting, the conclusion was that “the project was
very much an action research and action learning process. Participants showed
great enthusiasm and commitment to the research aims. Implementing a new
nursing service is a change management process and in-country change cycles
at the time of the multinational study were diverse. Some had developed a
fully functional FHN programme and had advanced into a second phase.
Some countries had not yet implemented the FHN programme whilst others
were in the process of their implementation” (p. 10). One example of a country that published an impressive report upon completion of the Family Health
Nurse Project initiated by WHO was Scotland, at the University of Stirling
(Murray, 2008).
The evolution of family nursing is most evident in the textbooks utilized in
the field. Five major textbooks on family health nursing in North America referenced throughout this text are now in their second to sixth editions. 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.”

FAMILY ASSESSMENT
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. Economists, for example, have been concerned with how the family
works together to meet material needs. Sociologists are concerned with the
family as a specific group in society. Mischke-Berkey, Warner, and Hanson
(1989); Hanson and Boyd (1996); and Tarko and Reed (2002) have identified and described several family assessment models and instruments developed by nurses and non-nurses. 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

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4 Nurses and Families: A Guide to Family Assessment and Intervention

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.

CALGARY FAMILY ASSESSMENT MODEL:
AN INTEGRATED FRAMEWORK
The Calgary Family Assessment Model (CFAM) was one of the four models
identified in The Family Nurse: Frameworks for Practice monograph by the
International Council of Nurses (Schober & Affara, 2001). The 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’ (1983) family assessment model
and has been substantially embellished since the first edition of this textbook
in 1984. The model is also embedded within larger worldviews of postmodernism, feminism, and biology of cognition. Diversity issues are also emphasized and appreciated within this model.
Of course, any model is useful only if it can be comprehended by nurses
and then transferred into their generalist practice with families. One
encouraging study to substantiate that CFAM is an easily comprehensible
model was conducted at the University of Hong Kong with senior baccalaureate nursing students. Following the teaching of CFAM, there was a
significant increase in the perceived understanding of all subcategories in
CFAM compared with the control group of baccalaureate nursing students
who completed an elective nursing course in women’s health (Lee, Leung,
Chan, et al, 2010).
An advancement in research has been the psychometric development of
the Iceland-Family Perceived Support Questionnaire (ICE-FPSQ) and the
Iceland-Expressive Family Functioning Questionnaire (ICE-EFFQ), based on
the CFAM and CFIM (Sveinbjarnardottir, Svavarsdottir, & Hrafnkelsson, in
press; Sveinbjarnardottir, Svavarsdottir, & Hrafnkelsson, in press). These
questionnaires will provide further credence and validity to the usefulness of
the CFAM and CFIM. See Chapter 3 for a detailed description of CFAM and
Chapter 4 for CFIM.

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,

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Chapter 1: Family Assessment and Intervention: An Overview 5

a judgment must be made about whether that particular illness or problem
should be approached within a family context.
Here are some examples of indications for a 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).
■ A family member is being admitted to the hospital for psychiatric or
mental health treatment.
■ A child is being admitted to the hospital.
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. In advanced nursing practice, particularly family systems nursing, assessment of individuals and of the family
system occur simultaneously (Wright & Leahey, 1990).
Some situations contraindicate 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).
During the engagement process, nurses must explicitly present the rationale for a family assessment. (Suggestions for how to do this are given in
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 the nurse has completed the family assessment, he or she 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

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6 Nurses and Families: A Guide to Family Assessment and Intervention

in Chapters 4, 8, and 9. The three most common errors in working with
families are discussed in Chapter 11.

NURSING INTERVENTIONS: A GENERIC DISCUSSION
Numerous terms are used to distinguish and label the treatment portion of
nursing practice, including intervention, treatment, therapeutics, action, activity, moves, and micromoves (Bulechek & McCloskey, 1992, 1999; Wright &
Bell, 2009). This textbook prefers the designation intervention. The most rigorous effort to standardize the language for nursing interventions is the work
of Bulechek and McCloskey (1992, 1999) and their colleagues at the University
of Iowa. More recently, these authors have worked to build taxonomies such
as the Nursing Interventions Classification, which is based on nurses’ reports
of their practice (Bulechek, Butcher, & McCloskey Dochterman, 2008).
Our practice differs in that after assessing a family, we prefer to generate a
list of strengths and problems 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 ethnic and cultural issues. 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 nurses 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
Bulechek and McCloskey (1999) define nursing interventions as “any treatment based upon clinical judgment that a nurse performs to enhance patient/client outcomes. Nursing interventions include both direct and indirect
care; those aimed at individuals, families, and the community; including
nurse-initiated, physician-initiated treatments and other provider-initiated
treatment” (p. xix). 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.” Wright
and Bell (2009) expand on their definition of intervention by suggesting that
an intervention “usually implies a one-time act with clear boundaries, frequently offering something or doing something to someone else.” 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

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Chapter 1: Family Assessment and Intervention: An Overview 7

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
(Bulechek & McCloskey, 1999) and are not usually interactional in nature.
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 (Bulechek, Butcher, & McCloskey Dochterman, 2008).

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). This next section discusses some specific aspects of family
interventions. It also presents indications for and contraindications to
family interventions.

Conceptualization of 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

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8 Nurses and Families: A Guide to Family Assessment and Intervention

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
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.
The effectiveness of family interventions in the treatment of physical illness
has been examined in two integrative reviews conducted by Campbell and
Patterson (1995) and Campbell (2003). These reviews included only studies
that used a control group. Support was found for the effectiveness of interventions directed to the family rather than just the individual diagnosed with
the illness.
Another important study to examine if family interventions improve
health in persons with chronic illness and their family members across the
life span was conducted by Chesla (2010). 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.
Weihs and colleagues (2002) reported the efforts of a multidisciplinary
group that reviewed and collated existing literature about family interventions in chronic illness. Three general goals for family-focused interventions
were identified: helping families cope with the challenges of chronic illness
management, mobilizing family support, and reducing intrafamilial hostility
and suffering.
Evidence has been found for a significant reduction in the use of healthcare services following individual, marital, and family therapy (Crane &
Payne, 2011; Law, Crane, & Berge, 2003). These studies substantiate the
need for more family intervention research in nursing.
There are now a few studies that have begun to uncover family interventions with families experiencing physical illness, particularly about 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; Noiseux
& Duhamel, 2003; O’Farrell, Murray, & Hotz, 2000). 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

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Chapter 1: Family Assessment and Intervention: An Overview 9

significant positive difference between parents’ coping patterns than before
the intervention.
Documentation of clinical experience indicates that interventions normally
directed at challenging the meanings or constraining beliefs about suffering
tend to have the most sustaining changes (Bell, Moules, & Wright, 2009; Bell
& Wright, 2011; Bohn, Wright, & Moules, 2003; Duhamel & Talbot, 2004;
Houger Limacher & Wright, 2003, 2006; Moules, 2002, 2009; Moules, et al,
2007; Moules, Thirsk, & Bell, 2006; Wright & Bell, 2009).
Efforts to develop and identify intervention strategies for family health
promotion are also being made, although little documentation of their effectiveness is evident (Loveland-Cherry & Bomar, 2004). Family health promotion is an area of family nursing in which there are tremendous opportunities
for the development and testing of family interventions. An example of
nurses taking the initiative to promote family health, in this case 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 life, Kendall and
Tabacco designed a program to provide both assessment and resources. This
is an impressive effort to empower families, particularly mothers, in their
daily management of these children.
Another innovative intervention program promoting family health is a
Web-based asthma education project (Garwick, Seppelt, & Belew, 2011).
This program addressed the cultural and literacy backgrounds of families
and involved family members in the actual needs assessment and in the
development of the Web site.
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 interviewing are based on the nurse’s and family’s influence on
the experience of suffering, a problem, or an illness. If engagement and
assessment have been adequate, the interventions are generally more
effective. For example, if a nurse working with a Latino family perpetually
addresses family members other than the father first, the family may
disengage. The opportunity to further intervene will be eliminated. In
this example, the nurse must possess family interviewing skills and must
be sensitive to ethnic issues 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 practice offered
to families. We have found it heartening to learn about the increased examples of intervention programs to assist families.

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10 Nurses and Families: A Guide to Family Assessment and Intervention

Indications and Contraindications for Family Interventions
After a family assessment, a nurse must decide whether to intervene with a
family. The nurse should consider the family’s level of functioning, his or her
own skill level, and the resources available. We recommend intervention in
the following circumstances:
■ A family member presents with an illness that has an obvious detrimental impact on other family members. For instance, a grandfather’s
Alzheimer’s disease may cause his grandchildren to be afraid of him, or
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. For example, 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. For example, 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. For example, 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. For example, 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. For example, 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.

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

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Chapter 1: Family Assessment and Intervention: An Overview 11

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, he or she may have the opportunity
for only one or two meetings before discharge, whereas a community health
nurse may be able to schedule a series of meetings. The context in which the
nurse encounters families commonly dictates the frequency and number of
family meetings. Whether a nurse has one or ten meetings with a family for
assessment or intervention, there are important considerations for terminating with families. Additional information on termination is discussed in
Chapter 12.
Family intervention is not always required, and contraindications for family
intervention exist, including:
■ 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.
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. This situation will be
discussed more fully in Chapter 12.
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, he or she has an easier time initiating family interventions.

DEVELOPMENT, IDENTIFICATION, AND IMPLEMENTATION
OF NURSING INTERVENTIONS WITH FAMILIES
The slower pace of developing nursing interventions with families has been
due in part to the lack of appreciation for the interactional aspect of families
and illness. The lack of specific interventions with families has been caused
by the lack of nurse educators who are also skilled family clinicians. Lack of
administrative support for implementation of family nursing and the lack of
ongoing educational support of family interventions in clinical settings have
negatively influenced the adoption of family nursing (Leahey & HarperJaques, 2010). However, since the fifth edition of Nurses and Families
(2009), significant strides have been made in all of these areas.

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12 Nurses and Families: A Guide to Family Assessment and Intervention

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. Very few nursing interventions with families have been tested. This
fact is not surprising given that the nursing profession is still at a very early
stage in simply identifying and describing family interventions. However,
there are encouraging signs with more publications in the Journal of Family
Nursing and presentations at the International Family Nursing Conferences
discussing family interventions. 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. We believe these trends will continue with even more rigor
and dedication over the next few years.
In a thoughtful editorial about evidence-based nursing, interventions,
and family nursing, Hallberg (2003) offers specific recommendations for
nursing interventions with individuals and families. Specifically, the author
recommends that nurses develop and examine “interventions that acknowledge family members as experts and that acknowledge their role as
primary caregivers; interventions directed at older people, especially those
between 80 and 100 years and those dependent on others as opposed to
independent older people; and interventions that elaborate on ways in
which professionals can cooperate with families caring for older people
in their homes and that apply a perspective of family caregiving as more
complex than only a burden or a strain” (p. 21). Hallberg strongly
emphasizes the belief that interventions with older people and their families are the most urgent need of the three. Therefore, nurse educators, researchers, and practicing nurses in the area of geriatric nursing have an
urgent call for more knowledge about how to best assist and intervene
with elderly families and their caregivers.
One program of research has responded to this call and is reported by
Ducharme (2011) and her team, who have developed an in-home psychoeducational intervention program for family caregivers of seniors. Although
they acknowledge that this program does not address the family from a systemic perspective, their program does respond to the family’s needs and
offers important education to the primary family caregiver of the senior. The
family caregiver is often the member suffering the most under the burden
and strain of caring for a loved one.
Nurses in direct clinical contact with families perceive family interventions differently from 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. One such clinical project
shed some light on nurses’ primary needs and concerns in their work
with families (Duhamel, Dupuis, & Wright, 2009). Nurses were found
to have difficulty integrating the theoretical aspects of family systems

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Chapter 1: Family Assessment and Intervention: An Overview 13

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.
In this project, 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 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. Through these various
studies, it becomes evident that a circular, interactional process between
education, research, and practice needs to be adhered to and respected
(Duhamel & Dupuis, 2011).

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. Since the
last edition of this text, more intervention studies have been conducted.
These studies increase nurses’ understanding of what is helpful to families
and what is not. 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?
A seminal study by Robinson and Wright (1995), which is also one of the
top ten cited articles in the Journal of Family Nursing, 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 softened their suffering. The nursing interventions that

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14 Nurses and Families: A Guide to Family Assessment and Intervention

made a difference for these families fell within two stages of the therapeutic
change process:
■ Bringing the family together to engage in new and different conversations (this fell within the stage of “creating the circumstances for
change”).
■ Establishing a therapeutic relationship between the nurse and family,
particularly in the areas of providing comfort and demonstrating trust
(within the stage of “creating the circumstances for change”).
Within the stage of “moving beyond and overcoming problems,” families
identified four interventions that promoted healing:
■ 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
Recent studies indicate that nurses are eager to learn more about the usefulness of family interventions that target family interactions and examine
the influence of each family member’s illness experiences on other family
members (O’Farrell, Murray, & Hotz, 2000).
A few additional qualitative studies have also been useful in examining
particular family interventions. Studies such as unpacking the interventions
of commendations (Houger Limacher & Wright, 2003, 2006), spiritual care
practices (McLeod, 2003), and therapeutic letters (Moules, 2002, 2003) have
enhanced our understanding of how, when, and why these interventions are
healing for families. Other intervention studies have focused on what is significant for therapeutic change to occur (Bell & Wright, 2011; Duhamel &
Talbot, 2004; Wright & Bell, 2009), while still others examined particular
populations experiencing illness: interventions for parents with children undergoing bone marrow transplants (Noiseux & Duhamel, 2003), interventions in perinatal family care (Goudreau & Duhamel, 2003), interventions
for families experiencing chronic illness (Robinson, 1998; Robinson &
Wright, 1995), interventions for families experiencing heart disease (Tapp,
2001), interventions for families experiencing childhood cancer (West, 2011),
interventions for grieving families (Thirsk, 2009), and interventions for
families experiencing HIV/AIDS (Wacharasin, 2010).
Duhamel and Talbot (2004) conducted an ambitious, labor-intensive study
to evaluate the usefulness of a family systems nursing approach utilizing the
CFAM and CFIM with families experiencing cardiovascular and cerebrovascular diseases. Because interventions are actualized only within the context
of a relationship between the nurse and the family, it is important to study
the process itself rather than simply the results. The Duhamel and Talbot
(2004) study was extremely beneficial because it was based on a participa-

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Chapter 1: Family Assessment and Intervention: An Overview 15

tory research design that allowed for continuous feedback and improvement
of the interventions throughout the study.
In such a study, the participants are all concerned with the problem:
nurses, patients, their spouses, and caregivers. 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” (Duhamel
& Talbot, 2004, p. 21) as the most useful interventions. Although all of these
interventions are part of CFAM and CFIM, Duhamel and Talbot’s 2004
study results provide interesting insights to substantiate their usefulness.
The study also had a positive impact on the nurses involved as
co-investigators—a revealing finding. For example, the 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 and a humanistic and personalized approach, centered
on family members’ specific concerns to reduce their anxiety, and integrated new family systems nursing interventions into their practice.
The identification of these interventions offers incredibly useful ideas for
improving the care of families experiencing illness. However, many more studies are needed to ascertain families’ responses to the interventions offered.

CALGARY FAMILY INTERVENTION MODEL:
AN ORGANIZING FRAMEWORK
The 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 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 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

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16 Nurses and Families: A Guide to Family Assessment and Intervention

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).
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. Consequently, the emphasis in the practice of family nursing at the generalist level is on the family as context.
In contrast, the practice of family systems nursing at the specialist level
emphasizes the family as the unit of care. 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. At Brandon University, a Family Case Model was
developed within the curriculum that embedded family nursing across five
courses in an undergraduate curriculum (Fast Braun, Hyndman, & Foster,
2010). This method of teaching family nursing to undergraduate students
invited a focus on the reciprocity between illness, family members, and the
nurse across courses.

CONCLUSIONS
We consider it a great privilege to work with families experiencing illness
and/or suffering, loss, and disability. We are also grateful for opportunities
to teach professional nurses and nursing students how to involve families in
health care. Through this process, we recognize the extreme importance of
nurses having sound family assessment and intervention knowledge, skills,
and compassion. The remainder of this textbook is our effort to help nursing
students, practicing nurses, and nurse educators learn new ways to heal families with our offering of specific knowledge and skills for maximizing family
collaboration and healing.
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L.M. Wright (Eds.): The Cutting Edge of Family Nursing. Calgary, Alberta: Family
Nursing Unit Publications, pp. 95–109.

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Chapter

2

Theoretical Foundations of the
Calgary Family Assessment and
Intervention Models
Models are useful ways to bring clusters of ideas, notions, and concepts into
awareness. However, models cannot stand alone. For example, nursing practice models are built on a foundation of many worldviews, theories, beliefs,
premises, and assumptions. These models are more comprehensible and
meaningful if the underlying theories, assumptions, and premises are explained. Therefore, to comprehend and use the Calgary Family Assessment
Model (CFAM; see Chapter 3) and the Calgary Family Intervention Model
(CFIM; see Chapter 4) in nursing practice with individuals, couples, and
families, nurses must understand the theoretical assumptions underlying
these models.
We believe no one overall model or theory of family nursing exists. “No
one theoretical or conceptual framework adequately describes the complex
relationships of family structure, function, and process. No single theoretical perspective gives nurses a sufficiently broad base of knowledge
and understanding for use as a guide to family assessment and interventions with families. Thus there is no single theoretical basis that guides
nursing care of families. Rather, nurses must draw on multiple theories
and frameworks to guide their work with families and take an integrated approach to practice, research, and education in family nursing”
(Kaakinen & Hanson, 2004, p. 111). We concur with Kaakinen and Hanson
on this.
The six theoretical foundations and worldviews that inform the CFAM
and CFIM (and the family nursing practice guidelines presented in the rest
of this textbook) are postmodernism, systems theory, cybernetics, communication theory, change theory, and biology of cognition. Each theory or

23

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24 Nurses and Families: A Guide to Family Assessment and Intervention

worldview and some of its distinguishing concepts are presented and related
to clinical practice with individuals, couples, and families.

POSTMODERNISM
Humans seem to delight in rethinking, reexamining, reconstructing, and
deconstructing their history and culture. One popular way to do this
is through the lens of postmodernism. Anything before the present
“enlightened” worldview is considered modernist and therefore less
desirable to those who rigidly hold postmodernist beliefs. Consequently,
the influence of the ideas, conditions, and beliefs of postmodernism
have been demonstrated in art, literature, architecture, science, culture,
religion, philosophy, and, more recently, in family therapy and nursing,
particularly family nursing (Becvar & Becvar, 2003; Glazer, 2001;
Kermode & Brown, 1996; Moules, 2000; Tapp & Wright, 1996; Watson,
1999). The popularity and increasing acceptance of postmodern ideas in
nursing are even making their way into propositions of spiritual care
and postmodernism coexisting, although this is an unlikely connection
(Salladay, 2011).
We, too, have been influenced by and have embraced many of the notions
of postmodernism. These ideas have proved useful in our clinical nursing
practice with families. However, we do not wish to imply that we have been
able to successfully distance ourselves from all modernist ideas, nor would
we want to. We concur with Glazer (2001), who criticizes the postmodern
movement for abandoning the biological underpinnings of nursing. We cannot deny our history and culture and how they have influenced who we were
and are. Therefore, we acknowledge the previous and continuing influences
of both modernist and postmodernist paradigms on our lives and our practice of relational family nursing.

CONCEPT 1

Pluralism is a key focus of postmodernism.
Postmodernism offers the end of a single worldview and a resistance to
single explanations and offers a respect for difference. One of the major notions of postmodern thinking is the idea of pluralism, or a belief in multiplicity—there are as many ways to understand and experience the world as
there are people who experience it (Moules, 2000; Watson, 1999; Wright &
Bell, 2009). In family nursing practice, this idea becomes operational by recognizing that there are as many ways to understand and experience illness
as there are families experiencing it. In an ethical and relational family nursing practice, it becomes operational by acknowledging the multiplicity of
cultural, ethnic, and religious beliefs and their influence on various complex
family structures.

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Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models 25

CONCEPT 2

Postmodernism is a debate about knowledge.
Postmodernism is partly a reaction to the modernist claim that knowledge emerges primarily from science and technology (Glazer, 2001). The
belief that progressive technology necessarily leads to a better world has
become open to reexamination, questioning, and doubt (Tapp & Wright,
1996). Therefore, an intense critique is being made of the grand belief systems that have formed the foundation of many scientific, religious, and political movements and institutions. As they are questioned, opportunities
arise to deconstruct or uncover certain beliefs and practices that are taken
for granted, to hear voices of marginal groups, and to value knowledge
from a variety of domains heretofore not legitimized (Tapp & Wright,
1996; Watson, 1999).
In encounters with families experiencing illness, much more emphasis is
now given to the illness narratives and experiences of family members
within their particular cultural context not just to medical narratives. Honoring the voices of families about their illness narratives has profound implications for nursing practice with families. It invites collaboration and
consultation between nurses and families to honor the knowledge and expertise of both nurses and family members. These practices are the cornerstone of relational nursing. Inviting the illness narratives of families also
enhances the possibilities for healing as their stories are heard, understood,
and witnessed.
Some offshoots of postmodernism include constructivism, social constructionism, and biology of cognition (also called “bring forthism“; Bell &
Wright, 2011; Maturana & Varela, 1992; Moules, 2000; Wright & Bell,
2009). Biology of cognition is the offshoot we have found most useful in our
clinical work and we discuss it in more detail later in this chapter.
The postmodernist movement has been strongly critiqued by feminists,
who claim that women’s voices continue to be diminished or ignored because of patriarchy and oppression (Kermode & Brown, 1996). This has
not been our experience in working with families. Evidence for the importance of acknowledging women’s voices and their illness burden in family
systems nursing practice can be found in Robinson’s 1998 study. She discovered that women in families experiencing chronic illness are vulnerable
to the demands of illness’s responsibility, work, and problems. As a more
equitable balance of illness demands was sought by the nurse and family
members, the women in this study found better lives for themselves and
were able to live beyond illness and the problems they experienced. They
also took on new views of their situations and thus behaved differently. This
study’s recognition of women’s voices as distinct and different from a collective “family voice” seems in keeping with the best that the postmodernist
movement has to offer.

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26 Nurses and Families: A Guide to Family Assessment and Intervention

SYSTEMS THEORY
For a number of years, health professionals have applied general systems theory, introduced in 1936 by von Bertalanffy, to the understanding of families.
In addition to the original writings on systems theory by von Bertalanffy
(1968, 1972, 1974), numerous articles and chapters in books have been written on this subject and its concepts. This proliferation of systems information
is also evident within nursing literature. We agree with Kaakinen and Hanson
(2010) in their belief that “family systems theory has been the most influential of all the family social science frameworks” (p. 73).
One of the most useful analogies that highlights systems concepts as applied to families is offered by Allmond, Buckman, and Gofman (1979). They
suggest that, when thinking of the family as a system, it is useful to compare
it to a mobile:
Visualize a mobile with four or five pieces suspended from the
ceiling, gently moving in the air. The whole is in balance, steady
yet moving. Some pieces are moving rapidly; others are almost
stationary. Some are heavier and appear to carry more weight in
the ultimate direction of the mobile’s movement; others seem to
go along for the ride. A breeze catching only one segment of the
mobile immediately influences movement of every piece, some
more than others, and the pace picks up with some pieces unbalancing themselves and moving chaotically about for a time. Gradually the whole exerts its influence in the errant part(s) and
balance is reestablished but not before a decided change in direction of the whole may have taken place. You will also notice the
changeability regarding closeness and distance among pieces, the
impact of actual contact one with another, and the importance
of vertical hierarchy. Coalitions of movement may be observed
between two pieces. Or one piece may persistently appear isolated
from the others; yet its position of isolation is essential to the
balancing of the entire system (p. 16).

Keeping the analogy of the mobile in mind, some of the most useful
concepts of systems theory, which have frequent application in clinical
practice with families, are highlighted in the following paragraphs. These
systems concepts provide a theoretical foundation for understanding the
family as a system. A system can be defined as a complex of elements in
mutual interaction. When this definition is applied to families, it allows
us to view the family as a unit and thus focus on observing the interaction
among family members and between the family and the illness or problem
rather than studying family members individually. However, remember
that each family member is both a subsystem and a system in his or
her own right. An individual system is both a part and a whole, as
is a family.

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Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models 27

CONCEPT 1

A family system is part of a larger suprasystem and is
composed of many subsystems.
The concept of hierarchy of systems is very useful when applied to families.
It is especially helpful for nurses struggling with how to conceptualize complex
family situations. A family is composed of many subsystems, such as parentchild, marital, and sibling subsystems. These subsystems are also composed of
subsystems of individuals. Individuals are extremely complex systems composed of various subsystems, some of which are physical (e.g., the cardiovascular and reproductive systems) or psychological (e.g., cognitive, affective, and
behavioral systems). At the same time, the family is just one unit nested in
larger suprasystems, such as neighborhoods, organizations, or church communities. Drawing a large circle and placing elements, parts, or variables inside
the circle can be a helpful way to visualize a system. Inside the circle, lines can
be drawn among the component parts to represent relationships between elements. Outside the circle is the larger context, where all other factors impinging
on the system can be placed. Thus, a nurse can draw a circle to visualize a
family and then place the individual family members within it (Fig. 2–1).
Systems are arbitrarily defined by their boundaries, which aid in specifying
what is inside or outside the system. Normally, boundaries associated with
living systems are physical in nature, such as the number of people in a family.

Suprasystem

A

B

C

D

Family System

Individual System

F I GU R E 2-1: Family system.

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28 Nurses and Families: A Guide to Family Assessment and Intervention

It is also possible to construct a boundary and therefore create a system
around ideas, beliefs, expectations, or roles. For example, a person may have
a system of multiple roles, such as daughter, partner, colleague, wife, sister,
nurse, mother, and grandmother. However, from time to time, it may be useful
to draw an imaginary boundary and create, for example, a system of parental
beliefs about the use of nonmedical drugs by their children.
When working with families, nurses should initially consider:
■ Who is in this family system?
■ What are some of the important subsystems?
■ What are some of the significant suprasystems to which the family
belongs?
In addition, within family systems and their subsystems, nurses should
assess the permeability of the boundaries (see Chapter 3 for further understanding about boundaries when conducting a family assessment). In
family systems, the boundaries must be both permeable and limiting. If
the family boundary is too permeable, the system loses identity and integrity (e.g., members may be too open to input from the outside environment, such as extended family, friends, or health professionals) and
therefore does not allow the family to use its own resources in decisionmaking. However, if the boundary is too closed or impermeable, necessary
interaction with the larger world is shut off (e.g., an immigrant family
from Afghanistan that relocates to Pennsylvania may inadvertently remain
closed initially because of great differences in language and culture). With
increased use of cellular phones; the Internet; personal digital assistants;
e-mail; e-Books; blogs; Skype; chat rooms; and social networking sites
such as Facebook, Twitter, and YouTube, the permeability of boundaries
has changed dramatically in the last decade.
Hierarchy of systems and the boundaries that create systems are useful
concepts to apply when working with and attempting to conceptualize the
uniqueness of each particular family. Among certain ethnic groups—for
example, Iranian families—honoring hierarchies and boundaries is essential.

CONCEPT 2

The family as a whole is greater than the sum of its parts.
When applied to families, this concept of systems theory emphasizes that
the family’s “wholeness” is more than simply the addition of each family
member. It also emphasizes that individuals are best understood within their
larger context, which is normally the family. To study individual family members separately does not equate to studying the family as a unit. By studying
the whole family, it is possible to observe interaction among family members,
which often more fully explains individual family member functioning. Consider this clinical scenario: A young Filipino mother whose 3-year-old child

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Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models 29

has temper tantrums that she cannot control asks a community health nurse
(CHN) for guidance. The CHN could intervene in a variety of ways:
■ See the mother individually and discuss some behavioral methods that
could be used to assist in controlling her child’s temper tantrums.
■ See the child individually and do an individual assessment.
■ See the whole family (mother, father, and child) and perform a childand-family assessment (see Chapter 3) in order to understand the child,
the child’s behavior in the family context, and the Filipino family’s
beliefs about discipline.
Because the CHN understood the importance of Concept 2, she chose to
see the whole family. During the first session with the family, the child was
well behaved for the first half hour of the interview. Then the child had a
temper tantrum, in response to which the mother became annoyed and the
father withdrew. The CHN was astute enough to observe the sequence of interaction before the temper tantrum. When the child had the temper tantrum,
the parents were in a heated argument about their parenting styles. Once the
tantrum started, the parents stopped arguing and focused on the child. This
child might have been responding to the tension between the parents and
using the temper tantrums to stop the parents’ conflict. Thus, the temper
tantrums were understood quite differently in the context of the family than
they would have been if the child had been assessed in isolation. In this example, the family is the client, but an individual family member is the reason
for initiating care (Schober & Affara, 2001). Any time a family seeks assistance because of a concern or problem with an individual family member,
the nurse can initiate family nursing with the entire family unit.
Therefore, when possible, nurses should see whole families and observe
family interaction to more fully understand family member functioning. This
type of observation enables assessment of the relationships among family
members and individual family member functioning. You cannot understand
the parts of a body, a family, or a theory unless you understand how the whole
works, for the parts can be understood only in relation to the whole. Conversely, you cannot grasp how the whole works unless you have an understanding of its parts. However, family nursing is not about how many family
members are present in the room with the nurse but rather how the nurse
conceptualizes the interaction between illness and family dynamics. (See
Chapter 10 for a clinical example of interviewing an individual to obtain a
family perspective with chronic illness.)

CONCEPT 3

A change in one family member affects all family members.
This concept aids the recognition that any significant event or change
in one family member affects all family members to varying degrees as was

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30 Nurses and Families: A Guide to Family Assessment and Intervention

illustrated in the analogy of the mobile. It can be most useful to nurses considering the impact of illness on families. For example, the father of a Somali
family experienced a myocardial infarction. This event affected all family
members and various family relationships. The father and mother were unable to continue their joint participation in sports, and the mother increased
her employment from part-time to full-time to supplement the substantially
reduced income during the father’s convalescence. The eldest daughter, who
had been isolated from the family since her marriage, began visiting her father more often. The youngest daughter provided emotional support and so
became closer to her mother. Thus, all family members were affected, and
the organization and functioning of the family changed.
This concept can also be used to understand how a nurse can change the
family system by implementing family interventions—that is, if one family
member changes, other family members cannot respond as they previously
did because the individual family member now behaves differently.

CONCEPT 4

The family is able to create a balance between change
and stability.
Over the past few years, there has been a shift away from the belief that
families tend toward maintaining equilibrium. Instead, the popular belief
now is that families are really in constant states of flux and are always changing. The pendulum has now swung to the other end of the continuum. However, von Bertalanffy (1968) warned many years ago to avoid this polarized
view of families. He suggested that systems, in this case family systems, can
achieve balance among the forces operating within them and on them and
that change and stability can coexist in living systems (see the “Change Theory”
section later in this chapter).
However, when change occurs in a family, the disturbance can cause a
shift to a new position of balance. The family reorganizes in a way that is
different from any previous organization. For example, if a family member
is diagnosed with a long-term chronic illness, such as multiple sclerosis, the
entire family must reorganize itself in ways that are totally different from the
ways it was organized before the diagnosis. The balance between change and
stability constantly shifts during periods of remission and exacerbation; however, a balance between change and stability is most common.
The concept of change and stability coexisting is perhaps one of the most
difficult concepts of systems theory for nurses to understand. This is partly
because, in actual clinical practice, families frequently present themselves as
being either in rigid equilibrium or in constant change rather than manifesting an observable balance between the two. However, the more experienced
one becomes in family nursing, the greater appreciation one has for the complexity of families. In many cases, when families are “stuck” or experiencing

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Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models 31

severe difficulties, they are polarized in maintaining rigid equilibrium or are
in a phase of too much change. Eventually, the family needs to find ways to
obtain a more equal balance between the phenomena of stability and change.
In our own practice over the last several years, we have noticed how military
families and other families directly affected by terrorism and war have developed creative solutions to cope with the fluctuations of stability and
change.

CONCEPT 5

Family members’ behaviors are best understood from a
view of circular rather than linear causality.
One method of dealing with the massive amounts of data presented in a
family interview is to observe for patterns. Tomm (1981) offers a useful discussion of the differences between linear and circular patterns:
One major difference between linear and circular patterns lies in the
overall structure of the connections between elements of the pattern.
Linear patterns are limited to sequences (e.g., A → B → C) whereas
circular patterns form a closed loop and are recursive (e.g., A → B
→ C → A → . . . or A → B, B → C, C → A). A less obvious but more
significant difference lies in the relative importance usually given to
time and meaning when making the connections or links in the pattern. Linearity is heavily rooted in a framework of a continuous progression of time. . . .Circularity. . .is more heavily dependent on a
framework of reciprocal relationships based on meaning (p. 85).

Linear causality, defined as a relationship in which one event causes another, can serve as a useful and helpful function for individuals and families.
For example, when the clock strikes 6:00 PM, a family routinely eats supper.
This is an example of linear causality because event A (the clock striking
6:00 PM) is seen as the cause of event B (the eating of supper), or A → B,
whereas event B does not affect event A.
However, circular causality occurs when event B does affect event A. For
example, if a husband takes an interest in his wife’s ostomy care (event A)
and the wife responds by explaining the daily procedures (event B), then it
is likely to result in the husband continuing to take an interest and offer
support regarding his wife’s ostomy care and his wife continuing to feel
supported; thus, the cycle continues (A → B → A). Each individual’s behavior
has an effect on and influences the other individual’s behavior. A method for
diagramming these very useful circular interactional patterns is discussed in
Chapter 3.
The application of these concepts in clinical practice affects the nurse’s
style of questioning during a family interview. Linear questions tend to
explore descriptive characteristics (e.g., “Is the father fearful of another heart

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32 Nurses and Families: A Guide to Family Assessment and Intervention

attack?”), whereas circular questions tend to explore interactional characteristics. Types of circular questions include difference questions (e.g., “Who is most
worried about Sunil having another heart attack?”), behavioral effect questions
(e.g., “What do you do, Amal, when your wife’s pain becomes unbearable for
you?”), hypothetical or future-oriented questions (e.g., “What might you do in
the future to prevent your elderly father from falling?”), and triadic questions
(e.g., “When your dad shows support to your sister Manisha, how does your
mom feel?”) (Loos & Bell, 1990; Selvini-Palazzoli, et al, 1978; Tomm, 1984,
1985, 1987a, 1987b, 1988; Wright & Bell, 2009). Bateson (1979) offers the
idea that “information consists of differences that make a difference” (p. 99).
Tomm (1981) connects the idea of “differences” to relationships:
Differences between perceptions, objects, events, ideas, etc. are
regarded as the basic source of all information and consequent
knowledge. On closer examination, one can see that such relationships are always reciprocal or circular. If she is shorter than he, then
he is taller than she. If she is dominant, then he is submissive. If one
member of the family is defined as being bad, then the others are
being defined as being good. Even at a very simple level, a circular
orientation allows implicit information to become more explicit and
offers alternative points of view. A linear orientation on the other hand
is narrow and restrictive and tends to mask important data (p. 93).

Various types of assessment and interventive questions that could be asked
during a family interview are highlighted in Chapters 3, 4, and 6 through 10.
With regard to family member interaction, the assumption is made that
each person contributes to adaptive and maladaptive interaction. For example,
in geriatric health-care facilities, it is common for elderly parents to complain
that their adult children do not visit enough and therefore withdraw; on the
other hand, the adult children complain that their elderly parents constantly
nag them when they visit (see Chapter 10 for a clinical example). Each family
member is “correct” in the perception of the other, but neither recognizes
how his or her own behavior influences the behavior of the other family
member.
Normally, families and their individual members need help to move from
a linear perspective of their situation to a more interactional, reciprocal, and
systemic view. This shift is possible only if the nurse avoids linear thinking
when attempting to understand family dynamics.
The five concepts previously listed are by no means inclusive of all systems
concepts, but they reflect those that are deemed most significant and important to the theoretical foundation for working with families.

CYBERNETICS
Cybernetics is the science of communication and control theory. The term
cybernetics was originally coined by the mathematician Norbert Weiner. It is
important to differentiate between general systems theory and cybernetics.We

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Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models 33

do not use the terms synonymously although some people regard each as a
branch of the other. Systems theory is primarily concerned with changing the
conceptual focus from parts to wholes, whereas cybernetics is concerned with
changing focus from substance to form.

CONCEPT 1

Family systems possess self-regulating ability.
Interpersonal systems, particularly family systems, “may be viewed as
feedback loops, since the behavior of each person affects and is affected by
the behavior of each other person” (Watzlawick, Beavin, & Jackson, 1967,
p. 31). We have found this idea to be very useful in family work because
recognizing that each family member’s behavior affects other family members and, in turn, that person is affected by other family members’ behavior
removes any tendency or impulse a nurse may have to blame one person
in a family for the difficulties that an entire family is facing. For any substantial change to occur in a relationship, the regulatory limits must be adjusted so that a new range of behaviors is possible or an entirely new
pattern can emerge (transformation). Tomm (1980) offers a useful method
of applying cybernetic regulatory concepts to actual clinical interviewing.
His method of diagramming circular patterns of communication is discussed in Chapter 3.

CONCEPT 2

Feedback processes can simultaneously occur at several systems levels with families.
Initially, the application of cybernetic concepts in family work began
by observations of simple phenomena (e.g., a wife criticizes, the husband
withdraws); this is generally referred to as simple cybernetics. However,
as cyberneticians began examining more complex orders of phenomena,
they recognized different orders of feedback (such as feedback of feedback and change of change). Maturana and Varela (1980) suggest a
higher-order cybernetics that links the organization of living process and
cognition.
Therefore, the simple feedback phenomenon observed in the interactional pattern of criticizing wife—withdrawing husband may also be understood to be part of a larger feedback loop involving the couple’s
relationship to their families of origin, which may recalibrate the lowerorder loop of the couple’s interaction. This concept can be especially helpful to nurses working with complex family situations. Thus, cybernetics
of cybernetics moves into a larger context that includes both the observer
and the observed.

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34 Nurses and Families: A Guide to Family Assessment and Intervention

COMMUNICATION THEORY
The study of communication focuses on how individuals interact with one
another. Within families, the function of communication is to assist family
members in clarifying family rules regarding behavior, to help them learn
about their environment, to explicate how conflict is resolved, to nurture
and develop self-esteem for all members, and to model expressions of feeling
states constructively within the family as a unit. One of the most significant
contributions to the understanding of interpersonal processes is the classic
book Pragmatics of Human Communication (1967) by Watzlawick, Beavin,
and Jackson. The concepts presented here are primarily drawn from this important book on communication and have been updated by the research
studies of Dr. Janet Beavin Bavelas in 1992.

CONCEPT 1

All nonverbal communication is meaningful.
This concept helps us to realize that there is no such thing as not communicating because all nonverbal communication by a person carries a message
in the presence of another (Watzlawick, Beavin, & Jackson, 1967). In personal communications and in her 1992 publication, Dr. Beavin Bavelas states
that she now distinguishes between nonverbal behavior (NVB) and nonverbal communication (NVC). NVC is viewed as a subset of NVB. NVB
involves an “inference-making observer,” whereas NVC involves a “communicating person” (encoder). In the original text by Watzlawick, Beavin,
and Jackson, the concept was presented that all NVB is meaningful.
A significant component of this concept is context. Behavior is relevant
and meaningful only when the immediate context is considered. For example, if a mother complains to a CHN that she has been experiencing insomnia for 2 months and finds herself irritable because of the prolonged
sleep deprivation, the mother’s behavior must be understood in her immediate context. On further exploration, the nurse discovers that this mother
has a child on an apnea monitor and that the father sleeps soundly. Also,
the family apartment is close to a subway. With this additional context information, the mother’s insomnia can be more fully understood and treated
by the CHN.

CONCEPT 2

All communication has two major channels for
transmission: digital and analog.
Digital communication is commonly referred to as verbal communication. It consists of the actual content of the message, or the brute facts. For

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Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models 35

example, a man might proudly say, “I lost 15 pounds this past month,” or
a 10-year-old girl might say, “I can now give myself my own insulin.” However, when the analogical communication is also taken into account, the
meaning of these statements may change dramatically.
Analogical communication consists not only of the usual types of NVC,
such as body posture, facial expression, and tone, but also of music, poetry,
and painting. For example, a man who is obese and proudly states that he
lost 15 pounds in a month sends a more positive message, both digitally and
analogically, than a man who is emaciated and states that he lost 15 pounds.
When discrepancies exist between analogical and digital communication,
then the analogical message is considered more pertinent to the nurse’s
observing eye. For example, a teenager who has been placed in a cumbersome cast for a fractured femur might state, “It doesn’t bother me,” but her
eyes are filled with tears. In this situation, the nurse must recognize the
importance of the analogical message. To the teenager’s boyfriend, the digital
communication may be the most relevant. He may not perceive the significance of the analogical communication. More suggestions for operationalizing this concept are included in the CFAM in Chapter 3.

CONCEPT 3

A dyadic relationship has varying degrees of symmetry
and complementarity.
The terms symmetry and complementarity are useful in identifying typical
family interaction patterns. Jackson (1973) defined these terms:
A complementary relationship consists of one individual giving and the
other receiving. In a complementary relationship, the two people are
of unequal status in the sense that one appears to be in the superior
position, meaning that he initiates action and the other appears to follow that action. Thus the two individuals fit together or complement
each other. The most obvious and basic complementary relationship
would be the mother and infant. A symmetrical relationship is one between two people who behave as if they have equal status. Each person exhibits the rights to initiate action, criticize the other, offer advice
and so on. This type of relationship tends to become competitive; if
one person mentions that he has succeeded in some endeavor, the
other person mentions that he has succeeded in an equally important
endeavor. The individuals in such a relationship emphasize their equality or their symmetry with each other. The most obvious symmetrical
relationship is a pre-adolescent peer relationship (p. 189).

Both complementary and symmetrical relationships are appropriate
and healthy in certain situations. For example, a staff nurse must take a
“one-down” position to her nurse manager most of the time. If the staff nurse

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36 Nurses and Families: A Guide to Family Assessment and Intervention

cannot do this, conflict could result and the relationship could become predominantly symmetrical. This symmetrical escalation could result in the
nurse manager filing incident reports about the staff nurse or the staff nurse
quitting on unpleasant terms. An example of a healthy symmetrical relationship is one between spouses, who may, for instance, debate where to spend
their next vacation.
In family relationships, predominance of either complementary or symmetrical behavior usually results in problems. However, some cultural groups
may prefer one style over another. Couples need to balance symmetry and
complementarity in their various experiences. Parent-child relationships,
however, typically gradually shift from a predominantly complementary relationship to a more symmetrical, egalitarian relationship as the child moves
into the teenage and young adult years.

CONCEPT 4

All communication has two levels: content and relationship.
Communication consists of what is being said (content) and information
that defines the nature of the relationship between those interacting. For example, a father might say to his son, “Come over here, son. I want to tell
you something,” or he might say, “Get over here. I’ve got something to tell
you!” These statements are similar in content, but each implies a very different relationship. The first statement could be viewed as part of a loving relationship, whereas the second statement implies a conflictual relationship.
In this instance, it is the tone of the content that gives evidence to a particular
kind of relationship. Therefore, “family communication not only reveals a
message about ‘who is saying what and when,’ it also conveys a message
about the structure and functions of family relationships in relation to the
power base, decision-making processes, affection, trust, and coalitions”
(Crawford & Tarko, 2004, p. 162).

CHANGE THEORY
The process of change is a fascinating phenomenon, and researchers and
clinicians have a variety of ideas about how and what constitutes change in
family systems. In the discussion of change theory that follows, the most
profound and salient points from an extensive review of the literature are
synthesized and presented along with our own beliefs about change and the
conditions that affect the change process.
Systems of relationships appear to possess a tendency toward progressive
change. However, a French proverb states, “the more something changes,
the more it remains the same.” This paradox beautifully highlights the
dilemma frequently faced in working with families. The nurse must learn to
accept the challenge of the paradoxical relationship between persistence

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Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models 37

(stability) and change. Maturana (1978) explains the recursiveness of change
and stability in this way: Change is an alteration in the family’s structure
that occurs as compensation for perturbations and has the purpose of maintaining structure and stability. Change itself is experienced as a perturbation
to the system, so change generates further change and stability. A change in
state is exhibited as behavior; therefore, differences in family interactional
patterns must be explored. Changes in behavior may or may not be accompanied by insight. However, “the most profound and sustaining change will
be that which occurs within the family’s belief system (cognition)” (Bell &
Wright, 2011; Wright & Bell, 2009).
Watzlawick, Weakland, and Fisch (1974) were the first to suggest that
persistence and change must be considered together despite their opposing
natures. These researchers offer a widely accepted notion of change and suggest that two different types or levels of change exist. They refer to one type
as change occurring within a given system that remains unchanged itself. In
other words, the system itself remains unchanged, but its elements or parts
undergo some type of change. This type of change is referred to as firstorder change. It is a change in quantity, not quality. First-order change involves using the same problem-solving strategies over and over again. Each
new problem is approached mechanically. If a solution to the problem is
difficult to find, more old strategies are used and are usually more vigorously applied. An example of first-order change is the learning of a new behavioral strategy to deal with a child’s excessive computer use. A parent
who formerly disciplined his child by restricting the child’s access to the
computer is said to have undergone first-order change when he then limits
the child’s spending money.
The second type of change, referred to as second-order change, is one
that changes the system. Second-order change is thus a “change of change.”
It appears that the French proverb is applicable only to first-order change.
For second-order change to occur, actual changes in the rules governing the
system must occur, and therefore the system is structurally transformed. It
is important to note that second-order change is often in the nature of a discontinuity or jump and can be sudden and radical. Other times, secondorder change occurs in a logical sequence with the person almost seemingly
unaware of the change until it is noted by others.
This type of change represents a quantum jump in the system to a different
level of functioning. Second-order change can be said to occur, for example,
when a family now spends more time together and is able to raise conflictual
issues with one another as a result of resolving their teenager’s refusal to eat
with the family.
Watzlawick, Weakland, and Fisch (1974) also refer to the most obvious
type of change, spontaneous change. In spontaneous change, problem resolution occurs in daily living without the input of professionals or sophisticated theories. For example, an anorexic young woman suddenly and
apparently spontaneously begins to eat regularly after 2 years of not doing

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38 Nurses and Families: A Guide to Family Assessment and Intervention

so, or a man suffering from shingles (herpes zoster) reports that his chronic
pain disappeared overnight.
Bateson (1979) offers a most thought-provoking statement with regard
to change when he proposes that people are almost always unaware of
changes. He suggests that changes in social interactions and in the environment are dramatically and constantly occurring but that people become
accustomed to the “new state of affairs before our senses can tell us
that it is new” (p. 98). Bateson also offers the idea that, with regard to
the perception of change, the mind can receive only news of difference.
Therefore, as Bateson states, change can be observed as “difference which
occurs across time” (p. 452). These ideas concur with those of Maturana
and Varela (1992), who offer the idea that change occurs in humans
from moment to moment. This change is either triggered by interactions
or perturbations from the environment in which the system (family member) exists or is a result of the system’s (family member’s) own internal
dynamics.
Our own view of change in family work draws from the above authors
and from our clinical experience in working with families. Change is constantly evolving in families, and people are frequently unaware of it. This
type of continuous or spontaneous change occurs with everyday living and
progression through individual and family stages of development. These
changes may or may not occur with professional input.
Major transformations of an entire family system can occur and can be
precipitated by major life events—such as serious illness; disability; divorce;
unemployment; addictions; terrorism; displacement from home as a result
of terrorism, war, floods, hurricanes, or tsunamis; or death of a family
member—or through interventions offered by nurses. Change within a family
can occur within the cognitive, affective, or behavioral domains, but change
in any one domain impacts the other domains. Therefore, family-nursing interventions can be aimed at any domain or all three domains. Interventions
are discussed further in Chapter 4, in which the CFIM is presented. We
believe that directly correlating interventions with resulting changes is
impossible; therefore, predicting outcomes or the types of change that will
occur within families is also impossible.
An important role for nurses (operating from a systems perspective) is to
carefully observe the connections between systems. To effect change within
the original system (the individual), it is necessary to intervene at a higher
systems level or at the metalevel (the family system [see Fig. 2–1]). In other
words, if nurses wish to effect change within family systems, they need to be
able to maintain a metaposition to each family. They must simultaneously
conceptualize both the family system interactions and their own interactions
with the family. However, if a problem arises between the nurse and the family, this problem must be resolved at a higher level than the nurse-family
system, preferably by a supervisor, who can examine the problem from a
higher metaposition.

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Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models 39

CONCEPT 1

Change is dependent on the perception of the problem.
In a now-famous statement, Alfred Korzybski proclaimed that “the map
is not the territory.” In other words, the name is different from the thing
named and the description is different from what is described. In applying
this concept to family interviewing, the “mapping” of a particular situation
or a nurse’s perception of a problem follows from how that nurse chooses
to see it. How a nurse perceives a particular problem has profound implications for how the nurse will intervene and therefore how change will occur
and whether it will be effective.
One of the most common traps for nurses working with families is
acceptance of one family member’s perception or perspective as the “truth”
about the family. There is no one “truth” or “reality” about family functioning,
or perhaps it is more accurate to say that there are as many “truths” or “realities” as there are members of the family (Maturana & Varela, 1992). The
error of taking sides in relational family nursing is discussed in Chapter 11.
The important task for the nurse is to accept all family members’ perceptions,
perspectives, and beliefs and offer the family another view of their health
concerns, illness, or problems. Individual family members construct their
own realities of a situation based on their history of interactions with people
throughout their lives and their genetic history (Maturana & Varela, 1992).
Maturana, in an interview with Simon (1985), offers an even more radical
idea with regard to different family members’ perceptions:
Systems theory first enabled us to recognize that all the different
views presented by the different members of a family had some validity. But, systems theory implied that these were different views of
the same system. What I am saying is different. I am not saying that
the different descriptions that the members of a family make are different views of the same system. I am saying that there is no one
way which the system is; that there is no absolute, objective family.
I am saying that for each member there is a different family; and that
each of these is absolutely valid (p. 36).

Maturana and Varela (1992) emphasize that human systems “bring forth”
reality, in language and living with others. Problems can be perceived in very
different, yet valid, ways. However, nurses are part of a larger societal system
and thus are bound by moral, legal, cultural, and societal norms that require
them to act in accordance with these norms regarding illegal or dangerous
behaviors (Wright & Bell, 2009).
If a nurse does not conceptualize human problems from a systems or cybernetics perspective, the nurse’s perceptions of the family and their illness,
problems, and concerns will be based on a completely different conception

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40 Nurses and Families: A Guide to Family Assessment and Intervention

of “reality” based on different theoretical assumptions. This text emphasizes
different theoretical assumptions as opposed to more correct or “right” views
of problems.

CONCEPT 2

Change is determined by structure.
Changes that occur in living systems (i.e., human systems) are governed
by the present structure of that system. The concept of structural determinism (Maturana & Varela, 1992) offers the notion that each individual’s
biopsychosocial-spiritual structure is unique and is a product of that person’s genetic history (phylogeny) and his or her history of interactions over
time (ontogeny).
The implication for nursing practice is that an individual’s present structure determines the interpersonal, intrapersonal, and environmental influences that are experienced as perturbations (i.e., that trigger structural
changes). Therefore, we cannot say beforehand which family nursing interventions will be useful in promoting change for this particular family member
at this time and which will not. Consequently, individuals are selectively perturbed by the interventions that are offered by nurses according to what does
or does not “fit” their unique biopsychosocial-spiritual structures. We cannot
predict which family nursing interventions will fit for a particular person and
which will disturb that person’s structure. This theoretical assumption is why
we prefer that interventions be tailored to each family rather than standardized interventions for particular kinds of problems.
A deep respect and awe for and curiosity about family members develop
in nurses who are cognizant of the notion of structural determinism. When
structural determinism is applied to clinical work with families, Wright and
Levac (1992) suggest that the description of families as noncompliant, resistant, or unmotivated is not only “an epistemological error but a biological
impossibility” (p. 913). This concept has made a dramatic difference in the
way in which we think about families and the interventions that we offer.

CONCEPT 3

Change is dependent on context.
Efforts to promote change in a family system must always take into account the important variable of context. Interventions must be planned with
sufficient knowledge of the contextual constraints and resources. This is particularly important considering the emphasis in the health-care industry on
accountability, cost-effectiveness, efficiency, and time-effective intervention.
Nurses need to be aware of their position in the health-care delivery system
vis-à-vis the family. For example, are other professionals involved with the

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Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models 41

family, and if so, what are their roles with the family? How do these roles
differ from the nurse’s role? How are the nurse and family influenced by and
influential on the context in which they find themselves, be it a hospital, a
primary care clinic, or an extended-care facility? It is particularly useful to
underscore the positive contributions each health-care stakeholder can make
to the family’s care rather than attributing or assuming self-serving motives
to stakeholders who have different vested interests in family care (such as
limiting costs).
Larger systems (e.g., schools, mental health agencies, hospitals, public
service delivery systems) frequently impose certain “rules” on families that
ultimately serve to maintain the larger system’s stability and impede change
(Imber-Black, 1991; Imber Coppersmith, 1983). One example is the rule
of linear blame—that is, institutions tend to blame families for difficulties
(e.g., lack of motivation) and tend to make referrals for family treatment in
order to “cure” or “fix” the family. This process is similar to the one that
families use to refer another family member to be “cured.”
Because members of some larger systems, particularly nursing staff,
become intensely involved in a patient’s or family member’s life, they commonly tend to go beyond the immediate concerns. The end result is that patients in hospitals and their families find themselves inundated with services
that commonly usurp the family’s own resources. This then places the family
in a “one-down” position in terms of articulating what they perceive their
present needs to be. When a nurse is asked to complete a family assessment,
he or she may become one more irritant in the family’s life and can be
hamstrung before even beginning because of the number of professionals
involved. This is another reason why nurses should carefully assess the larger
context in which the family and the staff find themselves. In some cases, the
more serious problem is at the interface of the family with other professionals
rather than within the family itself. Thus, interventions aimed at the
family–professional system would need to occur before addressing problems
at the family system level.
Another situation that can arise is unclear expertise and leadership.
Families may find themselves in a larger system, such as an outpatient drug
assessment and treatment clinic. They may receive different ideas on how
to deal with a particular problem (e.g., cocaine addiction), depending on
whether they are seen at the clinic, at home, or in a class. This usually occurs
because no one clinic or educational program offered within a hospital setting has more decision-making power than another regarding a particular
family’s treatment plan.
Conflicts can also occur between larger systems or between families and
larger systems. Unacknowledged or unresolved conflicts commonly result in
triads, which inhibit healthy behavior. For example, if parents wish to send their
adolescent son to a drug rehabilitation center but the nurse and rehabilitation
director have been in conflict over rehabilitation policies, the family is placed
in a situation in which pressure from the larger system (nurse–rehabilitation

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42 Nurses and Families: A Guide to Family Assessment and Intervention

director system) leads them to align or take sides with either the nurse or the
rehabilitation director.
How the family is being influenced by and is exerting influence on their
involvement with these suprasystems is important information. Change
within a family can be thwarted, sabotaged, or impossible if the issue of
context is not addressed.

CONCEPT 4

Change is dependent on co-evolving goals for treatment.
Change requires that goals between nurses and families co-evolve within
a realistic time frame. In many cases, the main reason for failure in working
with families is either the nurse or family setting unrealistic or inappropriate goals. Frank and open discussions with family members regarding
treatment goals can help avoid misunderstandings and disappointments
on both sides.
Because one of the primary goals of family intervention is to alter the family’s views or beliefs of the problem or illness and alleviate suffering (Wright
& Bell, 2009), nurses should help family members to search for alternative
behavioral, cognitive, and affective responses to problems. Therefore, one
of the nurse’s goals is to help the family discover or reclaim its own solutions
to problems.
The task of setting specific goals for treatment is accomplished in collaboration with the family. Part of the assessment process is to identify the current suffering or problems with which the family is most concerned and the
changes they would like to see. This provides a baseline for the goals of
family interviews and becomes the therapeutic contract.
Contracts with families can be either verbal or written. In our clinical
practice and in the practice of our nursing students, we typically make verbal
contracts with families that state which problems will be tackled during what
specified period of time or number of sessions. At the end of that period,
progress is evaluated and either contact with the family is terminated or a
new contract is made if further therapeutic work is required.
In most instances, clear goals (in the form of a contract) can be set
with families with verbal commitments by family members to work on
the problems outlined. On conclusion of the contract, evaluation should
consist of assessing changes in the family system and in the identified
patient.
In summary, family assessment and intervention are often more effective
and successful if they are based on clear therapeutic goals. However, families
rarely come to family interviews with the understanding or desire that family
change is required. Therefore, in addition to goal setting, the nurse must help
the family to obtain a different view of their problems. First, the nurse needs
to engage the family; this can most easily be accomplished by first focusing

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Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models 43

on understanding and exploring their current suffering, the presenting problems and concerns, and the changes the family desires in relation to them.
More detailed information about goal setting, contracts, and termination is
given in Chapters 7, 10, and 12.

CONCEPT 5

Understanding alone does not lead to change.
Changes in family work rarely occur by increasing a family’s understanding of problems but rather through effecting changes in their beliefs and/or
behavior. Too often, health professionals engaged in family work assume that
understanding a problem brings about a solution by the family. From a systems perspective, however, solutions to problems occur as beliefs about
health and illness, problems, and patterns change, regardless of whether this
is accompanied by insight (Wright & Bell, 2009).
There has been a tendency in nursing to believe that one must understand
“why” in order to solve a problem. Thus, nurses with good intentions spend
many hours attempting to obtain masses of data (usually historical) in order
to understand the “why” of a problem. In many cases, patients and families
encourage the nurse in this quest and participate in it. For example, a patient
might ask, “Why did I have my heart attack?” “Why won’t my son give up
crack?” or “Why did my wife have to die so young?” We strongly discourage
searching for the answers, because we do not believe this is a precondition
for change; rather, it steers one away from effective efforts at change. The
prerequisite or precondition for change is not understanding the “why” of a
situation but rather understanding the “what.” Therefore, we recommend
that nurses ask, “What is the effect of the father’s heart attack on him and
his family?” and “What are the implications of the father’s heart attack on
his employment?” These questions serve a much more useful purpose in
paving the way for possible interventions than do those focusing on the
“why” of the situation.
“Why” questions seem to be entrenched in psychoanalytic roots that
bring forth psychopathologies. These perspectives are not congruent with
a systems or cybernetic foundation of understanding family dynamics that
focuses on human problems such as the experience of illness, loss, or disability as interpersonal crises or dilemmas. Even if the “why” of a problem
is occasionally understood, it rarely contributes to a solution. Therefore,
it is more useful to explore what is being done in the here and now that
perpetuates the problem and what can be done in the here and now to effect a change. The search for causes should be avoided because it inadvertently can invite family members to view problems from a linear rather
than a systemic or interactional perspective. In other words, we prefer
to believe that most problems reside between persons rather than within
persons—that is, they are relational.

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44 Nurses and Families: A Guide to Family Assessment and Intervention

CONCEPT 6

Change does not necessarily occur equally in all family
members.
Recall the analogy of the mobile previously presented in this chapter.
Imagine the mobile after a wind has passed it. Some pieces turn or react more
rapidly or energetically than do others. This is similar to change in family
systems in that one family member may begin to respond or change more
rapidly than others and, by this very process, set up an opportunity for
change throughout the rest of the family. This occurs because other family
members cannot respond in the same way to the family member who is
changing, so a ripple effect of change occurs through the system. We have
observed this phenomenon in practice with military families when a spouse
returns home from a war or a peacekeeping mission. The desire for family
members to “return to normal” (i.e., their pre-posting functioning) often
conflicts with the returning member’s experience of change. This event
typically precipitates a time of intense adjustment for all family members.
Robinson’s (1998) research also highlighted the concept that when families
experience chronic illness, all family members are affected but not necessarily
equally. In her study, women suffered more emotionally than other family
members whether the illness was their own, their spouse’s, or their child’s.
Change depends on the recursive (cybernetic) nature of a family system.
Therefore, a small intervention can lead to a variety of reactions, with some
family members changing more dramatically or quickly than others.

CONCEPT 7

Facilitating change is the nurse’s responsibility.
We believe that it is the nurse’s responsibility to facilitate change in collaboration with each family. Facilitating change does not imply that a nurse can
predict the outcome, and a nurse should not be invested in a particular outcome. However, there is a distinct difference between facilitating change, directing change, being an expert in resolving family problems, or assuming what
must change. We believe families possess expertise about their experiences of
their health, illness, and disabilities, whereas nurses have expertise in ideas
about health promotion and management of serious illness and disability. It is
also crucial for nurses to avoid making value judgments about how families
should function. Otherwise, the changes or outcomes in a family system may
not be satisfying to the nurse if they are incongruent with how the nurse perceives a family should function. It is more important that the family be satisfied
with their new level of functioning than that the nurse be satisfied.
From time to time, nurses must evaluate the level or degree of responsibility they feel for treatment. The level of responsibility is out of proportion

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Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models 45

if a nurse feels more concerned, worried, or responsible for family problems
than the families feel themselves. In the opposite response, sometimes nurses
experience a detachment or a lack of concern, compassion, or responsibility
for facilitating change within families. Both of these extreme responses
indicate the need to obtain clinical supervision.
How much change nurses should expect to facilitate in family work
depends on their own competence, their capacity for compassion, the context
of family treatment, and the family’s response. Nurses need to be cognizant
that they are not change agents; they cannot and do not change anyone
(Bell & Wright, 2011; Wright & Bell, 2009; Wright & Levac, 1992). For some
nurses, not being a change agent is counterintuitive to their desire and manner
of being helpful. But when nurses can let go of the notion of being a change
agent and instead become a facilitator of change, they can move into a truly
relational and collaborative relationship with families entrusted in their care.
Ultimate and sustained changes in family members are determined by each
member’s biopsychosocial-spiritual structures, not by the nurse (Maturana
& Varela, 1992). Therefore, it is the nurse’s responsibility to facilitate a context for change. Paying attention to windows of opportunity for facilitating
change is one idea put forth by Robinson, Bottorff, and Torchalla (2011).
Their findings support the idea that at the time of a diagnosis of lung cancer,
families may be more open to addressing smoking-cessation strategies.

CONCEPT 8

Change occurs by means of a “fit” or meshing between the
therapeutic offerings (interventions) of the nurse and the
biopsychosocial-spiritual structures of family members.
The concept of “fit” or “meshing” arises from the notion of structural
determinism (Maturana & Varela, 1992). That is, the family member’s structure, not the nurse’s therapeutic offering, determines whether the intervention
is experienced as a perturbation that triggers, facilitates, or stimulates change.
This concept is aligned with the guiding principle that the nurse is not a
change agent (Wright & Levac, 1992) but rather one who, among other
things, creates a context for change (Bell & Wright, 2011; Wright & Bell,
2009). In our clinical experience, family members who respond to particular
therapeutic offerings do so because of a fit, or meshing, between their current
biopsychosocial-spiritual structures and the family nursing intervention offered. (For more information on this, see Chapter 4 and the discussion of
the CFIM.) This includes nurse sensitivity to the family’s race, ethnicity, sexual orientation, and social class.
The concept of “fit” allows nurses to be nonblaming of patients and themselves when nonfit—and consequently nonadherence and non-followthrough—occurs (Bell & Wright, 2011; Wright & Bell, 2009; Wright & Levac,
1992). Nurses operating from a therapeutic stance who appreciate fit can be

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46 Nurses and Families: A Guide to Family Assessment and Intervention

highly curious about ways to increase the suitability of interventions for
particular family members at a specific time. When the concept of fit is overlooked, neglected, or not appreciated, nurses operate with more lecturing,
prescribing behaviors, and often labeling family members as noncompliant,
not ready for change, or defiant of the professional system.

CONCEPT 9

Change can be the result of a myriad of causes or reasons.
Change is influenced by so many different variables that, in most cases,
knowing specifically what precipitated, stimulated, or triggered the change
is difficult. Change is not always a result of well-thought-out intervention.
Commonly, it can be the result of a collaborative relationship between the
nurse and family and/or the method of inquiry into family problems. Asking
interventive questions (see Chapter 4 for an in-depth discussion about
the nurse–family relationship and questions within the CFIM, and see
Chapters 8 and 9 for how to use questions in family interviewing) may in
and of itself promote change. It is more important for nurses to attribute
change to families than to concern themselves with what they did to create
change (see Chapter 12 for more information on concluding meetings with
families). To search for or take undue credit for change is inappropriate at
this stage of our knowledge of the change process in families.

BIOLOGY OF COGNITION
The biology of cognition has been described and articulated by two neurobiologists, Maturana and Varela (1992), in their landmark publication The Tree
of Knowledge: The Biological Roots of Human Understanding. They offer
the idea that humans bring forth different views to their understanding of
events and experiences in their lives. This idea is not new, but Maturana and
Varela’s perspective on how humans make and claim observations is much
more radical: It is based on biology and physiology, not philosophy (Bell &
Wright, 2011; Wright & Bell, 2009; Wright & Levac, 1992). If a nurse adopts
a particular view of reality, it then follows that he or she now encompasses a
particular view of people and their functioning, relationships, and illnesses.

CONCEPT 1

Two possible avenues for explaining our world are objectivity and objectivity-in-parentheses (Maturana & Varela,
1992; Wright & Bell, 2009; Wright & Levac, 1992; Wright,
Watson, & Bell, 1990).
The view of objectivity assumes that one ultimate domain of reference exists for explaining the world. Within this domain, entities are assumed to

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exist independent of the observer. Such entities are as numerous and broad
as imagination might allow and may be explicitly or implicitly identified as
mind, knowledge, truth, and so on. Within this avenue of explanation, people
come to believe they have access to a true and correct view of the world and
its events, an objective reality. From this “objectivist” view, “a system and
its components have a constancy and a stability that is independent of the
observer that brings them forth” (Mendez, Coddou, & Maturana, 1988,
p. 154). Nursing diagnoses, emotional conflict, pride, and politics are all
products of an “objective” view of reality.
When objectivity is “placed in parentheses,” people recognize that objects
do exist but that they are not independent of the living system that brings
them forth. The only “truths” that exist are those brought forth by observers,
such as nurses and family members. Each person’s view is not a distortion
of some presumably correct interpretation. Instead of one objective universe
waiting to be discovered or correctly described, Maturana has proposed a
“multiverse,” where many observer “verses” coexist, each valid in its own
right. To increase options and possibilities for families to cope with illness
using a variety of strategies or to improve their well-being, nurses need to
help family members drift toward objectivity-in-parentheses. When nurses
are able to maintain an objective stance, they are increasingly able to invite
family members to resist the “sin of certainty”—that is, to resist the notion
that there is only one true or correct way to manage health or illness, loss,
or disability.

CONCEPT 2

We bring forth our realities through interacting with the
world, ourselves, and others through language.
We propose that reality does not reside “out there” to be absorbed; rather,
people exist in many domains of the realities that they bring forth to explain
their experiences (Maturana & Varela, 1992). The ability to bring forth
personal meaning and to respond to and interact with the world and with
each other, but always with reference to a set of internal coherences, can be
seen as the essential quality of living. Maturana and Varela (1980) assert that
this statement applies to all organisms, with or without a nervous system.
They further suggest that it is best to think of cognition as a continual interaction between what people expect to see (owing to unconscious premises
or beliefs) and what they bring forth. In a telephone interview, Maturana
(1988) embellished this notion of reality as follows:
We exist in many domains of realities that we bring forth . . . What
I’m saying in the long-run is that there is no possibility of saying absolutely anything about anything independent from us. So whatever
we do is always our total responsibility in the sense that it depends
completely on us, and all domains of reality that we bring forth are

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48 Nurses and Families: A Guide to Family Assessment and Intervention

equally legitimate although they are not equally desirable or pleasant
to live in. But they are always brought forth by us, in our coexistence
with other human beings. So if we bring forth a community in which
there is misery, well, this is it. If we bring forth a community in which
there is well-being, this is it. But it is us always in coexistence with
others that . . . are bringing forth reality. Reality is indeed an explanation of the world that we live [in] with others.

In sum, the world everyone sees is not the world but a world that they
bring forth with others (Maturana & Varela, 1992). When nurses adopt this
particular ethical stance, they find themselves more curious about the world
each family member brings forth and how this world influences the person’s
ability or inability to cope with or manage his or her illness.

CONCLUSIONS
Nursing is striving to articulate and describe more clearly the theories that
inform clinical practice models. In an important and useful review of family
studies and interventions, Hallberg (2003) found “a lack of congruence between the theoretical framework, the intervention, and the outcome measure” (p. 9). This chapter has attempted to provide insight about the theories
or worldviews that provide the foundations of the CFAM and CFIM. This
was done to clarify the connection between our theoretical frameworks and
our family assessment and intervention models. Nurses need to continue to
conduct research-based practice and practice-based research that enhance
our understanding of which theories are most significant to inform practice,
especially the offering of interventions.
References
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50 Nurses and Families: A Guide to Family Assessment and Intervention

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Wright, L.M., & Levac, A.M. (1992). The non-existence of non-compliant families: The
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Chapter

3

The Calgary Family
Assessment Model
The Calgary Family Assessment Model (CFAM) is an integrated, multidimensional framework based on the foundations of systems, cybernetics, communication, and change theory and is influenced by postmodernism and
biology of cognition. This text discusses the distinction between using CFAM
to assess a family and using it as an organizing framework, or template, for
helping families to resolve issues.
CFAM has received wide recognition since the first edition of this book in
1984. Our model has been adopted by many faculties and schools of nursing
and hospital settings in some 26 countries: Australia, Great Britain, Brazil,
Hong Kong, Canada, Chile, China, Denmark, Japan, Finland, Sweden, Korea,
Taiwan, Portugal, Singapore, Spain, Iceland, New Zealand, Norway, Qatar,
Germany, Scotland, Switzerland, United States, Vietnam, and Thailand. It has
also been referenced frequently in the literature, especially in 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), CFAM was substantially revised in 1994,
2000, 2005, and 2009, and it is now even more developed in this Sixth Edition.
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 a first meeting with a family, and some subcategories need never be assessed. If the nurse uses too many subcategories, he
or she may become overwhelmed by all the data. If the nurse and the family
51

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52 Nurses and Families: A Guide to Family Assessment and Intervention

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 (Fig. 3–1). As nurses use the subcategories on the right of the branching diagram, they collect more and more
microscopic data. It is important for nurses to be able to move back and
forth on the diagram 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 and beliefs
and his or her relationships with those being interviewed. It should not be
considered as “the truth” about the family, but rather one perspective at a
particular point in time.

Internal

Structural

External

Context

Family composition
Gender
Sexual orientation
Rank order
Subsystems
Boundaries
Extended family
Larger systems
Ethnicity
Race
Social class
Religion and/or spirituality
Environment

Stages
Family
assessment

Developmental

Tasks
Attachments

Instrumental
Functional
Expressive

F I GU R E 3-1: Branching diagram of CFAM.

Activities of daily living
Emotional communication
Verbal communication
Nonverbal communication
Circular communication
Problem-solving
Roles
Influence and power
Beliefs
Alliances/coalitions

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Chapter 3: The Calgary Family Assessment Model 53

We believe 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 to help a specific family address their health issue. When learning
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 also find the model useful. This use of the model involves asking family members questions about themselves for the purpose
of gaining a snapshot of the family’s structure, development, and functioning
at a particular point in time.
In our own work, we have used CFAM in a clinical rather than a research
manner. Once a nurse becomes experienced with the categories and subcategories of CFAM, he or she can use 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 their teenager’s unexpected illness. The nurse, being reminded of
family developmental stages by using CFAM, will draw forth those resiliencies. She will ask questions and collaboratively develop interventions with
the family to enhance their functioning during this health-care episode.
Families do not generally present to health-care professionals to be “assessed.” Rather, they present themselves or are encountered by nurses while
coping or suffering with an illness, loss, and/or disability or are seeking assistance to improve their quality of life. 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. It is important that nurses do
not ask these questions in a routine or disembodied manner. Real-life clinical
examples are provided in Chapters 4, 7, 8, 9, and 10 so that readers can see
how to use the sample questions and apply CFAM.
To assist in understanding further how to implement the CFAM in clinical
practice, we have produced the educational DVD Calgary Family Assessment
Model: How to Apply in Clinical Practice (Wright & Leahey, 2001) (www.
familynursingresources.com). The use of assessment and interventive questions will be discussed in Chapter 4. Again, we wish to emphasize that not
all questions about various subcategories of the model need to be asked at
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, what is the connection among family members vis-à-vis those
outside the family, and what is the family’s context. Three aspects of family

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54 Nurses and Families: A Guide to Family Assessment and Intervention

structure can most readily be examined: internal structure, external structure,
and context. Each of these dimensions of family structural assessment is addressed separately.

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 several 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. There are
five critical attributes to the concept of family:
1. The family is a system or unit.
2. Its members may or may not be related and may or may not live
together.
3. The unit may or may not contain children.
4. There is commitment and attachment among unit members that include
future obligation.
5. The unit’s 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; the child-free by choice family; and the lesbian, gay,
bisexual, queer, intersexed, transgendered, or twin-spirited (LGBQITT)
couple or family. Designating a group of people with terms such as couple,
nuclear family, multinuclear 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

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Chapter 3: The Calgary Family Assessment Model 55

most useful in our clinical work: The family is who they say they are. With
this definition, nurses can honor individual family members’ ideas about
which relationships are significant to them and their experience of health
and illness. For example, does the family include the surrogate mother and
the commissioning couple?
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.
For example, we support the American Academy of Pediatrics (2002) policy
advocating that children who are born or adopted by one member of a samesex couple deserve the security of two legally defined parents. We know that
gays and lesbians often refer to their friendship network as “family” and that
for many gays and lesbians, this family is often as crucial and influential as
their family of origin and at times even more so.
Other family configurations include grandparents as primary caregivers
for their grandchildren. In the United States, 1 child in 10 lives with a grandparent, and according to the Pew Research analysis of census data, there
has been a sharp increase in 2007–2008 along with the recession (Livingston
& Parker, 2010). Approximately 41% of those children are being raised by
their grandparent.
Some authors, such as Penn (2007), have questioned the commonly held
belief that all couples want to live together. He discusses “commuter couples,” an alternate form of relationship in which each partner retains his
or her own separate living quarters while remaining in a committed,
monogamous, loving relationship. A rhythm that ensures both solitude and
passionate connection is highly valued by these couples. Dual-dwelling
duos (DDDs) and other new alternative pair-bonding structures, such as
cohabitation and nonmarital coparenting, have also emerged. Our definition of family is based on the family’s conception of family rather than on
who lives in the household.
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 such as a new baby, an elderly parent, a nanny, or a boarder.
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 live temporarily with other relatives and then move on. In New York City in 2002,
more than 13,000 children spent their nights shuttling between shelters and
other living accommodations (Egan, 2002).
Losses tend to be more severe depending on how recently they have occurred, the younger some of the family members are when 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

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56 Nurses and Families: A Guide to Family Assessment and Intervention

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, especially by violence or
war, can lead to profound disruption in the family. The simultaneous deaths
of both parents by car or plane crash, murder/suicide, natural disasters
such as earthquakes and tsunamis, wars, terrorist acts such as September
11, domestic terrorism such as the Virginia Tech killings, or the absence of
one parent in jail and the death of the other parent can result in aunts and
uncles raising nieces and nephews or grandparents raising grandchildren,
an often undernoticed family structural arrangement. Other family arrangements can occur when one parent is in a rehab facility owing to military
injuries.
The extent of a death’s impact on the family depends on the social and
ethnic 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). Research by Bowse and colleagues (2003) indicates that the extent of HIV risktaking in adulthood is positively related to unexpected deaths experienced
early in life and related inadequate mourning. We agree with these authors’
recommendation that prevention efforts need to be more family-based and
family-focused.
Our own reflections in the aftermath of September 11 and those of the
families we work with have only increased our sensitivity to loss, its meaning
in our culture, and its very specific meaning for each family in terms of how
they cope and deal with uncertainty. 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 do not immediately assume 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 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? So, your
family consists of you and Faris, your 35-year-old son who just returned
from Afghanistan. Anyone else? Has anyone recently moved out? Is there

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Chapter 3: The Calgary Family Assessment Model 57

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 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 differences between women and men can be changed, discarding unhelpful cultural scripts for women and men, and recognizing and attending to hidden
power and influence issues. We think it is also important to consider friendship networks in our discussions with men and women. McGoldrick (2011b)
asserts that for women, “close female friendships appear second only to good
health in importance for satisfaction throughout the life cycle” (p. 56). Mock
(2011) believes men seek companionship and comfort in closeness through
shared activities with other men rather than through communication at a
deep emotional level or through intimacy. In addition, friendships can be an
important source of support for families dealing with illness.
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.
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 and by class and sexual orientation.
They are in some ways more important than anatomic differences, although
persons with ambiguous genitalia are often referred to as having an intersex
orientation.
Gender plays an important role in family health care, especially child
health care. Differences in parental roles in caring for an ill child may be significant sources of family stress. For example, when a child is ill, the majority
of help-seeking is initiated by the mother. Robinson (1998) found role strain
among families in which chronic illness became an unwelcome, dominant,
powerful burden: “It became clear that the women—the wives and mothers
in these families—were responsible for day-to-day, 24-hour, day-in, day-out
protection” (p. 277). The women carried both the burden of responsibility
and the majority of the workload.
In 2009, Neufeld and Kushner reported on men’s experiences as family
caregivers and what the men found as nonsupportive interactions, such as a
lack of orientation to the caregiving situation, an unsatisfactory linkage to
support sources, insufficient support, and hurtful interactions. We have

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58 Nurses and Families: A Guide to Family Assessment and Intervention

found that men and women report more similar than dissimilar challenges
in caregiving.
Levac, Wright, and Leahey (2002) recommend that assessment of the gender’s influence 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:
■ 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, intersexed, and transgendered persons. Examples of questions we
ask them to consider include the following: As a woman, how do you believe you should behave toward men? How do you expect them to behave
toward you? How do you believe men should behave toward ill family
members? What ways have you noticed that men express emotion? What
are your thoughts about couples who choose a child’s sex? Whose work
do you express more interest in: husband’s or wife’s? Who do you feel
more comfortable inviting to an interview: husband or wife? If a father
answers the phone, who do you ask to set the appointment with: father,
mother, or both?
Questions to Ask the Family. Sabeen, 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, Hashim, 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. Heterosexism, the preference of heterosexual orientation over other sexual orientations, is a form of multicultural bias that has
the potential to harm both families and health-care providers. Sexual minority
populations include LGBQITT persons. This acronym attempts to be inclusive
but is not definitive. Queer refers to individuals whose gender identity does
not strictly conform with societal norms traditionally ascribed to either male

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or female and who define themselves outside of these definitions. The premise is that sexual identity is socially constructed. Although the term queer
previously was used in a negative manner, now it has a more positive connotation. Intersexed describes someone with ambiguous genitalia or chromosomal abnormalities. Two-spirited denotes an individual in the Aboriginal
culture with close ties to the spirit world and who may or may not identify
as being lesbian, gay, bisexual, or transgender. Overall, it indicates a duality
existent in a person.
Discrimination, lack of knowledge, stereotyping, and insensitivity about
sexual orientation are being addressed in North American society. However,
discussions about gay marriage have at times clouded the issue of equal treatment. Despite the fact that approximately 1% of all U.S. households are identified as consisting of same-sex couples (USA Today, 2003), the topic of
sexual orientation is one that nurses approach with varying levels of acceptance, comfort, and knowledge. For example, nurses’ first encounters with
transgendered persons often pose unfamiliar challenges. Weber (2010) points
out that “families headed by parents who are sexual orientation or gender
minorities may require special guidance for navigating an unusually complicated terrain related to parenting and family life” (p. 379). We agree with
him. Lesbians, gay men, queers, and heterosexual women and men live in
partially overlapping but partially separate cultures, and their gender role
development often follows distinctive trajectories leading to different outcomes. In addition, immigrants may have also been exposed to varying beliefs about gay culture. Samir (2002) states that “there’s absolutely no gay
culture in Iraq. Not a hint of it. The only Arab country establishing a gay
culture is Lebanon … Homosexuality in most Arab countries is frowned
upon and in some it is a crime punishable by extreme sentences” (p. 98).
In our clinical supervision of relational family nursing, we have found it
useful to reflect critically on attitudes about sexual orientation. When comparing lesbian couples with heterosexual couples, we use parallel terms as
opposed to comparing them to “normal” couples—that is, we do not say that
lesbian couples as compared to “normal” couples have more coping skills.
Rather, we say that lesbian couples believe this and heterosexual couples
believe that. We do not assume that what applies to gay relationships can be
applied to lesbian relationships or that a patient is heterosexual if the patient
says that he or she is dating. We know there are mixed orientation marriages
in which gay, bisexual, and lesbian spouses manage homoerotic feelings or
activities while maintaining their marital relationship and being sensitive to
the needs of their partner (Hernandez, Schwenke, & Wilson, 2011). We believe
that nurses should be able to support a patient along whatever sexual orientation path he or she takes and that the patient’s sense of integrity and interpersonal relatedness are the most important goals of all. If a nurse is not able
to support a patient’s explorations or decision to live openly or not as a
heterosexual, homosexual, bisexual, queer, intersexed, or transgendered person, the nurse should excuse himself or herself from treating such patients.

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60 Nurses and Families: A Guide to Family Assessment and Intervention

We have found the sample questions exploring heteronormative assumptions posed by McGeorge and Carlson (2011) useful for self-reflection. We ask
ourselves, What did my family of origin teach me about sexual orientation,
bisexuality, and same-sex relationships? What are my beliefs about how a person “becomes” gay, lesbian, or bisexual? What is my initial reaction when
I see a gay or lesbian couple expressing physical affection? What do the religious
or spiritual texts of my particular faith teach me about sexual orientation?
Questions to Ask the Family. Elsbeth, at what age did you first engage in sexual

activity (rather than asking, At what age did you first have intercourse)? 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, LeeArius, 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, because sibling relationships can be significant across the family developmental life cycle. Siblings tend to spend the most time with each other
as youngsters; in later life, with parents living longer, the siblings’ relationship
is often intensified as brothers and sisters have to work out long-term caregiving arrangements.
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 sex differences. For example, we have found that siblings of children
with attention deficit hyperactivity disorder (ADHD) frequently felt victimized
by their ADHD sibling and that their experiences were often minimized or
overlooked in the family. Bellin, Bentley, and Sawin (2009) argue for multilevel interventions to support siblings based on their study of siblings of
youths with spina bifida.
Although we believe that sibling patterns are important to note, we urge
nurses to remember that different child-rearing patterns have also 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. Newman (2011) notes that in the last 20 years, the number of families

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with just one child in the United States has more than doubled to between
20% and 30%. In Spain and Portugal, 30% of families have one child and in
England it’s up to 46% while in Canada it is approximately 40%.
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 reevaluation 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 injection? The nurse 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 or mother–child, can be seen as subsystems.
Subsystems can be delineated by generation, sex, interest, function, or
history.
Each person in the family is a member of several different subsystems. In
each, 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

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62 Nurses and Families: A Guide to Family Assessment and Intervention

over his younger brother in the sibling subsystem when he interacts with
his stepmother in the parent–child subsystem. An only girl living in a singleparent household has different subsystem challenges when she lives on
alternate weekends with her father, his new wife, and their two daughters.
The ability to adapt to the demands of different subsystem levels is a necessary skill for each family member. It is also an important factor for nurses to
consider in working with families. For example, children are often affected
by a parent’s mental (Beardslee, 2002) or physical illness. The nurse could
inquire if the parent is worried about the children. The response to this
question might shed light not only on the parental subsystem but also on the
sibling subsystem.
In our clinical practice, we have found it useful to consider whether clear
generational boundaries are present in the family. If they exist, 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, the women do certain things while the men do other things. Do
different subgroups exist in your family? If so, what effect does this have on
your family’s stress level? If you were to look at your family as being made
up of two teams, who would be on each team? When Mom and your sister,
DeRong, stay up at night and talk about Dad’s use of crack, what do the
boys do? Which subgroup in the family is most affected by Cleve’s crack
problem and how? Who gets together in the family to talk about Shabana’s
self-mutilating behaviors?
When asking questions pertaining to subsytems, nurses can focus on
particular ones such as parent-child, marital, or sibling.
Parent–child: How has your relationship with Bamboo changed since her
diagnosis with severe acute respiratory syndrome?
Marital: How much couple time can you and Gbope 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 AhPoh 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.”

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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 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 and can become ambiguous during
the process of reorganization after acquisition or loss of a member. This is
particularly evident with 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. Families caring for a member with
Alzheimer’s disease may experience the opposite phenomenon: The member
is physically present but may often be psychologically absent.
Other variations include the ambiguity experienced by some families when
a family member is in prison and then returns home. With approximately
650,000 ex-convicts leaving state or federal American prisons in 2006 (Penn,
2007), the impact on families is significant. Family boundaries can also be
challenged when family members, especially young parents, are soldiers at
war or live in a rehab hospital following a tour of duty. The concept of ambiguous boundaries was quite evident in the days shortly following 9/11 or
Hurricane Katrina, when people were missing. Boss (2002) named the situation “ambiguous loss” and further described it as the most difficult loss
there is, because families and friends feel helpless and the cultural tendency
in the United States is to seek closure. During the early days post September
11, 2001, there was little closure for families who had missing relatives.
Many Arab Americans and other immigrant groups experienced flashbacks
of terror and connected to a history of oppression in the Middle East.
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 vis-à-vis outside systems may be quite firm and rigid but
may gradually become more flexible. For example, some Muslim families’
preference for greater connectedness, more hierarchical family structure,

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64 Nurses and Families: A Guide to Family Assessment and Intervention

traditional dress, and an implicit communication style can be a challenge
for their teens adjusting to a North American urban lifestyle.
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), information space (information known about each other), shared private conversations separate from
others, and decision 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 neighborhood
and in the city. The nurse considers whether there is a parental subsystem, a
marital subsystem, a sibling subsystem, and so forth. 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. The nurse can infer the boundaries, for example,

by asking a husband if there is anyone with whom he can talk when he feels
stressed by his upcoming retirement. The nurse can ask the wife 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 your 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:
1. Extended family
2. 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, conflictual and
painful relationships can seem fresh and close at hand despite the extended
family living far away or not 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.
We recommend assessment of the quantity and type of contact with extended family to provide information about the quality and quantity of support. For example, the importance of social media connections cannot be

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overemphasized. A young man paralyzed following a sports injury need not
be isolated. Contact through Facebook, Twitter, Pinterest, and blogs 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, texting, Skype, iChat,
FaceTime, and Internet chat groups? Are they in physical proximity?
Questions to Ask the Family. Where do your parents live, Michiko? How
often do you have contact with them? What about your brothers, sisters,
step-relatives? Which family members do you never see? Which of your
relatives are you closest to? Who phones who? With what frequency? Who
do you ask for help when problems arise in your family, Zabin? What kind
of help do you ask for? Would your family in Shanghai be available if you
needed their help? Would you feel more comfortable contacting them 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 watch their language 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. Having family
group conferences such as those begun as a legal process in New Zealand
can be another way of fostering a participatory model of decision making with
families in child protection (Connolly, 2006). Such a practice strengthens
families. We are particularly drawn to clinicians who engage families as experts
and create community-based programs for families using a collaborative family
program development model. We advocate that professionals adopt the stance
of being respectful learners and form collaborative professional relationships
with families. The work of Looman (2011) reminds us of the importance of
understanding the family-community interface—that is, some individualistic
societies focus on loose ties between individuals, groups, and families, whereas
collectivist societies are associated with a sense of duty toward one’s group and
social harmony.

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66 Nurses and Families: A Guide to Family Assessment and Intervention

Some families and larger systems 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. These health-care professionals
limit their perspective by using these labels. In their study evaluating the quality
of care coordination provided for children with developmental disabilities,
Nolan, Orlando, and Liptak (2007) found that 50% of the 83 families said
that medical personnel never or rarely communicated with schools, and 27%
never or rarely involved families in decision making. Communication about
care across systems was key to satisfaction with service.
Another larger system relationship that nurses should consider is the computer network. Social media, electronic bulletin boards, chat rooms, blogs,
texting, and discussion groups abound. Internet infidelity, pornography, and
cybersex as a prelude to affairs and often sexual addiction are hot topics of
conversation for many couples and nurses. We believe that infidelity consists
of taking energy of any sort (thoughts, feelings, and behavior) outside of the
committed relationship in such a way that it damages the relationship. Internet romance may begin outside any real-life context, but it quickly can escalate to a context all its own.
But the Internet can offer families valuable assistance in terms of information, validation, empathy, advice, and encouragement. Some have used
e-mail, blogs, and online resources to augment, extend, deepen, inform, enrich, and prepare for in-person psychotherapy. However, we have found that
online dialogues can sometimes be more sustaining than transformative—in
other words, these dialogues tend to support the status quo rather than stimulate change.
Vigorous attention should be given to ways that professional expertise
and electronic connectivity can be combined. Telenursing is one such example. Questions for consideration in providing family-centered telehealth care
include how do health professionals ensure that the voices of all family members are part of the discussion between the nurse and the family? Using videoconferencing or Skype to gather all the larger system helpers in one space
with the family to discuss, plan, and evaluate care can be a solution. We believe that increasingly health care will be provided in people’s homes. Equipment necessary for such care continues to decline in price and simultaneously
is easier to use. In working with technology and larger systems, nurses need
to continue to find ways to address such challenges as telehealth infrastructure changes, reimbursement for services, liability, and licensing issues.
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: 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

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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? When one young woman suffering from
metastases from breast cancer was asked, “Who do you think of as family?”
she 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, class, 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:
1. Ethnicity
2. Race
3. Social class
4. Spirituality and/or religion
5. 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 and between 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” (either legally or undocumented) immigrant families, of whom some
are refugees. Another category is “immigrant American” families, in which
the parents were born in a foreign country but their children were born in
the United States.

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68 Nurses and Families: A Guide to Family Assessment and Intervention

The U.S. Census Bureau reports that 12% of the nation’s population were
foreign-born and another 11% were native-born with at least one foreign-born
parent in 2009, making one in five people either first- or second-generation
U.S. residents (United States Census Bureau, 2010b). Many were separated
from one or both parents for extended periods. Suarez-Orozco, Todorova, and
Louie (2002) report that results from their study of 385 early adolescents originating from China, Central America, the Dominican Republic, Haiti, and
Mexico indicate that “children who were separated from their parents were
more likely to report depressive symptoms than children who had not been
separated” (p. 625). The immigration experience is central, not incidental, to
health care.
For some immigrant families, the impact of cultural adjustment can be seen
as a transitional difficulty, with issues such as economic survival, racism, and
changes in extended family and support systems needing to be addressed. Specific life experiences, such as a trade school or college education, financial
success in business, or family intermarriage, can encourage assimilation into
a dominant culture, whereas isolation in a rural area or an urban ghetto tends
to foster continuity of ethnic patterns. It is important, though, to recognize
that these views of assimilation and isolation are from our “observer perspective.” What matters is the family’s cultural narrative, how it is deconstructed
and co-constructed.
Ethnic differences in family structure and their implications for intervention have often been highlighted in a stereotypical manner. For example,
Italians in North America usually have strong extended family connections
and loyalties. African American families tend to have flexible family boundaries, and some may include the grandmother in child-rearing. Members of
some Latin American cultures encourage emotionality between relatives and
between generations, whereas the Irish in North America tend to have more
strictly defined boundaries between generations.
In our clinical work, we have found it essential to recognize the infinite
variety and lack of stereotypes among families from various ethnic groups.
This is particularly important as Internet dating sites and more frequent opportunities for intermingling in the workplace and socially are introducing
more diverse singles than ever before. Immigration and intermarriage (e.g.,
interracial) are shifting demographics in the United States. Cultural diversity
is a matter of balance between validating the differences among us and appreciating the forces of our common humanity. 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 listening to history and context in caring
for refugee immigrant women cannot be overestimated.
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”

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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, 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 whether in working with aboriginal communities or with other ethnic groups. For example, the findings from the
study by Hiott and colleagues (2006) of gender differences in anxiety and
depression among immigrant Latinos suggest that clinicians should ask questions about social isolation and separation from family. Answers to such
questions may provide insights into stress and its contribution to significant
anxiety and depression; these should also be considered when devising a
treatment plan.
Some questions that we have found useful to ask ourselves include, 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
Iran 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 Chinese
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; it both constrains
and empowers identities. Contributors to an empowering identity include
the participants having multiple reference group orientations, being strong,
and refusing to take sides with, for example, blacks or whites. 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.
The “myth of sameness” (Hardy, 1990) has been challenged and the
uniqueness of various family forms emphasized more so in the last decade,

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especially with increased use of the Internet and other social media. Many
college-age and younger Americans are rejecting the color lines that once defined racial identity in favor of a much more fluid identity. The crop of students moving through college right now includes the largest group of
mixed-race people ever to come of age in the United States, and they are only
the vanguard (Saulny, 2011). Saulny states that “nearly 9% of all marriages
in the U.S. in 2009 were interracial or interethnic, more than double the percentage 30 years ago. Gender, race, and ethnicity are important influential
variables. For example, black men marry someone from a different group
twice as often as black women do while among Asians, the gender pattern is
reversed” (2011, p. 21).
Family clinicians appreciate that the variations in family structure and development of African Americans, Asians, Hispanics, whites, and others are
potential strengths in helping these families to function under various economic and social conditions. 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.
The rapid change in racial patterns in the United States is important to note.
Hispanics or Latinos constitute 16% of the total U.S. population, forming the
second largest ethnic group after non-Hispanic white Americans (a group composed of dozens of subgroups, as are Hispanic and Latino American groups;
Humes, Jones, & Ramirez, 2011). Mexican Americans, Cuban Americans,
Columbian Americans, Dominican Americans, Puerto Rican Americans, Spanish
Americans, and Salvadoran Americans are some of the larger national origin
groups. The black or African American group represented 13% of the total
U.S. population in the 2010 census, while 5% of all respondents identified as
Asian alone (Humes, Jones, & Ramirez, 2011).
Racial differences, whether intracultural or intercultural, are not problems
per se. Rather, prejudice, discrimination, and other types of intercultural aggression based on these differences are problems. With the number of interracial families continuing to rise in the United States, we believe race will
become less divisive than it was. About 8% of U.S. marriages are mixed race,
a rise of 20% since 2000, although a marked drop-off from the 65% increase
between 1990 and 2000. Interracial families are quietly eroding many assumptions that have guided America’s politics, customs, and habits for many
decades.
For some persons, whether of the majority or minority race, the word race
is very distasteful, as 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 “the myth

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Chapter 3: The Calgary Family Assessment Model 71

of sameness” and to vigorously pursue the differences between and within various racial groups. For example, we ask ourselves how a Jamaican American
family might differ from an African American family in their beliefs about hospitalization or how a Vietnamese couple might differ from a Japanese couple
in their beliefs about whether to institutionalize an aging grandmother.
We believe health professionals should be racially and culturally competent. For example, non–African Americans working with African American
families should not assume familiarity but should address issues of racism,
intervene multisystemically, use a problem-solving and solution focus, and
acknowledge strengths. These guidelines apply equally well for all races
working with each other.
Questions to Ask the Family. What differences do you notice between, for

example, your Hong Kong relatives’ child-rearing practices and your own?
If you and I were the same race, would our conversation be different? How?
Would our different type of conversation be more or less likely to assist you
in regaining your health? Could you help me to understand what I need to
know to be most helpful to you?
Social Class

Social class shapes educational attainment, income, and occupation. It is frequently confused with socioeconomic status (SES). Kliman (2011) points out
that SES is typically a decontextualized and hierarchical formula of education, occupation levels, and income dividing people into upper-upper, lowerupper, upper-middle, lower-middle, upper-lower, or lower-lower segments.
Without taking into account the family’s context, SES can obscure more than
shed light on how a family has access to resources, information, privilege,
and power. For example, an undocumented young man earning $20,000 in
a full-time job has access to different resources than a graduate student working part-time, earning the same amount of money, and enjoying the privileges
of his parents’ accumulated wealth. Each class position has its own clustering
of values, lifestyles, and behavior that influences 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-today living; and how they meet challenges, struggles, and crises. Class position
can intensify or soften the impact of crises at each family life cycle stage. For
example, middle-class seniors are likely to help their adult children, whereas
working-class older adults are 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.
Because poverty is disproportionately concentrated among racial minorities,
many professionals have considered the African American statistical subgroup to represent the lower-income class and the white statistical subgroup

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72 Nurses and Families: A Guide to Family Assessment and Intervention

to represent the middle- or upper-income class. Furthermore, although
Hispanics, including Mexicans, Puerto Ricans, Cubans, and people from
South and Central America, have increased substantially in number to become a sizable group within the United States, until recently, data about
marriage and family have excluded them. Such data have generally been
limited to blacks and whites, without taking into account Hispanics or
Asians. Much of the literature confounds the effects of race and class, not
to mention the “myth of sameness” about families within each race or class.
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 a growth in the aging population,
many families are anxious about their long-term care and ability to provide
for their loved ones. Economic uncertainty, tsunamis, wars, fears of terrorism, and the aftereffects of 9/11 have created increased difficulties for the
working poor. We have found in our clinical work that particularly in lowincome situations, parents have to embed family time in other activities such
as meal preparation, shopping, or driving, and not in leisure activities or time
“off the clock” from mundane daily caretaking of children or elders.
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”, the “glass escalator”, and part-time temporary work versus full-time
permanent work with benefits. The upward mobility risks of harassment
faced by women entering some male-dominated work environments, such as
the military, should also be known to health-care professionals.
In our clinical work, we have often asked ourselves how a family’s social
class might influence their health-care 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.

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Chapter 3: The Calgary Family Assessment Model 73

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 AIDS? How many schools has your daughter,
Frishta, attended? How does your money situation influence your use of
health-care resources? What impact does Nuar’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 (2005)
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, 2005). 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, 2005).
We recommend that assessment of religion’s influence is most critical at
the time a chronic or life-threatening illness has been diagnosed and/or when
illness, disability, or loss has changed a family’s life and relationships forever.
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, 2005). This type of exploration about meaning and purpose in one’s
life following profound changes in family life opens the domain into spirituality. We prefer this more indirect method of inquiry about suffering than
directly asking about spiritual and religious beliefs. 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 is intricately related to
the Protestant work ethic. Community and family support, on the other
hand, is evident in the Mormon and Jewish religions, which 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. For example, espiritistas, or healers, can be found in

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74 Nurses and Families: A Guide to Family Assessment and Intervention

many Cuban and other Latino communities. 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.
We encourage nurses visiting families’ homes to note 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 and about traditional or alternative health practices influenced by
religious beliefs. However, we have been cautious not to assume that strong
spiritual or religious beliefs enhance marital happiness or interaction, although
they may diminish the possibility of divorce. It is interesting to note, though,
that the work of Parker and colleagues (2011) found that parents raising typically developing children scored higher on private and public religiosity and
marital satisfaction than parents raising a child with a disability. 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, 2005).
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. For a more in-depth
discussion of clinical ideas and examples addressing the connection between
spirituality and suffering, as well as how to assess and intervene, we encourage readers to peruse the 2005 text Spirituality, Suffering, and Illness: Ideas
for Healing by Lorraine M. Wright.
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, or
synagogue? Can you tell me if there are ceremonies or spiritual practices that
help keep your family strong and healthy or that you believe inhibit your
family? Would it help if we arranged for a visit from a tribal elder or medicine
man? 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

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Chapter 3: The Calgary Family Assessment Model 75

even if it has become dangerous to live there. Epstein (2003) raises a disturbing issue about the environment: “In America’s rundown urban neighborhoods, the diseases associated with old age are afflicting the young. Could it
be that simply living there is enough to make you sick?” Some of these neighborhoods have the highest mortality rates in the country owing to the prevalence of chronic diseases rather than gunshot wounds or drugs. Epstein
comments that “the grinding everyday stress of living in poverty in America
is ‘weathering,’ a condition not unlike the effect of exposure to wind and
rain on houses” (p. 76). We have adjusted our perceptions of homelessness
and come to grips with the idea that families with children are the fastestgrowing homeless group. Homelessness is neither an urban nor a regional
problem but rather one that is pervasive throughout North America.
In clinical work with families, nurses can ask themselves whether the
home is adequate for the number of people living there. 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.
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 (to
obtain the genograph, visit www.familynursingresources.com). Alternatively,
some computer programs (www.genopro.com) have genograms as a feature.
The genogram is a diagram of the family constellation. The ecomap 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 inadequate for African Americans or other racial or ethnic groups because
of its underlying assumption that family is strictly a biological entity. We encourage nurses to develop a fit between these tools to depict specific family
compositions.
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 and to detoxify and normalize families’ perceptions

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76 Nurses and Families: A Guide to Family Assessment and Intervention

of themselves. By pointing to the future and to the past and the present,
genograms facilitate alternative interpretations of family experience. They can
help 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 to help nurses increase their
self-awareness.
We agree with McGoldrick (2011a) that although much can be said about
expanding genograms to include issues from larger social contexts (i.e., 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.
Important issues that are difficult to capture on genograms include family
members involved in family business; family members’ relationships to the
health-care system; cultural issues; family secrets; particular family-relationship
nuances, including power, patterns of avoidance, and so on; patterns of friendship; relationships with work colleagues; spiritual and community connections;
and medical and psychological stressors.
Genograms do not 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 are not generally 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. We caution practicing
nurses 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.

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Chapter 3: The Calgary Family Assessment Model 77

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.” Sigurdardottir and
Sveinbjarnardottir (2011) have described their use of genograms in the
electronic health record as a way of supporting family nursing implementation and increasing family documentation. As an engagement tool, it
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 tends to follow conventional genetic and
genealogic charts. It is a family tree depicting the internal family structure.
It is usual practice to include at least three generations. Family members are
placed on horizontal rows that signify generational lines. For example, 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. A blank
genogram is shown in Figure 3–2.
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
upon. With increased use of computer genograms, symbols and color-coding
will become standardized.

Grandparents

Aunts & uncles

Parents

Children
F I GU R E 3-2: Blank genogram.

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78 Nurses and Families: A Guide to Family Assessment and Intervention

Female:

Male:

Children:
Birth order
(beginning with
oldest on left)

Sperm donor:
M 2011

Marriage (M)
or common law (CL):
(husband on left;
wife on right)

Miscarriage or abortion
(give year)

2012

Adoption

Index
person

(IP)
Twins:

2008
Death
(give date)

D 2009
Circle members of current household

Marital
separations
(give date)

S 2008

Divorce
(give date)

R 2010
Reconciliation
after separation
(give date)

F I GU R E 3-3: Symbols used in genograms.

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, 2011a). It is helpful to draw a circle around the different

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Chapter 3: The Calgary Family Assessment Model 79

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.
McGoldrick (2011a) offers an expanded description of symbols that could
be used in drawing genograms if the clinician so desired. We find it best to
keep the genogram symbols fairly simple so as to facilitate their adoption in
busy clinical settings.
An example of a nuclear and extended family genogram is given in
Figure 3–4 for the Lamensa family. Raffaele, age 47, has been married to
Silvana, age 35, since 2000. They lived common-law for 2 years prior to
their marriage. They have two children: Gemma, age 14, who is in grade 8,
and Antonio, age 7, who is repeating grade 1. Raffaele is employed as a machinist, and 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 also has a drinking problem. Young
2010

2008

2007
54
Nunziata

Antonio
Stroke

Cancer
Drank

Drinks

47
Raffaele

CL 1998
M 2000

35
Silvana

Machinist
"Alcoholic"

Homemaker
"Depressed"

14
Gemma

7
Antonio

Gr. 8

Gr. 1
Repeating

F I GU R E 3-4: Sample genogram: The Lamensa family.

Arthritis

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80 Nurses and Families: A Guide to Family Assessment and Intervention

Antonio was named for his grandfather. Silvana’s mother, Nunziata, age 54,
has arthritis, which has been getting progressively worse since her husband
died in 2007. Silvana has two older sisters and a brother.
Figure 3–5 illustrates a lesbian couple with a child born to one of them,
Jennifer (age 30), and adopted by the other, Amanda (age 28). Jennifer and
Amanda have lived as a couple since 2009 and have been married since 2011.
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 Jamaican retired nurse (age 65), divorced Jennifer’s father
in 1986, remarried in 1987, had another daughter, Mitzi, by her second husband and became a widow when he died in 1993. Mitzi 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 her half sister, Mitzi (age 25).
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

CL

D 1986

M 1987

Dan

65
1

1993
2

Adrienne:
Retired nurse

28

CL 2009
M 2011

28

25

Spencer

Mitzi

30
Jennifer

Amanda
Donor

8
Griffin:
Adopted by Amanda

F I GU R E 3-5: Sample genogram: Artificial insemination and lesbian couple.

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Chapter 3: The Calgary Family Assessment Model 81

the structure of the genogram to discern the family’s internal and external
structures as well as its context. Thus, the nurse gains an understanding of
the family’s composition and boundaries.
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.
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 were 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 infant 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.) Mmm.
Matias: Yeah, Old Stinko!
Nurse: And Teresita is how many weeks now?

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82 Nurses and Families: A Guide to Family Assessment and Intervention

Elena: She’ll be 21 days tomorrow. (Smiles at infant.)
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
(Fig. 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:
■ 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 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, 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.

M 1998-2008

34
Matias

2 3/4
Manandro

F I GU R E 3-6: Genogram of the Manuyag family.

M 2009

23
Elena

3 wks
Teresita

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Chapter 3: The Calgary Family Assessment Model 83

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 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 discussion about the present family situation to questions about the
extended family if it seems relevant (e.g., “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 (e.g., “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. St. Louis: Mosby, p. 14. Copyright
2002. Adapted with permission.

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84 Nurses and Families: A Guide to Family Assessment and Intervention

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.
Figure 3–7 illustrates a sample genogram of a stepfamily. In this stepfamily, Michael (age 35), has been living in a common-law marriage since 2011
with Melanie (age 33), who is a part-time waitress. Also in the household
are Melanie’s two children by her first marriage—Kathy (age 11) and Jacob
(age 9). Jacob has ADHD and is in a special third-grade class. Michael married his first wife, Laura, in 2001. They were divorced in 2005. Michael and
Laura had one son, who is now age 8. 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 2001, separated in 2008, and divorced in 2011. David, age 36, is a mechanic who is presently living in a common-law marriage with Camille and
2008
George

Robert

Laura

Suicide

36

37

M 2001
S 2008
D 2011

M 2001
D 2005

CL 2011
35
Michael

Laura

Truck driver

CL 2008
33
Melanie

Waitress
Part-time

36
David
Mechanic

8

11
Kathy

D 2004
R 2006
D 2007

9
Jacob

Gr. 3
Special class
Hyperactive

F I GU R E 3-7: Sample genogram of a stepfamily.

Camille

Rob

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Chapter 3: The Calgary Family Assessment Model 85

her three sons. Camille and her first husband, Rob, divorced in 2004, reconciled in 2006, and then divorced in 2007.
There are no specific guidelines for drawing genograms illustrating complex stepfamily situations. Generally, however, it works best if the nurse starts
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 (2011a) 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 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.
Challenges arise when there are multiple marriages, such as Qatari families
who may have one to four wives, 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. We advise nurses
to let usefulness 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 remembrances of information. Cook and Poulsen (2011)
have suggested using photographs with genograms as a way of creating a
dynamic, information-rich, and experiential environment. We think this
might be a useful idea if the nurse is working with patients in a long-term
care or rehabilitation facility.
Another, perhaps more typical stepfamily genogram is depicted in
Figure 3–8. In this genogram, the Faris family is composed of David (age 42),
a software designer who has been living common-law since 2009 with Patti
(age 40), a part-time retail associate. They have a daughter, Madison (age 1),
who was recently diagnosed with juvenile diabetes. David’s twin sons, Jack

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86 Nurses and Families: A Guide to Family Assessment and Intervention

93
19 94
L
9
C 1 01
M 20
D

Diabetic

Lloyd
2

Diabetic

12

06

D

20

42
David

CL

09
20

40
Patti

88
19 92
M 19
D
Jim
1

3
Software
designer

Retail
associate
part-time

3

Jack
6

Ben
6

Gr. 1
Gr. 1
alternate weeks

Madison
1
Diabetic

Dan
20

Tamika
16

Shannon
14
Gr. 8

F I GU R E 3-8: Sample genogram: Faris stepfamily.

and Ben (age 6), spend alternate weeks at their mom’s town house and at
their dad’s apartment. David was divorced in 2006; his former wife has a
daughter, age 3. Patti has a son, Dan (age 20), by her first husband, Jim,
who she divorced in 1992. Dan lives alone and works several part-time jobs
in bars. Patti also has two other daughters: Tamika (age 16), who recently
dropped out of school, and Shannon (age 14), who is in grade 8. They are
from her second marriage, to Lloyd, which ended in divorce in 2001. The
teenage girls 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 twins. David’s mom has diabetes, as does his older sister.
Another sample family situation is the Fitzgerald-Kucewicz family, in which
a child lives with the grandmother and her husband. The identified patient,
8-year-old Sophia Kucewicz, lives with her grandmother, 45-year-old Patricia
Fitzgerald; Vincent, Patricia’s common-law partner of 10 years; and Sophia’s
19-year-old aunt, Susan. Patricia was previously married to Steven Fitzgerald
for 14 years. Patricia and Steven had three children: 19-year-old Susan,
23-year-old Douglas, and 25-year-old Joan, who is Sophia’s mother. Joan became pregnant with Sophia when she was 16. Sophia’s father, Michael

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Chapter 3: The Calgary Family Assessment Model 87

Kucewicz, and her mother, Joan, had a brief relationship, through which she
was conceived. Although 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 2.5, her mother moved in
with Ben, who 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. Figure 3–9 shows the Fitzgerald-Kucewicz family
genogram.
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

Steven
48

M 14 yrs.
S 1 yr.
D 2001

CL 2001
Patricia
45

Vincent
49

Ben
28
3

L

C
05

20

Michael
25

?
2

CL
1 mo.

Joan
25

Douglas
23

1

Kayla
6

Sophia
8
Nightmares

F I GU R E 3-9: Genogram of the Fitzgerald-Kucewicz family.

Susan
19

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88 Nurses and Families: A Guide to Family Assessment and Intervention

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, health-care facilities,
and so forth. Increasingly, the ecomap is being used in a variety of ways to
promote family health. For example, Limb and Hodge (2011) have used spiritual ecograms with Native Americans to promote cultural competence.
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. In this
family, Raffaele, Silvana, Gemma, and Antonio are placed in the center circle.
Raffaele has strong connections with his workplace, where he is foreman and
a union representative. He has moderately strong bonds with his “drinking
buddies.” However, these relationships 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

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Chapter 3: The Calgary Family Assessment Model 89

HEALTH CARE
FACILITIES
HOUSING

WORK
Foreman
Union Rep.

Sees M.D. weekly
for nerves

CHURCH
EXTENDED
FAMILY

FAMILY OR
HOUSEHOLD
Drinking
buddies

Raffaele

Silvana

Grandmother
Nunziata visits
family home
every day
11AM–10PM

CHN visits
once a week

Jr. High
School
Average
Grade = D

Gemma

Antonio
RECREATION

RECREATION
With boyfriend
6 hrs/day

FRIENDS
SCHOOL

Fire setters

Special class
Enjoys

F IGU R E 3- 10: Lamensa family ecomap.

(CHN) once a week. Silvana’s mother, Nunziata, visits Silvana every day from
11:00 AM to 10:00 PM. 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.
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 with those inside
their household and with those outside the immediate family.

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90 Nurses and Families: A Guide to Family Assessment and Intervention

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 and
“knowing” 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.

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 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.
Family development is an overarching concept, but each family has its
own developmental path, influenced by its past and present context and its
future aspirations. Some consider family as those who are tied together
through their common biological, legal, physical, social, and emotional history and by their implied future together.
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 70s. This blurring of
boundaries can sometimes lead to tension and confusion within families.
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

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. St. Louis: Mosby, p. 14. Copyright
2002. Adapted with permission.

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Chapter 3: The Calgary Family Assessment Model 91

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.
In our clinical supervision with nurses, 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, social media, and smartphone usage; recessions; unemployment;
mortgage defaults; stock market fluctuations; company mergers; changes in
crime; and birth rates and immigration and migration).
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 in their life cycle the events
of birth, child-rearing, departure of children from the household, retirement,
and death. Such events generate changes requiring 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.
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 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 they have progressed through time.
A rich history about family development still pervades clinicians’ thinking.
We believe that 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 (Carter
& McGoldrick, 1988, 1999b; McGoldrick & Carter, 2003; McGoldrick,
Carter, & Garcia-Preto, 2011a).
Most early analyses of the family life cycle began with a discussion of the
first marriage but also considered activities that preceded the first marriage,
such as cohabitation. Lewin (2010) reported that cohabitation is a widely used
transitional step to marriage with approximately half of cohabitating couples
marrying within 3 years and about two thirds marrying within 5 years, according to the 2010 U.S. Census. Unfortunately, data are now coming forth
that indicate cohabiting couples who marry are more likely to divorce than
non-cohabiting couples. The median age at first marriage increased to 28.2

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92 Nurses and Families: A Guide to Family Assessment and Intervention

for men and 26.1 for women in 2010, an increase from 26.8 and 25.1 in 2000
according to the U.S. Census Bureau (United States Census Bureau, 2010a).
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 the Milan Group (Selvini-Palazzoli,
et al, 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, these therapists similarly sought to understand the relationship between psychopathology and the family’s
developmental life cycle stage.
Carter and McGoldrick (1988, 1999b) included the impact of transgenerational stress intersecting with family developmental transitions. They believed that if vertical (transgenerational) stress was too high, a small amount
of horizontal (current) stress would lead to great disruption and symptom
formation. More recently, McGoldrick, Carter, and Garcia-Preto (2011b)
have advocated adding friendship as a component of the family life cycle because it is part of our sense of home and the importance of community. In
addition, they recommend clinicians consider the family’s sense of what they
call homeplace, a place of acceptance and belonging essential to developing
a solid sense of self as a human being. What is a client’s sense of belonging
and connection to what is familiar? Clinicians have a significant role to play
in encouraging clients to think about the meaning of family and community
to them as they go through various life cycle stages.
Over the last decade, there have been a great many changes in the family
life cycle. First, there has been an increase in literature discussing families and
their developmental phases (e.g., divorce, remarriage, foster families, impact
of immigration, chronic illness, terrorism). Second, there has been an increased consciousness of differences in male and female development and a
rethinking of the trajectory of various ethnic groups in North American society. Third, there has been a lower birth rate, a longer life expectancy, a change
in the roles of women and men, an awareness of microtrends, and increasing
divorce and remarriage rates. Fourth, the conception of history as an “objective” ordering of the “facts” of the past has changed. 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

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Chapter 3: The Calgary Family Assessment Model 93

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 emphasize 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 believe that a systems approach to family development calls
for a dialectical integration of two tendencies: stability and change. The emphasis is therefore on both tendencies rather than on 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.
We believe that there is much evidence to support the position that nurses
will find heuristic value in the family development category of CFAM. However, they should be aware 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 implication 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 (Nichols, et al, 2000). Tensions and continuing change
brought about by contradiction between these progressions are normal. Family life is seldom smooth or bland; rather, it is zestful and active. Therefore,
when nurses use the family development category, we encourage them to
have families discuss their joys and satisfactions as well as their tensions and
stresses.
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. There is the need to
balance two life forces: (1) togetherness and the capacity for intense intimacy
in relationships and individuality, and (2) the capacity for independent thinking and goal-oriented action. 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

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94 Nurses and Families: A Guide to Family Assessment and Intervention

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, the relationship stresses and the hard choices economic
and social immigrants face with separations and reunions of parents, young
children, and elderly family members. We believe that difficult gender and
generational transformations need to be considered when discussing attachments. 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 (Fig. 3–11) are similar to
those used in the structural assessment diagrams. Again, 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.

Male:

Female:

Attachments:

Strongly attached
Moderately attached
Slightly attached
Very slightly attached
Negatively attached

F IGU R E 3-11: Symbols used
in attachment diagrams.

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Chapter 3: The Calgary Family Assessment Model 95

We like this concept because it expands attachment to include multiple system levels and networks, which is especially important as the baby boomers
increase in age. Attachment theory is relevant to more than just parent-infant
bonding; it is important for all ages. We believe that the key elements of attachment processes (i.e., 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.
In the CFAM developmental category, we discuss family life cycle stages,
the emotional process of transition (namely, key principles), and secondorder 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
2. Divorce and post-divorce
3. Remarried
4. Professional and low-income
5. Adoptive
6. Lesbian, gay, bisexual, queer, intersexed, transgendered, and twin-spirited

Middle-Class North American Family Life Cycle
We are grateful to Carter and McGoldrick (1988, 1999b) and McGoldrick,
Carter, and Garcia-Preto (2011b) for delineating six stages in the North
American middle-class family life cycle (Box 3–3). 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 is changing radically. We believe
that 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, long-distance married couples (commuter marriages), and sole-parent adoptions to list a few.
Transitional crises should not be thought of as permanent traumas. We
believe it is imperative that the use of language that links us to 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.
Stage One: The Launching of the Single Young Adult

In outlining the stages of the middle-class North American family life cycle,
we 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

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96 Nurses and Families: A Guide to Family Assessment and Intervention

Box 3-3

The Stages of the Family Life Cycle
Emotional Process
of Transition:
Key Principles
Accepting emotional and financial responsibility
for self

Second-Order Changes in Family
Status Required to Proceed
Developmentally
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. Spirituality

Joining of families
through marriage/
union

Commitment to
new system

a. Formation of partner systems
b. Realignment of relationships with
extended family, friends, and larger
community and social system to
include new partners

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,
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 move into and
out of system
b. Refocus on midlife couple and career
issues
c. Begin shift toward caring for older
generation
d. Realignment with community and
larger social system to include shifting
family of emerging adolescent and
parents in new formation pattern of
relating

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

Family Life Cycle
Stage
Leaving home:
emerging young
adults

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Chapter 3: The Calgary Family Assessment Model 97

Box 3-3

The Stages of the Family Life Cycle—cont’d

Family Life Cycle
Stage

Emotional Process
of Transition:
Key Principles

Second-Order Changes in Family
Status Required to Proceed
Developmentally
c. Realignment of relationships to
include in-laws and grandchildren
d. Realignment of relationships with
community and larger social system
to include new structure and 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 the
shifting generational roles

a. Maintenance of own and/or couple
functioning and interests in face of
psychological decline: exploration
of new familial and social role
options
b. Supporting more central role of
middle generations
c. Realignment of the system in relation to community and larger social
system to acknowledge changed
pattern of family relationships of this
stage
d. Making room in the system for the
wisdom and experience of the elders
e. Supporting older generation without
overfunctioning them

Families nearing
the end of life

Accepting the
realities of 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.). (2011). Overview: The Life Cycle in Its Changing
Context. The Expanded Family Life Cycle: Individual, Family and Social Perspectives, 4th edition, copyright
2011, pp16-17. Reprinted by permission of Pearson Education, Inc.. Upper Saddle River, NJ.

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98 Nurses and Families: A Guide to Family Assessment and Intervention

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.
A 2010 Pew Research found that millennials (today’s 18- to 29-year-olds)
value parenthood far more than marriage. Of the millennials, 52% stated
being a good parent was one of the most important things in life while only
30% said this about having a successful marriage (Wang & Taylor, 2011).
This stage may last for several years in a family’s development. It is an
opportunity for young adults to sort out emotionally what values and beliefs
they will hold onto 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 around work. Women may choose to define themselves in relation to a male and postpone or forgo establishing an independent identity.
Young men choosing to cohabit often do not think of the young woman as
the desired marital partner, whereas young woman who cohabit believe their
partner is their future marital partner.
In our clinical work, we 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. With approximately one in four single
Americans looking for a romantic partner using the 1,000 or more dating
Web sites, the previous venues for social networking are being replaced by
the Internet and chat rooms. Internet marriage is becoming increasingly
common, and this will likely lead to more diverse pairings across race, ethnicity, and nationality.
Tasks

1. 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, where the 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.
2. 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 model 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,

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Chapter 3: The Calgary Family Assessment Model 99

Facebook, Twitter, Pinterest, and chat rooms, the young adult will be
exposed to a wide variety of personal styles and personalities.
3. Establishment of self in relation 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 interests is typical. Young adults who are
committed to a career path or occupational choice by their late 20s or
early 30s are less vulnerable to self-doubt or decreased self-esteem than
young adults who lack direction. Young adults and their family of origin must sort through issues of competitiveness, expectations, and differences regarding work and financial goals.
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 another 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 stage 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 during
the young adult’s childhood. 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.
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, Manal,
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 Muslim 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?

Father

Mother

Young
Adult
F I GU R E 3- 12: Sample attachments in stage 1.

Mother

Father

Young
Adult

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100 Nurses and Families: A Guide to Family Assessment and Intervention

Stage Two: Marriage: 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: his family of
origin, her 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 Canada, gay marriages and civil
unions have increasingly been formally recognized. In the United States in
2009, the overall national rates of marital events for men were 19.1 marriages,
9.2 divorces, and 3.5 instances of widowhood per 1,000 men. For women
there were 17.6 marriages, 9.7 divorces, and 3.5 instances of widowhood per
1,000 women (Elliott & Simmons, 2011).
Tasks

1. Establishment of couple identity. 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 about 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 focuses
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 with an arranged marriage is quite different.
The health benefits of a good marriage have been touted and researched over many years, but more nuanced views of the so-called
marriage advantage are coming to light (Parker-Pope, 2010). Those individuals in troubled relationships appear far less healthy than if they
had never married. Nurses have wonderful opportunities to foster
healthy couple identity and relationships.
2. Realignment of relationships with extended families to include spouse.
A renegotiation of relationships with each spouse’s family of origin has
to occur 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 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.

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Chapter 3: The Calgary Family Assessment Model 101

3. Decisions about parenthood. For most couples, happiness is highest at
the beginning of the life cycle stage of marriage. Although a small but
increasing number of married couples are deciding to be childfree by
choice, most still plan on becoming parents. The question of when to
conceive is becoming increasingly complex, especially with the changed
role of women, the widespread use of contraceptives, the availability
of a wide range of fertilization strategies, and the trend toward later
marriages. Since 2008, there has been a sharp decline in the fertility
rate in the United States, and it is linked to the slumping economy (Pew
Research Center, 2011). It is interesting for clinicians to note that in
the United States, more than a quarter of the unmarried women who
gave birth in 2009 were living with a partner (Lewin, 2010). Couples
who have evolved more competent marital structures prenatally are
more likely to successfully incorporate a child into the family.
Attachments

Figure 3–13 illustrates a sample attachment for a couple in stage 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. A different type of attachment
(illustrated in the second diagram) 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.
Questions to Ask the Family. Which family, Sabeen, was most in favor of your

marriage to Hashim? How did you incorporate Pakistani 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 use your parents’ marriage as

Husband

Wife

F I GU R E 3- 13: Sample attachments in stage 2.

Husband

Wife

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102 Nurses and Families: A Guide to Family Assessment and Intervention

a model for your own marriage, what would you incorporate into your
marriage? How did the diagnosis of multiple sclerosis influence your bonding
as a couple?
Stage Three: Families With Young Children

During this stage, the adults now become caregivers to a younger generation. Family-of-origin experiences can influence the forming of a new family.
We have found in our clinical work that individuals who recollect negative
qualities in their parents’ relationship often report more negative changes
in the quality of their own marriages during their first year of transition to
parenthood.
The birth and rearing of a baby present varying challenges. Moreover,
taking responsibility 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. Sleep disruption and
loss contribute to a decline in marital satisfaction across the transition to
parenthood (Medina, Lederhos, & Lillis, 2009). Excessive and inconsolable
neonatal crying is one of the most challenging tasks for parents to manage
(Patrick, Garcia, & Griffin, 2010). The disposition of childcare 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, delegating, limiting avocational activities, and using social support significantly more often than do men.
We believe the work-family issue of juggling childcare 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. How the increase in
“old new dads” in the United States will impact this struggle is unknown.
What is evident is that the birth rate between 1980 and 2002 increased 32%
among fathers in the United States aged 40 to 44 and increased 21% among
fathers aged 45 to 49 (Penn, 2007). It went up almost 10% for dads aged 50
to 54. This trend means that the joys of family life go on well into many
dads’ 60s. Generational boundaries quickly become blurred with “old new
dads” being concerned simultaneously about children’s schools and sports
and their own retirement finances.
Tasks

1. Adjusting marital system to make space for a child. 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

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Chapter 3: The Calgary Family Assessment Model 103

are expected to fill. If the child has a handicap, the couple faces 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. Joining in childbearing, financial, and household tasks. The couple
must find a mutually satisfying way to deal with childcare responsibility
and household chores that does not overburden one partner. Dealing
with finances and juggling family and other responsibilities is a major
task. The emotional and financial cost of solutions to deal with childcare responsibilities must be addressed. The influence of illness, such
as autoimmune disease, on maternal fatigue and its impact on the caregiving environment, parental discipline style, and daily childrearing
practices needs to be considered (White, White, & Fox, 2009).
Both mothers and fathers 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
achieving at school. Some middle-class families, responding to intense
pressure from the school system, tend to stress the values of achievement and productivity, whereas some working-class families may respond to this pressure by 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 couple must design and develop the
new roles of father and mother 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.
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. Gottman and Notarius (2002)
report that for 40% to 70% of couples, marital quality drops following
the transition to parenthood, with people commonly reverting to stereotypic

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104 Nurses and Families: A Guide to Family Assessment and Intervention

gender roles as they become overwhelmed by the complexity of housework,
childcare, and work. Marital conversation and sex sharply decrease. However,
joy and pleasure with the baby increase.
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.
Figure 3–14 provides sample attachment diagrams for this stage. 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?
Stage 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, texting, social networks such as Twitter and Facebook, pornography, sports, and other activities all compete for
the adolescent’s attention. This stage is highly influenced by class. Adolescence
can begin early within poor, inner-city communities when, 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.

Father

Mother

Father

Mother

Child

Child

Child

Child

F I GU R E 3- 14: Sample attachments in stage 3.

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Chapter 3: The Calgary Family Assessment Model 105

Tasks

1. Shift in parent–child relationships to permit adolescents to move in or out
of the 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 re-create 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 in a balanced way
to their teens is often complicated if there are health problems. For example, Fulkerson and colleagues (2007) found that general family connectedness, priority of family meals, and positive mealtime
environment were significantly positively associated with psychosocial
well-being in overweight adolescents. These authors also noted that
weight-based teasing and parental encouragement to diet were associated with poor psychological health in the 7th to 12th graders they
studied. For parents to find a balance between encouraging healthy eating and avoiding encouraging dieting with at-risk-for-overweight or
overweight teens is a challenge. Rosenberg and Shields (2009) found
intriguing results from their study of parent-adolescent attachment in
the glycemic control of adolescents with type 1 diabetes. Mothers’ perception of more secure adolescent attachment was associated with better glycemic control. Neither fathers’ nor adolescents’ reports of
attachment were significantly correlated with glycemic control.
2. Refocus on midlife marital 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.
3. Beginning shift toward joint caring for older generation. As parents
are aging, so, too, are the grandparents. Parents (especially women)

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106 Nurses and Families: A Guide to Family Assessment and Intervention

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, while
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? Ask the adolescents: How
do you think your parents will handle it when your younger sister, Nenita,
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 crystal meth?
Stage Five: Launching Children and Moving On

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

Father

Teen

Mother

Teen

Child

F IGU R E 3- 15: Sample attachments in stage 4.

Father

Teen

Mother

Teen

Child

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Chapter 3: The Calgary Family Assessment Model 107

process of change. 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 marital 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 reexamined.
2. Development of adult-adult relationships between grown children and
their parents. 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-inlaw 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. Dealing with disabilities and death of 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 third
generation. The type of disability afflicting the seniors determines the
effects on the immediate family. For example, caregivers who do not
understand Alzheimer’s 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 have found that many times female
caregivers seek support for depression that often stems from the multiple roles, losses, and guilt they are experiencing.
We recommend that health professionals, in addition to attending to the
family’s multigenerational legacies of illness, loss, and crisis, also note

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108 Nurses and Families: A Guide to Family Assessment and Intervention

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 stage. 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.
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 leave 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?
Stage Six: Families in Later Life

This stage can begin with retirement and last until the death of both spouses.
However, it is hard to say when the stage actually begins for each family,
considering that “today there are 5 million people 65 and older in the US
labor force, almost twice what there were in the early 1980s and that number
is about to explode” (Penn, 2007, p. 29). 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. We agree with Walsh (2011) that as a society we
have been gerontophobic, and a larger vision of later life is required to recognize the growth, change, and new learning that can occur at this stage.
The idea of dividing up this life cycle stage into extended middle age (to age 75),
older seniors (75–85), and old age (85 and older) can be a useful way of
“doing hope” for seniors who hold a pessimistic, fearful view of aging.

Father

Mother

Father

Mother

Young
Adult

Teen

Young
Adult

Teen

F I GU R E 3- 16: Sample attachments in stage 5.

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Chapter 3: The Calgary Family Assessment Model 109

Tasks

1. Maintaining own or couple functioning and interest 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 finds 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 making 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. Another adjustment might be if the older seniors start dating
and/or marrying with the middle-aged family members feeling challenged or pressured to be supportive.
2. Making room in the system for the wisdom and experience of the
seniors. 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 phenomena
of “seniors caring for seniors” is another emerging area for healthcare providers to address.
The parents of the baby boomers are the current generation of
“young-old.” They are highly motivated to participate in self-help
groups and are 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,
Skype, and smartphones. 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 childrearing.
3. Dealing with loss of spouse, siblings, and other peers and preparation
for death. This is a time for life review and taking care of unfinished

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110 Nurses and Families: A Guide to Family Assessment and Intervention

business with family as well as with business and social contacts. Many
people find it helpful to discuss their life, review and reminisce, and
enjoy the opportunity of passing this information along to succeeding
generations. Often elders become useful and informative family historians by writing and/or recording their individual or family biographies
and collecting and identifying family pictures.
Attachments

The couple reinvests and modifies the marital relationship based on the level
of functioning of both partners. Between 1980 and 1990, 17% of those aged
65 and older in the United States lived in a multigenerational family household. Since then, this has increased to 20%. In 2008, a total of 6.6 million
older adults lived in a household with one or more children, and in 42% of
the situations the child was the head of household (Pew Social Trends Staff,
2010).
This stage is characterized by an appropriate interdependence with the
next generation. The concept of interdependence is particularly important
for nurses to understand in 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 and daughters-in-law than with
sons. Thus, the possibility of strong intergenerational attachments between
a daughter and her parents exists. In the attachment pattern illustrated in
Figure 3–17, the couple projects their conflicts onto the extended family.
This causes difficulty for the succeeding generations.
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?

Father

Mother

Adult
Daughter

Father

Son-inlaw

F I GU R E 3- 17: Sample attachments in stage 6.

Mother

Adult
Daughter

Son-inlaw

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Chapter 3: The Calgary Family Assessment Model 111

Divorce and Post-Divorce Family Life Cycle
Many changes in marital status and living arrangements are prevalent in
North America today. Noteworthy is the high level of divorce. In 2005, the
divorce rate in the United States was 3.6 per 1,000 population, down from
4.2 in 2000 and 4.4 in 1995 (Daily Almanac, 2007). Whether the divorce
rate will level off, climb, or decline is a matter of speculation that can be
backed up by various theories. Unstable economic conditions, fear of terrorism, and increased faith-based initiatives may cause divorce rates to decline. Ahrons (2011) believes age is the strongest predictor of divorce, with
couples under the age of 20 at the time of marriage having the highest likelihood of divorce. People with less income and less education tend to divorce
more frequently with an exception: “well-educated women with 5 or more
years of college with good incomes have higher divorce rates than do women
who are poorer and less educated” (Ahrons, 2011, p. 293). Single-parent
families are on the rise. The number of single-mother families increased from
3 million (12%) in 1970 to 10 million (26%) in 2000 in the United States.
Similarly, single-father families grew from 393,000 (1%) to 2 million (5%)
in 2000 (Fields & Casper, 2001).
Families experiencing divorce are often under enormous pressure. Singleparent families must accomplish most of the same developmental tasks as
two-parent families, but without all the resources. This places extra burden
on the remaining family members, who must compensate with increased effort to accomplish family tasks such as physical maintenance, social control,
and tension management. However, we caution nurses 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 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
church 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 submissiveness 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

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112 Nurses and Families: A Guide to Family Assessment and Intervention

autonomous and furthering their education, and they experience increased
confidence and feelings of control in the post-separation 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. Kelly’s review (2007) of the large empirical
research findings indicates “children’s contacts with their nonresident parent
should not be based on every-other-weekend guidelines but should reflect
the diversity of parental interest, capability, and the quality of the parentchild relationship” (p. 47). She recommends that children, depending on their
age and developmental capacity, should have input into the living arrangements but not be asked to choose between parents.
It should be noted that approximately 75% of children involved in divorce
are resilient and able to move on with their lives; only about 25% experience
more lasting problems in adjustment (Greene, et al, 2003). Findings from
Baum’s (2003) study of former couples in Israel showed that the longer and
more conflictual the legal proceedings, the worse the coparental relationship
in the view of both parents. Interestingly, Baum also found that the more responsibility the father took for the divorce and the more he viewed himself
as the initiator, the more he fulfilled his parental functions.
The findings from Ahrons’s longitudinal study (2007) of children 20 years
after their parents’ divorce showed that children who reported their parents
as being cooperative also reported better relationships with their parents,
grandparents, stepparents, and siblings. Whether family relationships improve post divorce, remain stable, or get worse is dependent on a complex
interweaving of many factors. Many of the problems previously attributed
to “the divorce” are now seen to be located in the predivorce family situation; divorce is a long-term process that begins prior to separation and lasts
long after the legal event of divorce (Ahrons, 2006, 2011).
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.
Ahrons found (2007) that when children’s relationships with their fathers
deteriorated after divorce, their relationships with their paternal grandparents, stepmothers, and stepsiblings were distant, negative, or nonexistent.

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Chapter 3: The Calgary Family Assessment Model 113

Nurses can be extremely helpful in intervening in these situations and fostering mutually agreeable post-divorce arrangements for the benefit of the
children. Nurses can help fathers redefine their parental roles and identity in
distinction from their spousal role and identity. For families locked in intractable disputes, we encourage them to develop a good-enough climate in
which parents maintain distance from each other, thus minimizing conflict
and triangulation.
Divorce may occur at any stage of the family life cycle and with any family, regardless of class 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 sample phases involved in divorce and post-divorce are depicted in
Box 3–4. McGoldrick and Carter (2011) found a clinical usefulness in the
distinctions made between the four columns given in the table. Column 1
lists the phase. Column 2 gives the tasks, and Column 3 lists the prerequisite
attitudes that will assist family members to make the transition and come

Box 3-4

Phase
Divorce

Additional Stages of Family Life Cycle for Divorcing
and Remarrying Families

Task
The decision
to divorce

Emotional Process of
Transition: Prerequisite
Attitude
Acceptance of inability to
resolve marital problems
sufficiently to continue
relationship

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
coparental relationship
and joint financial
support of children
b. Working on resolution
of attachment to
spouse

a. Mourning loss of intact
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

Developmental Issues
Acceptance of one’s own
part in the failure of the
marriage

Continued

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114 Nurses and Families: A Guide to Family Assessment and Intervention

Box 3-4

Phase

Postdivorce
family

Additional Stages of Family Life Cycle for Divorcing
and Remarrying Families—cont’d

Task

Emotional Process of
Transition: Prerequisite
Attitude

Developmental Issues

The divorce

Working on emotional
divorce: overcoming
hurt, anger, guilt, etc.

a. Mourning loss of intact
family; giving up fantasies
of reunion
b. Retrieving hopes,
dreams, expectations
from the marriage
c. Staying connected with
extended families

Single parent
(custodial
household
or primary
residence)

Willingness to maintain
financial responsibilities,
continue parental
contact 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

Recovery from loss of
1st marriage (adequate
emotional divorce)

Recommitment to marriage
and to forming a family with
readiness to deal with the
complexity and ambiguity

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

a. Working on openness in
the new relationships to
avoid pseudomutuality
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

Remarriage Entering new
relationship

Conceptualizing and
planning
new marriage and
family

1. Multiple new roles
2. Boundaries: space,
time, membership,
and authority
3. Affective issues: guilt,
loyalty conflicts, desire

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Chapter 3: The Calgary Family Assessment Model 115

Box 3-4

Phase

Additional Stages of Family Life Cycle for Divorcing
and Remarrying Families—cont’d

Task

Emotional Process of
Transition: Prerequisite
Attitude

Developmental Issues

for mutuality, unresolvable past hurts

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 “intact” family
Acceptance of different
model of family with
permeable boundaries

a. Restructuring family
boundaries to allow for
inclusion of new spousestepparent
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; Families Transformed by the Divorce Cycle: Reconstituted,
Multinuclear, Recoupled, and Remarried Families, Monica McGoldrick & Betty Carter. The Expanded Family
Life Cycle: Individual, Family and Social Perspectives, 4th edition, copyright 2011, pp 320-321. Reprinted
by permission of Pearson Education, Inc., Upper Saddle River, NJ.

through the developmental issues listed in Column 4 en route to the next
phase. We believe that clinical work directed at Column 4 will not succeed
if the family is having difficulty dealing with the issues in Column 3.
Questions to Ask the Family. How do you explain to yourself the reasons
for your divorce? Who initiated the idea of divorce? Who left who? 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
coparental relationship with you? How did you respond to this? What

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116 Nurses and Families: A Guide to Family Assessment and Intervention

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
“Stepfamilies are families emerging out of hope” (Visher, Visher, & Pasley,
2003, p. 171). The rise of remarriage and the stepfamily in North America
in recent decades has been striking. More than 4 in 10 Americans have at
least one steprelative in their families, according to a 2010 Pew Research
survey (Parker, 2011). While stepfamilies can be found among all races and
socioeconomic and age groups, there are demographic trends. Young people
under 30, blacks, and those without a college degree are significantly more
likely to report having a steprelative (Parker, 2011).
Although we sometimes use the term recoupled families to indicate the
centrality of the couple bond and the fact that many couples are not getting
married, we have chosen in this edition of our text to continue using the term
remarried families, as it is more familiar to most people. McGoldrick and
Carter (2011) have started using the term multinuclear families to depict the
fluid boundaries and multiple ties that these families have. It is a term we
find appealing because in recoupling there may be three, four, or more households at any one time.
Ahrons’s longitudinal study (2007) of children 20 years after parental divorce found that most of the children experienced the remarriage of one or
both parents, and one third of her sample remembered the remarriage as
being more stressful than the divorce. Two thirds reported their father’s remarriage as more stressful than their mother’s.
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. Some major issues include
dealing with feelings of being outsiders versus insiders, addressing boundary
disputes and power issues, handling conflicting loyalties, reducing rigid unproductive triangles, and unifying the couple relationship.
We have found the tips offered by Visher and Visher (stepparents themselves)
particularly helpful in our work with stepfamilies (www.smartmarriages.com/
stepfamily.tips.html). If a child is diagnosed with a potentially life-shortening
disease, such as cancer, then the shifting family boundaries after the diagnosis
require particular attention in stepfamilies. The work of Kelly and Ganong
(2011) points to the reinforcing that takes place in the biological family

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Chapter 3: The Calgary Family Assessment Model 117

boundary and the stress in the stepfamily boundaries as one area for healthcare attention and possible intervention.
Attachment theory is a useful framework for conceptualizing the impact
of structural change and loss on stepfamily adjustment. We think of the stepfamily as an emerging family system; problem patterns are understood in
this context where bids for connection may be missed or misinterpreted. We
believe nurses can assist stepfamilies in increasing emotional connectivity
and stability. If stepcouples have irresolvable problems, use extreme language, and persist with pervasive chronic problems, then we encourage
nurses to consider whether attachment injuries are present and need intervention (Sayre, McCollum, & Spring, 2010). In many cases, parental guilt
and concerns about the children are increased, and a positive or negative
rearousal of the old attachment to the ex-spouse may occur (McGoldrick
& Carter, 2011). Box 3–4 summarizes McGoldrick and Carter’s (2011) developmental outline for stepfamily formation.
Having been angered by a predominant emphasis on pathology in the
divorce literature, Ahrons (2001) conducted a study over 21 years of what
she calls “binuclear families.” This term refers to joint-custody families or
to families in which the relationship between ex-spouses is friendly, and it
also indicates a different familial structure, without inferring anything
about the nature or quality of the ex-spouses’ relationship. Ahrons and
Rodgers (1987), who worked with 98 divorced couples over a 5-year period, produced some interesting relationship types, including “perfect
pals,” a small group of divorced spouses whose previous marriage had not
overshadowed their long-standing friendship. The second group, “cooperative colleagues,” was a considerably larger and more typical group found
by Ahrons and Rodgers. Although not good friends, they worked well together on issues concerning their children. The third group was the “angry
associates,” and the fourth group was “fiery foes,” who felt nothing but
fury for their ex-spouses. Ahrons and Rodgers termed the fifth group “dissolved duos,” who after the separation or divorce discontinued any contact
with each other. Ahrons (2001) advocates for a normative process model
of divorce rather than focusing on evidence of pathology or dysfunction.
We agree with this stance, being mindful that approximately 25% of children involved in divorce do seem to have longer-lasting adjustment difficulties (Greene, et al, 2003).
We encourage nurses working with divorced and remarried families to
bring to their patients research and clinical knowledge of what works and
does not work to foster continuing family relationships. However, nurses
should be cautious, 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.

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118 Nurses and Families: A Guide to Family Assessment and Intervention

We also encourage nurses working with stepfamilies to increase their
knowledge about stepfamily issues and respect the uniqueness of complex
stepfamily life. Ganong (2011), for example, has conducted almost 20 studies
looking at how marital transitions affect family caregiving responsibilities and
whether beliefs about obligation to relatives are based on family structure,
family membership, or other contextual factors. He found that adult stepchildren and stepparents agreed that stepchildren have few obligations to assist
stepparents. However, the key in deciding whether there was a responsibility
to assist was how the relationship was defined. Nurses could assist stepfamilies to discuss topics such as these. 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 Cycles
The family life cycle of the poor commonly does not match the middle-class
paradigm so often used to conceptualize their situations. Anderson (2003)
points out that when poverty is factored out, the differences between the
adjustment of children in one- and two-parent families almost disappear.
Low-income single parents who are also minorities face special issues. Currently, close to 75% of all single-parent families are minorities (Anderson,
2003). The family life cycle of the poor can be divided into three phases: the
unattached young adult (perhaps younger than 12 years old), who is virtually
unaccountable to any adults; families with children—a phase occupying most
of the life span and including three- and four-generational households; and
the final phase of the grandmother who continues to be involved in central
childrearing in her senior years. 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. We
think of adoption as providing children with security and meeting their

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Chapter 3: The Calgary Family Assessment Model 119

developmental and biopsychosocial-spiritual needs through the legal transfer of ongoing parental responsibilities from the birth parents to the adoptive parents. In doing this, we recognize the creation of a new kinship
network that forever links these two families through the child.
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. Multiple statistical systems make it
difficult to find concrete data on the number of children adopted each year.
About 2% of all U.S. children were adopted according to a National Survey
of Adoptive Parents (2007). Of the 1.8 million adopted children in the United
States, 37% were adopted from foster care, 38% joined their families
through private domestic adoptions, and 25% were adopted internationally.
The survey excluded stepparent adoptions.
In their study of 20 families who adopted children from Russian and
Romanian institutions, Linville and Lyness (2007) reported that the families
described having gone through a metamorphosis particularly in the areas of
roles, emotional strain, parenting techniques, resilience, and connection to
the children’s country of origin. They suggest, and we agree, that the way
the story of international or cross-cultural adoption is told and retold in the
family can have lasting positive or negative consequences for the child’s adjustment and emotional well-being. This is an area in which nurses can have
a tremendous positive impact in assisting families.
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 and 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. Clark, Thigpen, and Yates’s
study (2006) of 11 families who reported having successfully integrated into

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120 Nurses and Families: A Guide to Family Assessment and Intervention

their family unit at least one older/special needs adoptive child poignantly
shows the process these families underwent. Parental perceptions that facilitated the successful process included finding strengths in the children overlooked by previous caregivers, viewing behavior in context, reframing negative
behavior, and attributing improvement in behavior to parenting efforts.
In our clinical work with adoptive families, we have found it useful to
consider many aspects of the adoption, including:
1. Genetic, hereditary factors in the child
2. Deficiencies in the child’s prenatal and perinatal care
3. Adverse circumstances of adoption, including the child’s having had
multiple disruptions in early life, such as foster care placements
4. Conditions in the adoptive home, including preexisting and current
family resiliencies, problems, and strengths
5. Temperamental similarities and differences between the adoptee and
the adoptive parents or family
6. Fantasy system and communication regarding adoption, including
parental attitudes about adoption
7. Difficulties establishing a firm sense of identity during adolescence
8. 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. For example, adopted children in the 2007 U.S. survey of adoptive
parents were found to be less likely than children in the general population
to excel in reading or math, but family relationship quality between children
and parents was more comparable between the groups. The exception is children adopted from foster care, who do show lower relationship quality than
other adopted children for some indicators, and also seem to account for
much of the difference between adopted children and children generally in
school performance (Bramlett, 2011).
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 if there
has not been ongoing contact with the biological parents.

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Chapter 3: The Calgary Family Assessment Model 121

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, Intersexed, Transgendered,
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, their structures, developmental life cycles, challenges,
strengths, and issues. Long and Andrews (2007) point out that for samesex couples, the family functions of formation and membership, nurturance
and socialization, and protection of vulnerable members are particularly
important. We believe that the popular family life cycle model does 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. For example, the term girlfriend does not connote
the significance of the relationship.
However, we believe 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 example, Shernoff (2006) points out—and we agree—that male couples
need to negotiate their views on monogamy. 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.

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122 Nurses and Families: A Guide to Family Assessment and Intervention

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 homosexual 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. Sample issues unique to parenting by lesbian and
gay couples include the limited options available for getting pregnant by such
means as artificial insemination owing to biases by fertility clinics, difficulties
with health insurance, the reaction of the family of origin and relatives to
the news about parenting, and the often blurred role of the nonbiological
parent (Ashton, 2011).
During middle 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. For nurses working with
these couples, some questions that might be useful to ask include:
■ 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 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

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Chapter 3: The Calgary Family Assessment Model 123

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, the couple childfree by choice 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 and expressive. Each will be dealt with separately.

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. A quadriplegic, for example, 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 example, 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, e-mail, text, 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. Denham’s 2011 work and the Web
site www.diabetesfamily.net are some creative examples of influencing the
family’s situation and their active behavioral response to the illness.
Buchbinder, Longhofer, and McCue (2009) found that families with young
children (ages 2–9) adjusting to life when a parent has been diagnosed with
cancer initially focused on disruptions in caregiving routines and changes in
rituals such as birthdays and holidays. Developing and stabilizing new routines and rituals were important positive coping mechanisms for them to
maintain a sense of normalcy. 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

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124 Nurses and Families: A Guide to Family Assessment and Intervention

children and the cancer patients themselves. The importance of family nursing care is thus highlighted.
As the nurse inquires into the ordinary routines that families living alongside illness have developed, 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 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:
1. Emotional communication
2. Verbal communication
3. Nonverbal communication
4. Circular communication
5. Problem solving
6. Roles
7. Influence and power
8. Beliefs
9. 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. A more recent study by Aarons and colleagues (2007) noted that the Family Assessment Device is less applicable
for Hispanic Americans than for Caucasian Americans. They suggest, for example, that Hispanic American families often operate according to more stable hierarchical roles, more often encourage the avoidance of interpersonal
conflict, and more often stress family collectivism compared to Caucasian
American families. The importance of cultural variability is highlighted.
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 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.

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Chapter 3: The Calgary Family Assessment Model 125

Before discussing each subcategory, we would like to point out that most
families must deal with a combination of instrumental and expressive issues.
For example, when an older woman experiences a burn, the instrumental issues revolve around dressing changes and an exercise program while 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?
■ How can we get Jasdev 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 family have a
conversation about family functioning. Robinson (1998) points out the importance of nurses attending to what she calls “illness work” and “illness
burden.” Making arrangements for managing chronic or life-threatening illness does not just happen. The ordinary context of women generally shouldering the larger burden of housework than men do is the one in which
additional illness arrangements are made.
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 the nurse and the 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 strengths, resources, and 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.
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 risk focusing too narrowly on

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126 Nurses and Families: A Guide to Family Assessment and Intervention

small, rather tight, recursive feedback loops. We have found this to be especially important since we have witnessed 9/11, random acts of terrorism, and
mass slayings at schools and universities, and we and families have struggled
to adapt to a changed social and political context.
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 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, valid, but 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 in the context of illness, loss, or disability 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.
The feelings of subjective well-being are usually unrelated to socioeconomic status, income, levels of education, gender, or race. Rather, they are
related to the genetic lottery and fortune’s favors, good or bad. The influence
of biology on emotional communication is an intriguing developing area,
and families will no doubt have many beliefs about this.
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

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Chapter 3: The Calgary Family Assessment Model 127

do you think your parents would react? When your brother Hiesem 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 shots 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 you rent, 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 a smartphone? By e-mail? Through texting or Twitter?
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. For example, in Taiwanese Chinese couples, indirect, nonverbal means of communicating and relating serve a positive function but
can be viewed among Euro-Caucasian groups in the United States as an indicator of intrusiveness or overinvolvement. Gestures such as hand signs,
shrugs, and posture shifts can be specific to different cultures, and as many
as 200 of these gestures may exist among all cultures.
Nurses should note the sequence of nonverbal messages as well as their timing. For example, when an older man starts to talk about his terminal illness

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128 Nurses and Families: A Guide to Family Assessment and Intervention

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. Her 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, do you think she might move closer to him?
Circular Communication

Circular communication refers to reciprocal communication between people
(Watzlawick, Beavin, & Jackson, 1967). A particular interactional 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.
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 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.
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. “The inference is entered
inside the enclosure and represents some internal process (what is going on

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Chapter 3: The Calgary Family Assessment Model 129
Performs Well

Senior

Adult Son
Adequate

“My father is very capable”

“My son has confidence in me”

Proud

Praises

F I GU R E 3- 18: Adaptive circular pattern diagram.

Behavior

Inference

Inference

(cognition or affect or both)

(cognition or affect or both)

Behavior

F I GU R E 3- 19: Basic elements of a CPD.

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”
(Tomm, 1980, 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.

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130 Nurses and Families: A Guide to Family Assessment and Intervention

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. Circularity has
been criticized 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. Fekete and colleagues (2007) point
out the importance of circularity in their study of 243 women experiencing
lupus flare-ups and their husbands. They found that more spousal emotional
(empathic) support was interpreted as the husband’s being more emotionally
responsive, which in turn was associated with the wife’s greater sense of wellbeing. In contrast, more problematic (minimizing) spousal support was interpreted as the husband’s being less emotionally responsive, which in turn was
associated with the wife’s poorer sense of well-being. These findings have
large implications for helping couples adjust and cope with chronic illness.
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 so sustains and supports him. This leads him to trust her more, and the
relationship progresses.
Sample Conversation With the Family

Nurse: You say your wife “always” criticizes you. (Nurse
conceptualizes Fig. 3–22.) What do you do then? (Nurse
tries to fill in the husband’s behavior in Fig. 3–23.)
Husband: 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.
Blames/Threatens

Anger

Anger

Blames/Threatens

F I GU R E 3- 20: CPD of a circular argument.

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Chapter 3: The Calgary Family Assessment Model 131
Sustains/Supports

“She cares
about me”

Concern
“He’s upset”

Trusts

Expresses his needs/fears

F I GU R E 3- 21: CPD of a supportive relationship.
Criticizes

?

?

?

F I GU R E 3- 22: Beginning conceptualization of CPD.
Criticizes

?

?

Avoids/Ignores

F I GU R E 3- 23: CPD illustrating husband’s and wife’s behaviors.

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132 Nurses and Families: A Guide to Family Assessment and Intervention

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 Fig. 3–24.)
Wife: 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?
Wife: Well, I don’t really criticize. I just—
Husband: 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 Fig. 3–24.)
Wife: I don’t know.
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?
Wife: 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 the other room. Other times he avoids issues,
and this arouses your frustration and criticism. (Nurse explains Fig. 3–25.)
Wife: It’s a vicious circle.
Husband: I don’t want it to go on this way anymore. We
both get too upset.
Once the nurse has elicited a CPD, he or she should ask the family members to contextualize their discussion. One context might be that the wife is
Criticizes

Annoyed

?

Avoids/Ignores

F IGU R E 3- 24: CPD illustrating wife’s emotion.

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Chapter 3: The Calgary Family Assessment Model 133
Criticizes

Frustration

Frustration

Avoids/Ignores

F I GU R E 3- 25: Nurse’s conceptualization of this couple’s communication pattern.

exhausted by her factory job and all the housework and childcare. The husband 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.
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 (i.e., routine
day-to-day logistics) or emotional problems? Families sometimes encounter
difficulties when they identify an emotional problem as an instrumental one.
For example, 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?
What are the family’s solution patterns? Are they proactive in planning
for issues that might arise? For example, a couple dealing with the wife’s
myeloma might decide to harvest stem cells as a proactive measure. Many
close-knit extended families rely on relatives for assistance in time of need.
Others tend to seek help from professionals while others go to the Internet
for information and/or support. 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. For example, older parents
move to a retirement community. The wife breaks her hip. The husband is

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134 Nurses and Families: A Guide to Family Assessment and Intervention

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 his wife’s care despite the fact that he is losing weight
and getting insufficient rest. The husband’s solution conflicts with that of
the nurse.
Knowing whether a family evaluates the cost of its solutions can be helpful
to the nurse. For example, a 68-year-old grandmother tells Kiran, the nurse,
“I can’t afford to let myself cry about the death of my son’s infant. I have to
go on for the sake of my other children.” Kiran was able to evaluate with
the grandmother the cost of her solution pattern. Neither the grandmother
nor the son discussed the infant’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 with his 4-yearold boy (the only surviving male child). By gently exploring the cost of the
solution (tension and overprotection), the nurse was able to suggest other
solution patterns (e.g., shared grieving).
Holtslander and colleagues (2011) have offered a helpful idea for nurses
to use in exploring problem solving solutions. They found that older persons
bereaved after caregiving for a spouse with advanced cancer walked a fine
line in finding balance between deep grieving and moving forward. We support the notion of asking familiy members about how they find balance in
their solutions.
DeJong and Berg (2008) offer many intriguing ideas for interviewing for
solutions, such as at the start of a second or third meeting, the clinician can
immediately ask clients, “What’s better?” This question reflects the notion
that clients are competent to have taken steps to progress in the direction
they have said they want.
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? Does it usually seem “the punishment fits
the crime” in your family? When your brother is punished, does it usually
seem he deserves it?
Roles

This subcategory refers to the established patterns of behavior for family
members. A role is consistent behavior in a particular situation. However,

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roles 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 some Hispanic families, for example, machismo can be very
significant for the hierarchical male role, and simpatia or the avoidance of
conflict and the ability to get along well, can be often highly valued. That
women have a life cycle apart from their roles as wife and mother is a relatively recent one and is still not widely accepted in our culture. The expectation for women has typically been that they would take care of the needs of
others, first men, then children, then the older generation.
The psychological cost of providing care for a parent with Alzheimer’s
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. Nevertheless,
on average, women still make less than men do for the same job. 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. 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. The
findings from a study (Stein, Rotheram-Borus, & Lester, 2007) of adolescents
whose parents had HIV/AIDS show that there can be positive effects to what
typically might be perceived as a negative role of a “parentified adolescent.”
Early parentification predicted better adaptive coping skills and less alcohol
and tobacco use 6 years later. The authors hypothesized that parentification

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136 Nurses and Families: A Guide to Family Assessment and Intervention

skills were adaptive in the long run, especially with adolescents who had dying
or ill parents, impoverished environments, and family instability.
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 compete,
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? Who would your
children say is the “favored” child in your family?
Influence and Power

This subcategory refers to behavior used by one person to 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
a hierarchical relationship, the needs of the dominant person take precedence
while the subordinate person stifles his or her own thoughts and feelings. In

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a more equal relationship, there is a give-and-take negotiation of individual
needs, goals, and desires.
Gender, race, and cultural issues are frequently intermingled with influence
and 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 influence, 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. We encourage nurses to discuss with family
members areas of power and influence such as decision making about illness
management, work, life goals and activities, housework, finances, and sex.
How a family member attempts to influence another is important for their relationship and can have consequences for illness management as well. For example, Stephens and colleagues (2010) found that warning and encouragement
were two types of negative and positive control strategies used by spouses to
urge patients with type 2 diabetes to improve adherence to the diabetic diet.
Warning consisted of the spouse emphasizing diabetic complications, demanding dietary adherence, and expressing doubts or concerns. Encouragement, on
the other hand, consisted of suggesting alternative healthy foods and complimenting dietary management. Spousal encouragement was significantly and
positively associated with patients’ reports of dietary adherence.
Miller (2009) noted that even in inherently unequal relationships such
as parent-child, there is significant value in collaborative decision making
for the management of chronic illness. Asking for other’s opinion and sharing information were two factors Miller noted as contributing to beneficial
collaboration.
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, Gerson, and Petry (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

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138 Nurses and Families: A Guide to Family Assessment and Intervention

3. Using children, being abusive, controlling, guilt-inducing or underresponsible 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; etc.) 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.
We have found the most important positive predictors of compliance for
children is 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 Nirmala

to take her medication? When Delvecchio dominates the conversation, what
effect does that have on Jamilett? 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 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.

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Families coevolve 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 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 to managing an illness (Wright & Bell, 2009).
It is usually not our actual beliefs that cause suffering but believing that
they are true without any self-inquiry. Therefore, when family members express frustration, anxiety, or anger about their illness based on a particular
belief, nurses can gently nudge constraining beliefs by simply asking, “Is that
true?” followed by “Can you absolutely know that it is true?” (Katie, 2003).
Of course, these questions must be asked with a truly genuine, caring, and
inquisitive tone so as not to sound insincere or sarcastic.
Which illness beliefs are considered to be constraining or facilitating is determined by the clinical judgment of the nurse in collaboration with the family.
However, any healing transaction involves at least three sets of beliefs: those
of the ill patient, those of other family members, and those of the nurse (Bell
& Wright, 2011; Duhamel & Dupuis, 2003; Hougher Limacher & Wright,
2006; James, Andershed, & Ternestedt, 2007; Marshall, Bell, & Moules, 2010;
Moules, 1998; Moules, Thirsk, & Bell, 2006; Watson & Lee, 1993; West,
2011; Wright & Bell, 2009; Wright & Nagy, 1993; Wright & Simpson, 1991;
Wright & Watson, 1988). Cousins (1979) offered the poignant idea that what
we believe is the most powerful option of all.
Beliefs and behavior 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 lifethreatening 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 (e.g., 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. For example, the meaning of pregnancy loss is intricately intertwined
with the woman’s emotional needs at the time of the loss. If a mother were
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.
In another example, 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

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140 Nurses and Families: A Guide to Family Assessment and Intervention

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 3–5 provides a
list of areas for nurses to explore when assessing family beliefs about the health
problem.
Questions to Ask the Family. How do you react when you believe that
thought? 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

Box 3-5

Beliefs About the Health Problem

A. Beliefs about:
1. Diagnosis
2. Etiology
3. Prognosis
4. Healing and treatment
5. Mastery, control, and influence
6. Religion and spirituality
7. Place of illness in lives and relationships
8. Role of family members
9. Role of health-care professionals
B. Influence of the family on the health problem
1. Resource utilization
• Internal (to family)
• External
2. Medication and treatment
C. Influence of the health problem on the family
1. Client response to the illness
2. Family members’ responses to illness
3. 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.

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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 war injuries? What do you
believe has been the most useful thing health professionals have offered to
help you cope with your suffering from PTSD? What has been the least
helpful? Have any of your Buddhist beliefs helped you to cope with the tragic
loss of your son in Afghanistan?
For a more in-depth reading of the interconnection of the illness beliefs
of patients, families, and health-care providers, see Beliefs and Illness: A
Model for Healing, written by Lorraine M. Wright and Janice M. Bell (2009).
Their advanced practice approach, the Illness Beliefs Model, is also offered
in their book. Refer to their Web site for more information about the model:
www.illnessbeliefsmodel.com.
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 threeperson 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
wars, 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 may help

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142 Nurses and Families: A Guide to Family Assessment and Intervention

with some types of pain 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 is 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 coparenting 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 coparenting 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,

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Chapter 3: The Calgary Family Assessment Model 143

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 imply an alignment between
two members with a third member being split off or opposed.
Questions to Ask the Family. When Demi and Tyson 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?

CONCLUSIONS
The CFAM, although a very comprehensive and inclusive family assessment
model, need not be overwhelming if viewed as a “map of the family” from
the nurse’s and the family’s observer perspectives. The model provides a
framework that can be drawn on as the nurse and the family discuss and collaborate about the issues. The nurse can use three main categories (structural,
developmental, and functional) to obtain a macroassessment of family
strengths, resources, problems, and/or suffering. Depending on his or her confidence and competence level, the nurse may also do a microassessment and
explore in detail specific areas of family functioning. In either situation, the
nurse needs to be able to draw together all relevant information into an integrated assessment. In doing this, the nurse synthesizes information and is not
stymied by complexity. It is insufficient to focus on a family’s difficulties with
problem solving when the specific family structure is unknown. Also, if the
nurse focuses too much on previous developmental history, he or she may be
ignoring important current functioning issues. Naturally, past history cannot
be ignored. It should be integrated, however, only insofar as it helps to explain
current functioning and not because of history taking for history’s sake.
Once a thorough family assessment has been completed, the nurse and
the family may now collaborate to determine whether intervention is needed.
However, we wish to emphasize that completing a family assessment utilizing
CFAM does not mean that the nurse or the family now has the “truth” about
the family’s functioning related to a health problem or concern. Rather, the
nurse and family members each have their own integrated assessment from
their own “observer perspectives” at one point in time.
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Chapter

4

The Calgary Family
Intervention Model
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. The importance and effectiveness of family interventions in
health care in the treatment of physical illness is receiving much more
recognition in the last few years (Campbell, 2003; Chesla, 2010). 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 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). Another example
is Rungreangkulkij and Gilliss’s (2000) use of the Family Resiliency
Model for the study of families that have a member with a severe and
persistent mental illness.
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 heartening to
note that Gottlieb (2012) has devoted an entire book to the importance of
focusing on strengths in nursing care.
Of course, the interventions offered should depend on the nurse’s scope
of practice, degree of independence, autonomy, and responsibility associated
with his or her role in family care (Schober & Affara, 2001). Nursing care
may range from “delegated tasks such as wound care in the home, to complex assessment and curative management in health centres and clinics”
(Schober & Affara, 2001, p. 23).

151

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152 Nurses and Families: A Guide to Family Assessment and Intervention

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 (Fig. 4–1). The elements of the CFIM are
interventions, domains of family functioning, and “fit” or meshing (i.e., effectiveness). The CFIM visually portrays the fit or meshing between a domain
of family functioning and a nursing intervention—that is, it answers the 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, and 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 & 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 in beneficial outcomes. Families are
more open to the ideas offered by a nurse when it is in the context of collaborative interaction (e.g., inviting, asking, encouraging, supporting)
rather than instructive interaction (e.g., instructing, directing, lecturing,
demanding).

Interventions Offered by Nurse
Cognitive
Domains of
Family Functioning

Affective

"Fit" or effectiveness

Behavioral

F I GU R E 4-1: CFIM: Intersection of domains of family functioning and interventions.

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Chapter 4: The Calgary Family Intervention Model 153

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 (Bohn, Wright, & Moules,
2003; Duhamel & Talbot, 2004; Houger Limacher & Wright, 2003, 2006;
Leahey & Harper-Jaques, 1996; Legrow & Rossen, 2005; McLeod &
Wright, 2008; Moules, 2002; Moules, et al, 2004, 2007; Robinson &
Wright, 1995; Sveinbjarnardottir, Svavarsdottir, & Saveman, 2011; Tapp,
2001; Thorne & Robinson, 1989) 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. 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. We provide examples
of interventions that we have found from our clinical practice and research
(Shields, et al, 2012) to be very useful. The interventions that we cite are
based on several important theoretical foundations: postmodernism, systems
theory, cybernetics, communication theory, change theory, and 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. Through therapeutic conversations, the family and nurse collaborate
and coevolve to discover the most useful fit (Bell & Wright, 2011; Duhamel
& Dupuis, 2004; Holtslander, 2005; McLeod & Wright, 2008; Moules,
et al, 2004, 2007, 2009; Wright & Bell, 2009).

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154 Nurses and Families: A Guide to Family Assessment and Intervention

We use the qualitative terms fit or meshing to emphasize whether or not
the interventions effect change and/or soften 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).

Linear Versus Circular Questions
Interventive questions are usually of two types: linear and circular (Tomm,
1987, 1988). 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 are investigative; they explore a family member’s descriptions or perceptions of a problem. For 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?” or “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 families’ problems,
whereas circular questions reveal families’ understanding of problems.
Circular questions aim to reveal explanations of problems. For example,
with the same family, the nurse could ask, “Who in the family is most worried about Cheyenne’s anorexia?” or “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, 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

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Chapter 4: The Calgary Family Intervention Model 155

the “sin of certainty” or objectivity without parentheses (Maturana & Varela,
1992) (see Chapter 2). 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, et al, 1980; Tomm, 1984, 1985, 1987)
(see Chapters 6, 7, 8, and 10).
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 (Keeney &
Keeney, 2012). 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 softens 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. Loos and
Bell (1990) creatively applied the use of circular questions to critical care
nursing. Wright and Bell (2009) demonstrated the therapeutic aspect of circular questions with families experiencing chronic illness, life-threatening illness, and psychosocial problems. 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).
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 difference questions, behavioral-effect questions, and hypothetical or future-oriented questions. 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 (Box 4–1).

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156 Nurses and Families: A Guide to Family Assessment and Intervention

Box 4-1

Circular Questions to Invite Change in Cognitive, Affective,
and Behavioral Domains of Family Functioning

1. Type: Difference Question
Definition: Explores differences between people, relationships, time, ideas, or beliefs.
Examples of intervening in three domains of family functioning:
Cognitive
Affective
Behavioral
• What is the best advice that • Who in the family is most • Who in the family is best
worried about how AIDS is at getting your son to
you have received about
take his medication
managing your son’s AIDS? transmitted?
on time?
• What is the worst advice?
• What information would be • Who finds your disclosure • When you first disclosed
of sexual abuse most
your sexual abuse, what
most helpful to you about
difficult?
actions by professionals
managing the effects of
were most helpful?
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. Examples
of intervening in three domains of family functioning:
Cognitive
Affective
• How do you make sense
• What do you feel when
of your husband not visiting you see your son crying
your son in the hospital?
after his treatments?
• What do you know about
• How does your mother
the effect of life-threatening show that she is afraid
illness on children?
of dying?

Behavioral
• What do you do when
your husband does not
visit your son in the
hospital?
• 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.
Examples of intervening in three domains of family functioning:
Cognitive
Affective
Behavioral
• What do you think will happen • If your son’s skin grafts are • How much longer do
you think it will be benot successful, what do
if these skin grafts continue
fore your son engages
you think his mood will
to be so painful for your son?
in treatment for his
be? Sad? Angry? Resigned?
contractures?
• How long do you think
• If your grandmother’s
• If the worst occurs, how do
your grandmother will
you think your family will cope? treatment does not go
have to remain in the
well, who will be most
hospital?
affected?
• If she stays longer,
• If you decide to have your
what new self-care
grandmother institutionalized,
behaviors will she be
with whom would you discuss
doing?
the decision?

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Chapter 4: The Calgary Family Intervention Model 157

We have also produced a DVD to demonstrate the use of questions
in actual clinical practice as part of the “How to” Family Nursing Series.
It is titled How to Use Questions in Family Interviewing (Wright & Leahey,
2006). This educational program demonstrates the use of interventive
questions in actual clinical interviews. To learn more about this DVD or
to view a sample video vignette, visit Family Nursing Resources at
www.familynursingresources.com.
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 wish to
strongly emphasize that the effectiveness, usefulness, and fit of the question,
rather than the specific question itself, are most critical in effecting change.

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:
■ 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

Interventions Offered by Nurse:
Circular Questions
Difference

Behavioral
Effect

Hypothetical

Cognitive
Domains of
Family Functioning

Affective
Behavioral

F I GU R E 4-2: Intersection of circular questions and domains of family functioning.

Triadic

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158 Nurses and Families: A Guide to Family Assessment and Intervention

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
(Fig. 4–3).
The following section describes each intervention and offers a case example
illustrating its application. We have chosen to cluster 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.

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.

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 (e.g., “Your family members are very loyal to one another”),
whereas a compliment is usually an observation of a one-time event (e.g.,
“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. In
many cases, families coping with health problems have not been commended

Intervention:
Offering Information
Cognitive
Domains of
Family Functioning

Affective
Behavioral

F I GU R E 4-3: Intersection of intervention (offering information) and domains of family
functioning.

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Chapter 4: The Calgary Family Intervention Model 159

for their strengths or made aware of them (McElheran & Harper-Jaques,
1994). We choose to emphasize strengths and resilience rather than deficits,
dysfunctions, and deficiencies in family members.
Immediate and long-term positive reactions to commendations indicate
that they are effective therapeutic interventions (Bohn, Wright, & Moules,
2003; Houger Limacher, 2008; Houger Limacher & Wright, 2003, 2006;
McLeod & Wright, 2008; Moules, 2002, 2009; Moules & Johnstone, 2010;
Wright & Bell, 2009). Robinson (1998) offers further credence to this belief
with her study that explored the processes and outcomes of nursing interventions with families suffering from chronic illness. The families in
this study reported the clinical nursing team’s “orientation to strengths,
resources, and possibilities to be an extremely important facet of the process”
(Robinson, 1998, p. 284). Focusing on strengths was most significant
and influential for the women in these families. In addition, families who
internalize commendations offered by nurses appear more receptive to other
therapeutic interventions that are offered.
Another fluent and moving piece of research focused on the commendation interventions offered in practice at the Family Nursing Unit of the
University of Calgary. Both families and nurses reported and reiterated the
value and power of commendations that brought forth “goodness” that
helped soften suffering (Houger Limacher, 2008; Houger Limacher &
Wright, 2003, 2006). This bringing forth of “goodness” becomes a relational phenomenon in the context of the nurse-patient and nurse-family
relationship. The routine practice by nurses of commending family and
individual strengths is a particular way of being in clinical practice. This
notion is best exemplified in the following quote: “We become our conversations and we generate the conversations that we become” (Maturana &
Varela, 1992).
In one family, 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. Offering commendations is a skill that both nonprofessionals and professionals can hone. Hughes, Kay-Raining Bird, and
Sommerfeld (2011) found that parents reported peer home visitors were
better able to celebrate and enable families after training. Changing the view
families have of themselves frequently enables families to view the health
problem differently and thus move toward solutions that are more effective.
Box 4–2 suggests helpful hints for offering interventions.

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160 Nurses and Families: A Guide to Family Assessment and Intervention

Box 4-2

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., 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:
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. The core utility of access to information, skill building, problem solving, and social support cannot be overestimated (Lucksted,
McFarlane, Downing, et al, 2012). Families most desire information about
developmental issues, health promotion, and illness management (Levac,
Wright, & Leahey, 2002; Robinson, 1998). For example, helping parents to
understand and help their children is a common but important intervention
for families (Levac, Wright, & Leahey, 2002). Nurses can teach families
about normal physiological, emotional, and cognitive characteristics and can
identify developmental tasks or goals of children and adolescents that can
be affected or altered during times of illness (Manassis & Levac, 2004). One
family found it useful when the nurse explained that siblings of children experiencing life-shortening illnesses commonly develop symptoms due to feeling lonely because parents are intently focused on their ill child. Box 4–3
suggests helpful hints for offering information and opinions.
Families with a hospitalized member have indicated 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. They can also empower families to
obtain information about resources. We have learned that this latter
approach is even more useful in some circumstances. Offering educational
information is an “essential intervention as it reassured family members
about certain aspects of the illness and reduced their level of stress”
(Duhamel & Talbot, 2004, p. 24).
One complex clinical example concerns a family of two aging parents and
their 34-year-old son, who had severe multiple sclerosis. The parents were

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Chapter 4: The Calgary Family Intervention Model 161

Box 4-3

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.
• 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:
Mosby, p. 13. Reprinted by permission.

constant, devoted caregivers but had 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 case example, the nurse offered an opinion that empowered
the son to change his cognitive set. The intervention fit the cognitive domain,
and results took place in the affective and behavioral domains of family
functioning.

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.

Validating, Acknowledging, or Normalizing
Emotional Responses
Validation or acknowledgment of intense affect can reduce or cushion feelings
of isolation and loneliness, soften suffering, and help family members to make

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162 Nurses and Families: A Guide to Family Assessment and Intervention

the connection between a family member’s illness and their emotional response
(Wright, 2008). For example, after diagnosis of a life-shortening illness, families
frequently feel out of control or frightened for a period. It is important for
nurses to acknowledge these strong emotions and to reassure and offer hope
to families that in time they will adjust and learn new ways to cope. In one clinical example, the nurse normalized changes in sexuality following a couple’s
experience with a cardiac condition. As a result, the wife reported, “I felt
that the question regarding our sexuality was well put, because [the nurse]
applied it to couples in general. The fact that others are going through the same
experience, well I thought it was good to know. It is a very personal and private
question, and you presented it well” (Duhamel & Talbot, 2004, p. 25).

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 (Tapp, 2001; Wright & Bell, 2009).
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.
Duhamel and Talbot’s (2004) study, which utilized the CFIM and this particular intervention, found that nurses agreed about the importance of
encouraging family members to share their experiences of cardiac illness
during and after the hospitalization period. Also, family members commented that through these types of clinical sessions, they were able to vent
emotions, which provided tremendous relief from suffering, healed psychological wounds, and enabled family members to acknowledge one another’s
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 if a family member is embracing some
constraining beliefs when a loved one is dying or has died (Moules, et al, 2004,

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Chapter 4: The Calgary Family Intervention Model 163

2007; Moules, Thirsk, & Bell, 2006; Wright & Nagy, 1993). By fostering
opportunities for family members to express feelings about this painful 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
sessions. 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.

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 (Ducharme, 2011). In an informative study about grandparents’ experience of childhood cancer, 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. LeNavenec and Vonhof (1996) offer the notion of “one day at
a time” as a useful coping strategy for families with a member experiencing
dementia. We encourage nurses to weigh with family members the ethical,
emotional, and physical balance between too much caregiving and not
enough caregiving.

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164 Nurses and Families: A Guide to Family Assessment and Intervention

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, especially 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. For example, one way to balance needs is to recommend that a family buy a less expensive prosthesis
and use the extra money for a family vacation. Another example of encouraging respite is to recommend that a mother and father with a
leukemic child have the grandparents babysit for a day while the couple
spends time together. Such “time-outs” or “times away” are essential for
families facing excessive caregiving demands.

Devising Rituals
Families engage in many types of rituals: daily (e.g., bedtime reading), yearly
(e.g., Thanksgiving dinner at Grandma’s), and cultural (e.g., ethnic parades).
Nurses can suggest therapeutic rituals that are not or have not been observed
by the family. Roberts (2003a) 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).

Nurses are also contributing to the literature about rituals, as evidenced
by a very comprehensive piece about rituals, routines, recreation, and rules
by Fomby (2004). She emphasizes the use of family rituals for health
promotion and claims the following benefits: cohesiveness among family
members, a sense of family pride, continuity, understanding, closeness,
and love.
In our clinical practice, we have observed that chronic illness and
psychosocial problems frequently interrupt the usual rituals. Roberts
(2003b) offers a poignant narrative of her experience with cancer and describes how rituals can “mark the path” of healing when a devastating
illness emerges. Rituals are best introduced when there is an excessive level

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Chapter 4: The Calgary Family Intervention Model 165

of confusion, and they can provide clarity in a family system. Designing and
implementing rituals for new life-cycle transitions can be a helpful intervention offered by the nurse. Imber-Black (2010) suggests “since rituals have
the capacity to hold and express differences rather than homogenize them,
they are particularly powerful resources for any life cycle transition that
differs from the conventional” (p. 439). For example, parents in a new
stepfamily 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 (SelviniPalazzoli, 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.
Another of our educational DVD programs that has been useful to assist
nurses in offering interventions is titled How to Intervene With Families With
Health Problems (Wright & Leahey, 2003). This educational program
demonstrates the use of particular interventions in actual clinical interviews.
To learn more about this DVD or to view a sample video vignette, go to
Family Nursing Resources at www.familynursingresources.com.

CLINICAL EXAMPLES
The following clinical examples illustrate the use of the CFIM. In these
real-life examples, 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, let us 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.

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166 Nurses and Families: A Guide to Family Assessment and Intervention

Domains of Family Functioning
Cognitive

Affective

Behavioral

Intervention: Offering Information and
Opinions
Offer a parenting book that explains what
bedtime means to children and suggests how
to put children to bed.
Inform the parents that it is important to admit
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 real
hard, dear; he’s a handful”).
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. Warn 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.

Clinical Example 2: Elderly Father Complains His Children
Do Not Visit Often Enough
Next, let us consider a clinical example that illustrates 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.
Parent-Child System Problem. An elderly father wants his adult children to
visit more often; the adult children do not enjoy visiting because their father
always complains that they do not visit often enough.
We believe very strongly that, in the examples noted in the table, 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

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Chapter 4: The Calgary Family Intervention Model 167

Domains of Family Functioning
Cognitive

Affective

Behavioral

Interventions: Encouraging Family
Members to Be Caregivers and Offering
Caregiver Support
Teach the adult children that their father is
having behavioral difficulty remembering their
visits (short-term memory deficits), a common
phenomenon of aging. Therefore, they need
not remind him of when they visited last.
Empathize with the father, for example, by saying that you understand that it must be lonely
at times being a resident in a geriatric care
center. The adult children might appreciate
knowing that their parent is lonely so that they
can respond appropriately. Therefore, advise
the father to avoid complaining to the children
and instead tell them how lonely he feels
sometimes and that he is happy that they
come to visit.
Advise 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.

problems do not occur overnight; therefore, their resolutions also require
reasonable lengths of time. Change can be observed, as Bateson (1972) states,
as “difference which occurs across time” (p. 452).

Clinical Example 3: Enuresis and Discipline
Problems With Child
To illustrate that change is observed over time, we now offer two more
actual case examples of clinical work, from beginning to end, with the
emphasis on the interventions that were used. In the first case, 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
eldest 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.

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168 Nurses and Families: A Guide to Family Assessment and Intervention

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, ages 8 and 6. 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.
In the first session, the graduate nursing student acknowledged that the
problems the family was experiencing were a usual part of the adjustment
process of stepfamilies. The intervention of offering information and opinions was directed at the cognitive area of family functioning. This new information seemed to relieve the parents a great deal. In addition, the student
gave advice by encouraging the parents to allow the children to have contact
with their biological mother when she again sought them out. Initially, the
parents were hesitant about this suggestion, 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.
Parent-Child Subsystem Problem. Maladaptive interactional pattern between
stepmother and eldest son (Fig. 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
eldest child, feared being abandoned again. Thus, the eldest 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. She encouraged
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.” This intervention of parent support and education was aimed at the
behavioral, affective, and cognitive domains of family functioning.
The behavioral task proved quite successful. 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. The nursing student also offered

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Chapter 4: The Calgary Family Intervention Model 169
DISQUALIFIES
(“You’re not my real mother”)

Fears Abandonment

Son
(Age 8)
“I could be left
alone again”

“I will never
be accepted
by him”

Stepmother

Feels Rejected

WITHDRAWS AFTER INITIAL
EFFORTS TO CONVINCE CHILD
OF CARING

F I GU R E 4-4: Circular pattern diagram.

commendations of family strengths (an intervention directed at the cognitive domain of family functioning) to the stepmother for her efforts to fulfill
her role, saying that she was an exceptionally warm and caring young
mother. The stepmother reported that she felt more relaxed in her parenting
after this intervention.
Individual Problem. Eldest 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 discussed the problem twice with the teacher
by telephone. The stepmother was also present during the session at school.
The main objective of the interventions was to enhance the eldest child’s
self-esteem by focusing on his positive behavior. The teacher agreed to implement an intervention focused at the behavioral domain of family functioning: to acknowledge the child’s positive behavior in front of his
classmates to give him a different status than “class clown.” The graduate
student also recommended that the stepmother minimize her contact with
the school and allow the teacher to assume more responsibility for the boy’s
behavior in class. Within a few weeks, the teacher reported a positive change
in the child’s behavior at school. The parents expressed great satisfaction
about their child’s improvement.
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.
It might seem that the interventions the graduate student chose in this
example were “simple.” However, we believe that, 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

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170 Nurses and Families: A Guide to Family Assessment and Intervention

for change. In both cases, we have found that 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 6 adult children (5 sons, ages 51, 48,
41, 37, and 35; and 1 daughter, age 44) and 12 grandchildren. Five of
the children were married, and all 6 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 for the past 4 years had been living alone in
a one-bedroom apartment. 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 student.

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Chapter 4: The Calgary Family Intervention Model 171

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 important 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 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!

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172 Nurses and Families: A Guide to Family Assessment and Intervention
■

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 (Bell, Moules, & Wright, 2009; Hougher Limacher &
Wright, 2006; Moules, 2002, 2003; Wright & Bell, 2009) to each of them.
This letter, written by the student and her faculty supervisor, is printed below
verbatim. It beautifully highlights the major interventions and again solicits
further assistance from the children. In addition, the student very nicely included some of the family strengths in the letter. Hopefully, the change
process in this particular family will continue to evolve long after this nursing
student’s termination of the therapeutic relationship with them.
Dear (real names omitted to preserve confidentiality):
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

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Chapter 4: The Calgary Family Intervention Model 173

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, 2002, 2003, 2009; White &
Epston, 1990; Wright & Bell, 2009). In addition, several interventions were
outlined in the letter. 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 exemplary
clinical work is a stellar example of effectively involving families in health
care by the use of family assessment and intervention models with clear
treatment goals by a student committed to improving family functioning
and softening suffering.

CONCLUSIONS
Interventions can be as straightforward and simple or as innovative and
dramatic as the nurse deems necessary for the health or illness problems presented. It also depends on the depth and intensity of possible constraining
beliefs that are inviting undue suffering. Interventions intended to promote
health and manage illness should be based on the assumption that individual
health behaviors are strongly influenced by those around us and that family
general well-being can promote the physical health of its members. All

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174 Nurses and Families: A Guide to Family Assessment and Intervention

interventions should be directed toward the healing and treatment goals
collaboratively generated by the nurse and the family. The rewarding work
of intervening to effect change involves nurses’ abilities and skills to actively
engage and thoroughly assess families; clearly identify problems, concerns,
and suffering; and set healing and treatment goals. The ultimate goal, of
course, is to aid family members in discovering new solutions to help soften
or alleviate emotional, physical, and/or spiritual suffering.
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Chapter

5

Family Nursing Interviews:
Stages and Skills
Once nurses have a clear, conceptual framework for assessing and intervening
with families, they can then begin to consider the various new competencies
and skills needed for family interviews. The clinical skills deemed necessary
by various authors on family work reflect each author’s theoretical orientation and preference regarding how to approach and resolve relational, family,
and individual problems. Therefore, the skills delineated in this chapter are
based on our postmodernist worldview. This includes, but is not limited to,
the theoretical foundations of systems theory, cybernetics, communication
theory, biology of cognition, and change theory that inform the Calgary
Family Assessment Model (CFAM) and the Calgary Family Intervention
Model (CFIM).
We favor an approach that is strengths and resiliency based, problem and
solution focused, and time effective. We emphasize that families possess the
ability to solve their own problems and/or diminish their suffering but often
lack the confidence or belief in their strengths due to the oppression felt by
families that often follows when illness arises. Our task as nurses is to help
families find and facilitate their own solutions to their emotional, physical,
or spiritual suffering through compassionate and competent therapeutic conversations. We do not propose that we know what is “best” for families.
Rather, we embrace the notion that the world has multiple realities—in other
words, that each family member and nurse sees a world that he or she brings
forth by interacting with others through language. We encourage openness
in ourselves, our students, and our families to the diversity of difference
among us. However, to be involved in helping families change requires that
nurses possess certain essential competencies and skills.
In the previous chapters, we discussed the theoretical knowledge base that
is necessary to begin to competently assess and intervene with families. We
also offered two practice models (the CFAM and CFIM) as frameworks to
conceptualize family dynamics and offer specific family interventions. This
179

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180 Nurses and Family: A Guide to Family Assessment and Intervention

chapter focuses on the specific beginning-level skills necessary for relational
family nursing interviews. In Chapter 10 we discuss how to move beyond
basic skills and offer ideas for tailoring advanced skills to the unique client
and clinical practice setting.
The literature on family work that has appeared in the past 35 years
indicates that myriad skills can be used when working with families
(Tomm & Wright, 1979; Wright & Bell, 2009). Various professional nursing
associations have made efforts to identify the necessary competencies for
practice. However, the two most significant documents with regard to the
specific development of family nursing skills and competencies are those
published by the International Council of Nurses (ICN). The first was
titled The Family Nurse: Frameworks for Practice developed by Madrean
Schober and Fadwa Affara (2001). These ideas were further expanded when
on May 12, 2002, the ICN selected the theme for International Nurses Day
to be “Nurses Always There for You: Caring for Families” and produced a
document with the same title (International Council of Nurses, 2002). In
the document is outlined the “nine-star family nurse.” We offer it below to
demonstrate the vastness of the possibilities of caring for families.

THE NINE-STAR FAMILY NURSE: MULTISKILLED
WITH DIVERSE ROLES
Nurses working with families play multiple roles, depending on the family
needs and the settings for care, which can include the home, health-care
facilities, temporary refugee shelters, or the streets. In an effort to capture
the full range of the nurse’s work with families, we will refer to the key
roles in terms of the nine-star nurse. The roles of the nine-star family nurse
include:
■ Health educator: Teaching families formally or informally about health
and illness and acting as the main provider of health information.
■ Care provider and supervisor: Providing direct care and supervising care
given by others, including family members and nursing assistants.
■ Family advocate: Working to support families and speaking up on issues
such as safety and access to services.
■ Case finder and epidemiologist: Tracking disease and playing a key role
in disease surveillance and control.
■ Researcher: Identifying practice problems and seeking answers and solutions through scientific investigation alone or in collaboration.
■ Manager and coordinator: Managing, collaborating, and liaising with
family members, health and social services, and others to improve access
to care.
■ Counselor: Playing a therapeutic role in helping to cope with problems
and to identify resources.

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Chapter 5: Family Nursing Interviews: Stages and Skills 181
■
■

Consultant: Serving as consultant to families and agencies to identify
and facilitate access to resources.
Environmental modifier: Working to modify, for example, the home
environment so that the disabled can improve mobility and engage in
self-care.

The nine-star family nurse uses a number of these roles to identify health
risks, a health problem or a need, and to address the situation working singly
or in partnership with families, other health professionals, and community
groups (p. 10).
Simply stating general skills such as “the student must be able to label
interactions accurately” says nothing about how that skill can be achieved.
The use of specific learning objectives helps to remove the mystery from what
a family nurse interviewer does. Thus, the learning objectives or skills become
a tentative “map” for the interview. However, it is essential to highlight that
the correlation of skills with client outcomes has not yet been established. The
skills described in this chapter emerge from our theoretical orientation and application of the CFAM and CFIM practice models. These skills become the
nurse behaviors that are unique to working with families. Of course, each
nurse also has a unique genetic and personality makeup and history of interactions, and these personalize the application of these skills.

EVOLVING STAGES OF FAMILY NURSING INTERVIEWS
Within the context of a therapeutic conversation between a nurse and a family, four major stages of family nursing interviews can be identified:
■ Engagement
■ Assessment
■ Intervention
■ Termination
These stages evolve throughout the interview. They tend to follow a logical
sequence during both the course of a given interview and the overall course
of contact. For example, a nurse engages family members and terminates
with them at the end of each interview and at the beginning and end of the
entire contact. Of course, there are times when a nurse may have to return
to a previous stage. For example, interventions may be offered too quickly
before a thorough assessment has been completed. Other times, the nurse
might want to revisit the engagement stage if a new family member attends
a meeting.
In the first stage, engagement, the nurse exercises skills that invite him
or her and the family to establish and maintain a therapeutic relationship.
Our preferred stance or posture with families is to be compassionate,
collaborative, and consultative (Leahey & Harper-Jaques, 1996). We also

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182 Nurses and Family: A Guide to Family Assessment and Intervention

encourage a posture of curiosity and interest in the family. This implies
greater equality and respect for the family’s resiliency and resourcefulness.
As long as there is an atmosphere of curiosity, judgment and blame are kept
at bay.
The nurse brings to the relationship expertise about promoting health and
managing illness, and family members bring their own expertise about their
understanding of health and their illness experiences. It is this synergy of
combined expertise that can generate new outcomes to constraining situations. Factors that appear to inhibit engagement by the family interviewer
are the lack of creating a context for change, and confrontation or interpretation too early in treatment. (Refer to Chapter 11 for a more in-depth reading about common errors in family interviews and how to avoid or correct
them.) Additional ideas and suggestions for the engagement stage are given
in Chapters 6 and 7.
Assessment, the second stage, includes the substages of problem identification and exploration plus delineation of a strengths and problems list.
During this stage, the nurse enables the family to tell the story about their
particular situation. The story is different for each family. It may be an illness
story; a story of loss and grief; a story of uncertainty about the health of
family members (e.g., a child’s developmental delay or undiagnosed symptoms); a story about terror, war, tsunamis, hurricanes, or unwanted migration; or a story of a desire to promote or maintain healthy lifestyles and
avoid obesity or alcoholism that has plagued a family. We stress that the
conversation between the nurse and the family is in and of itself part of
the therapeutic discourse (Wright & Bell, 2009). If the nurse attends
only to the signs and symptoms of disease, both the nurse and the family
will find themselves in a discourse emphasizing pathology. Alternative
discourses that emphasize “right answers” rather than an understanding of
the family’s frustrations, sufferings, dilemmas, and yearnings would be
equally unhelpful.
Beginning nurse interviewers generally lack a clear, stepwise rationale to
guide the collecting and processing of data during an interview. Thus, some
beginners commonly spend an inordinate amount of time collecting vast
amounts of information. Frequently, this information is tangential to the
presenting problem and is not usable. Alternatively, beginners sometimes
rush into inappropriate treatment because they do not have a clear formulation of the presenting problem. However, it is better for beginners to err on
the side of taking longer than usual to complete the initial assessment than
to prematurely rush to the intervention stage. Nurses in family work must
remember that assessment is an ongoing process. Thus, the strengths and
problems list may change over time as the nurse’s conceptual understanding
of the family becomes more systemic. Ideas for conducting a time-effective
15-minute interview are given in Chapter 9. Information on what areas
to assess and how to integrate the data is available in Chapters 3 and 7,
respectively.

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Chapter 5: Family Nursing Interviews: Stages and Skills 183

The third stage, intervention, is really the core of clinical work with families. It involves providing a context in which the family may make small or
significant changes. There are numerous ways to intervene, and treatment
plans should be co-constructed and tailored by the nurse and family to match
each family situation. Chapter 4 offers examples of specific interventions
that nurses can use, and Chapter 8 gives ideas of the kinds of questions that
can be used in family interviewing.
Termination, the last stage, refers to the process of ending the therapeutic
relationship between the nurse and the family in a manner that allows the
family to maintain and continue constructive changes, new understandings,
and facilitating beliefs. Therapeutic termination encourages the family’s ability to solve problems in the future. Specific ideas for therapeutic termination
are described in Chapter 12.

TYPES OF SKILLS
Each stage of family interviewing requires three types of skills:
■ Perceptual
■ Conceptual
■ Executive
Cleghorn and Levin’s (1973) identification and categorization of these
three skill types are considered a seminal contribution. Tomm and Wright
(1979) used the perceptual, conceptual, and executive skills framework as a
guide for their comprehensive outline, which offered examples of therapist
functions, competencies, and skills in each category over the evolution of a
family interview. In our text, we have kept Wright’s previous identification
of particular perceptual, conceptual, and executive skills across the four
stages of family interviews. However, we have adapted the perceptual, conceptual, and executive skills to be congruent with nurses who are just beginning to practice with families. Although we believe these skills are most
descriptive of the work of beginning family nurse interviewers, we do not
wish to imply that the skills are used only with “simple” family situations.
Rather, we recognize that all nurses, from beginner undergraduates to experienced practicing nurses, deal with complex family situations on a day-today basis. These skills provide a framework for relational family nursing
practice regardless of the complexity of the family’s presenting issue.
The skills that we have identified fit within the context of our particular
practice models—namely, the CFAM and CFIM. Perceptual and conceptual
skills are paired because what we perceive is so intimately interrelated with
what we think; in many cases, separating the perceptual from the conceptual
component is difficult. Perceptual and conceptual skills are then matched
with executive skills.
Perceptual skills relate to the nurse’s ability to make relevant observations.
The nurse’s age, ethnicity, gender, sexual orientation, race, and class are but

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184 Nurses and Family: A Guide to Family Assessment and Intervention

a few of the factors that influence his or her perceptions. The perceptual skills
required in individual interviewing are much different from those required in
family interviewing. This difference can be explained by the fact that, in family
interviewing, the nurse is involved in observing multiple interactions and relationships simultaneously; the interaction among family members and the
interaction between the nurse and the family are simultaneous.
Conceptual skills involve the ability to give meaning to the nurse’s observations. They also involve the ability to formulate one’s observations of the
family as a whole, as a system. Nurses must always be cognizant that the
meanings derived from observations are not “the truth” about the family;
instead, they represent efforts to make sense of observations.
We believe that a student entering the nursing profession has intuitive perceptual and conceptual skills that have been learned in other roles in previous
life experiences. However, the student is usually unaware of many of these skills.
As a nurse, he or she needs to develop an overt awareness of the perceptual
process. Perceptual and conceptual skills are the basis of the executive skills.
Executive skills are the observable therapeutic interventions that a nurse
carries out in an interview. These skills, or therapeutic interventions, elicit
responses from family members and are the basis for the nurse’s further observations and conceptualizations. As can be readily seen, the interview
process embedded within the therapeutic conversation is a circular phenomenon between the nurse and family. The process is highly influenced by the
nurse’s and family members’ gender, ethnicity, class, and race. Of course, the
types of therapeutic interventions the nurse offers are highly dependent on
his or her clinical expertise and experience in working with families.

DEVELOPMENT OF FAMILY NURSING INTERVIEWING SKILLS
In the education of nurses developing family nursing skills, emphasis should
be placed first on the development of perceptual and conceptual skills. This
can be accomplished by several methods. Lectures and readings are helpful.
Role-playing, practicing reflective inquiry, and observing and analyzing
videos or DVDs of actual family interviews are all useful and effective
ways to increase perceptual and conceptual skill accuracy. For this reason,
we have developed the “How to” Family Nursing Series, available on
DVD at www.familynursingresources.com. This DVD series comprises
eight educational programs, which present live clinical scenarios that demonstrate family nursing in actual practice, including interviews with families
with young children, middle-aged families, and later-life families. The
health problems and health-care settings are varied, as are the ethnic and
racial groups. The emphasis is on demonstrating how to practice these
skills. The DVD most related to this chapter is Family Nursing Interviewing
Skills: How to Engage, Assess, Intervene, and Terminate (Wright & Leahey,
2002). See the notice following the Index for a full description of each DVD
and for ordering information.

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Chapter 5: Family Nursing Interviews: Stages and Skills 185

Application of family nursing interview skills is one of the most meaningful skill-development opportunities for both graduate and undergraduate
nurses. Moules and Tapp (2003) offer some creative, innovative ideas and
exercises for educators conducting family nursing labs for undergraduate
students. In their research, they found that experiential and interactive,
inquiry-based activities aimed at creating personal, meaningful, relational
family nursing practice received positive student feedback. For example, the
authors shifted from using role-plays to using a questioning exercise to emphasize reciprocity between the family and the nurse interviewer. After selecting one student in the group, every other student asks questions of that
student based on their knowledge and experience of that person as a classmate or friend. The power and timeliness of interventive questions quickly
become evident to the students at a very personal level. The exercise continues until each student has had the opportunity to be the questioned member.
Moules and Tapp (2003) also fashioned a commendations exercise aimed
at offering students the opportunity to genuinely look for, find, and then
offer a sincere acknowledgment to a real student. The exercise was designed
in a similar fashion to the questioning exercise, with one student receiving
commendations offered by other group members. They reported that the experiential, personal component of these exercises enriched students’ valuing
of relational family nursing practice. In 2010, Moules and Johnstone reported similar findings of the value of personal reflections, commendations,
and life-changing realizations for both students and faculty after a student
completed a spontaneous piece of reflective writing.
If a nurse is unable to perform a specific executive skill, it is useful to find
out whether he or she has developed a perceptual and conceptual base for
that particular skill. This is the value of matching these skills in pairs. We
encourage nurses to reflect on their practice to distinguish their areas of
strengths and weaknesses in the conceptual, perceptual, or executive areas.
Leahey and Harper-Jaques’s (2010) work with practicing nurses demonstrates how this can be done in a relational clinical setting. Nurses were asked
to create a clinical vignette of a client presenting to their setting and then
discuss the conceptual, perceptual, and executive skills involved in that
client’s care. Nurses shared these vignettes and skill descriptions at their
monthly team seminars. This contributed to advancing their personal skill
development and increasing team focus on clinical practice.
Family assessment is generally well taught at the baccalaureate level and in
masters and doctoral programs specializing in community and/or family nursing
in North America. However, family interventions and the accompanying skills
at both the undergraduate and graduate levels still need to be greatly enhanced
and improved. One of the most exciting new developments in advancing family
nursing has been the endowment of $7 million in 2008 to establish the
Glen Taylor Nursing Institute for Family and Society (http://ahn.mnsu.
edu/nursing/institute/) at the School of Nursing at Minnesota State University,
Mankato, Minnesota. Their vision is to create landmark innovations in the

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186 Nurses and Family: A Guide to Family Assessment and Intervention

scholarship of family and society nursing practice (Eggenberger, 2010). Already
they have designed and transformed core curriculum in undergraduate and
graduate education emphasizing family nursing practice.
Live supervision of clinical practice with families, particularly at the graduate level, is regularly provided in a very few locations worldwide (Duhamel,
2010; Wright & Bell, 2009). Case discussion and process recording remain
the predominant method of supervision in the development of family nursing
skills. However, live supervision is essential to developing and achieving therapeutic competence in nursing practice with families (Tapp & Wright, 1996;
Wright, 1994; Wright & Bell, 2009). Observing peers as a mirror of one’s
own development and seeing one’s own internal experience as normal were
reported as helpful to increasing self-confidence.
A useful study that examined the pedagogical practices in family systems
nursing at the Family Nursing Unit, University of Calgary revealed that feeling supported through live and video supervision, having competencies emphasized, and receiving feedback about specific in-session positive behaviors
contributed to increased self-confidence and the development of advance
practice clinical skills (Moules, Bell, Paton, et al, 2012). However, the study
also gleaned that the intensity of the learning process was reported to have
both useful and limiting consequences by masters and doctoral students.
Learning from peers is useful in three ways: First, when a novice asks the
inexperienced clinician for suggestions, the novice can see that the peer
can be a valuable resource. Second, as the inexperienced clinician seeks out
consultation from a novice, the novice is able to see himself or herself as
competent with the person to whom they are offering consultation. And
third, the supervisor gets to hear multiple problem definitions and a variety
of solutions. If the treatment team is multidisciplinary, issues of power and
hierarchy can become transparent. Different philosophical positions can become overt without attempting to hierarchically position one model over another (Harper-Jaques & Houger Limacher, 2009).
It is especially encouraging to note the increase of nurse educators both in
academia and in practice settings enhancing the development of family nursing skills. Specific examples include teaching students to “think family,” to
offer family nursing workshops within practice settings, and to integrate family nursing into everyday practice in mental health urgent care (Southern, et
al, 2007) and in critical care (Nelmes & Eggenberger, 2010). Evidence for the
continuing and deepening efforts to enhance and increase nursing students’
and practicing nurses’ competencies and skills in their care of families is showing up in the literature, conference abstracts, and Listservs. Learning-centered
and outcome-based pedagogies in family nursing are part of the trend in multidisciplinary professional education, especially in marriage and family therapy, medicine and psychiatry, psychology, and social work (Gehart, 2011).
Specific skills for interviewing families are listed in logical sequence in
Table 5–1. However, during the course of an actual interview, the nurse
should not follow this outline rigidly. Rather, this outline serves as a “map

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Chapter 5: Family Nursing Interviews: Stages and Skills 187

Table 5-1 | Family Interviewing Skills for Nurses
STAGE 1: ENGAGEMENT

Perceptual/Conceptual Skills

Executive Skills

1. Recognize that an individual family member
is best understood in the context of the
family.

1. Invite all family members who are concerned or
involved with the problem, suffering, or illness
to attend the first interview.

That is, no individual exists in isolation.

2. Appreciate that initial efforts to involve both
spouses/parents enable (from the onset)
a more holistic view of the family and
increase engagement.
That is, fathers should definitely be involved
for effective family work.

3. Recognize that providing a clear structure
to the interview reduces anxiety and
increases engagement.
That is, people generally feel anxiety related
to the uncertainty of being in a new setting
and of not knowing how to behave in the
situation. Structure is particularly important
if the family is experiencing a crisis.
4. Recognize that initially members are most
comfortable talking about the structural
aspects of the family.
That is, note nonverbal cues indicating level
of comfort, such as taking coat off, adequate
versus minimal time spent talking, and
participating in versus ignoring conversation.

For example, grandparents or other relatives or
friends living inside or outside of the home
should also be invited to attend if they are involved with the problem or illness.
2. Employ all efforts to initially involve both
spouses/parents in early sessions.

The spouses/parents have the greatest influence
on the identification, understanding, and resolution of the problem, softening suffering; and/or
managing illness.
3. Explain to family members the purpose, length,
and structure of the interview and ask if they
have any questions relating to the interview.
For example, say, “I thought we could spend
about 10 minutes together discussing the issues
that you are concerned about.”

4. Ask each family member to briefly relate information with regard to name, age, work, or
school; years married; and so forth.
For example, introduce yourself directly by giving
your name and either shaking hands or making
some physical contact (such as touching a
baby’s head). After introductions, ask questions
about information that is familiar to all family
members, because this type of conversation is
least threatening.

STAGE 2: ASSESSMENT

Perceptual/Conceptual Skills

Executive Skills

1. Realize the importance of having a
conceptual assessment map to understand
family dynamics.

1. Explore the components of the structural, developmental, and functional aspects of CFAM to assess strengths and problem areas.

That is, a conceptual assessment map
provides the nurse with several possible
courses for focused exploration.

Not all components of CFAM need to be explored if they are not relevant to the present issues, problems, or illness.

2. Realize the importance of beginning a family
assessment by obtaining a detailed description and history of the presenting problem,
concern, or illness.

2. Ask each family member, including the children,
to share his or her knowledge and understanding of the presenting concern.
Continued

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188 Nurses and Family: A Guide to Family Assessment and Intervention

Table 5-1 | Family Interviewing Skills for Nurses—cont’d
STAGE 2: ASSESSMENT

Perceptual/Conceptual Skills
That is, the presenting problem usually
serves as an entry point for the family to
seek help. Focusing on addressing the
problem is time-effective.
3. Realize that the presenting problem is
commonly related to other concerns in the
family.
That is, a child’s temper outbursts may be
related to family conflict (e.g., the child may
be triangulated into a family conflict over
caring for the grandmother).

4. Realize that eliciting differences generates
more specific information for family
assessment.

Executive Skills
For example, ask the father, “How do you see
the problem?” or ask the whole family, “What is
the main problem or issue that each of you
would like to see changed?”
3. Explore with the family if there are other
problems or concerns connected to the
presenting problem.
For example, say, “We have been talking for
some time about the problem of Theo’s refusal
to take his meds in the mornings. I am wondering if there are any other problems the family is
presently concerned about or that relate to
Theo’s issue?”
4. Inquire about differences between individuals,
between relationships, and between various
points in time.

(b) Clarification of differences between
relationships is a significant source of
information about family structure and
alliances.
(c) Clarification of differences in family
members or in relationships at various
points in time is a significant source of
information about family development.

For example:
(a) To explore differences between individuals,
ask the child, “What is expected of you before you go to bed at night?” and then ask,
“Who is the best, mother or father, at getting
you to do those things in the evening?”
(b) To explore differences between relationships, ask, “Do your father and Ingo argue
more or less than your father and Hannah
about how to care for your younger sister?”
(c) To explore differences before or after important points in time, ask, “Do you worry more,
less, or the same about your husband’s
health since his heart attack?”

5. Use the information obtained from the
family assessment to begin formulating
hypotheses in the form of a strengths and
problems list.

5. Obtain verification of the nurse’s understanding
of strengths and problems by listing them to the
family for their agreement and eventually
recording them.

That is:
(a) Clarification of differences between
individuals is a significant source of
information about family functioning.

Offering conclusions or a summary of the
nurse’s assessment ideas enhances engagement and collaboration and allows for selfcorrection—that is, structural, developmental,
and functional strengths and problems may
be present at various systems levels. For
example, whole family system issues:
(a) Structural: Adjusting to new family form
of single-parent household.
(b) Developmental: Family in life cycle stage
of children leaving home.
(c) Functional: Family belief that “Father would
be displeased with us for still crying about
his death.”

For example, say, “We have identified that being
a new single parent and also having to cope
with your child (who has a developmental
delay) leaving home are your two major concerns. We have also discussed that your family is
very well respected in the Latino community.
Have I understood things correctly?”

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Chapter 5: Family Nursing Interviews: Stages and Skills 189

Table 5-1 | Family Interviewing Skills for Nurses—cont’d
STAGE 2: ASSESSMENT

Perceptual/Conceptual Skills

Executive Skills

6. Assess whether any of the identified problems are beyond the scope of the nurse’s
competence.

6. Tell the family whether you will continue to
work with them on problems. (If a decision is
made to refer them to another professional,
proceed to Stage 4A: Termination.)

That is, it is appropriate to consider referral
when medical symptoms have not been
fully assessed or long-standing emotional
or behavioral problems exist.
7. Recognize that a more extensive inquiry into
the most pressing problems is necessary
before intervention plans can be
implemented.
That is, initially families are usually most
concerned with the presenting problem or
the area of greatest suffering.
8. Recognize that the assessment is complete
when sufficient information has been
obtained to formulate a treatment plan.
That is, nurses sometimes rush into inappropriate treatment because they are without
a clear understanding of the presenting
problem or other significant related
problems.

For example, tell the family, “Now that I have a
more complete understanding of your concerns,
I think it is necessary to have your son’s
headaches checked out medically. I would like
to refer you to a pediatrician.”
7. Seek the family’s opinion of which issue they
perceive as most important and/or where there
is the greatest suffering, and explore it in depth.
If the family cannot agree, then discuss the lack
of consensus.
For example, ask, “About which of the
problems we have discussed today are you
most concerned?”
8. State your integrated understanding of problems to the family and obtain their commitment
to work on a specific problem.
For example, say, “Because everyone agrees that
Soon’s bulimia is connected to the other addictions in the family, I would like to suggest that
we focus on this problem for three interviews.
Would you be willing?”

STAGE 3: INTERVENTION

Perceptual/Conceptual Skills

Executive Skills

1. Recognize that families possess
problem-solving abilities.

1. Encourage family members to explore possible
solutions to problems and to soften suffering.

That is, recognizing that families possess the
capability to change and can identify and
implement solutions for how to change
helps the nurse avoid becoming overcontrolling or over-responsible.

For example, say, “Sanjeshna, you have mentioned that your mother is too blaming of herself. Do you have any ideas of what she could
do to blame herself less about experiencing a
chronic illness?”

2. Recognize that interventions are focused on
the cognitive, affective, and behavioral
domains or areas of functioning in families,
as described in the CFIM.

2. Plan interventions to influence any one or all
three of the domains of functioning described in
the CFIM.

That is, it is not always necessary or efficient
to design interventions for all three domains
of functioning simultaneously.

For example:
(a) Cognitive: Invite the family to think
differently.
(b) Affective: Encourage different affective
expression.
(c) Behavioral: Ask the family to perform new
tasks either within or outside of the interview.
Continued

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190 Nurses and Family: A Guide to Family Assessment and Intervention

Table 5-1 | Family Interviewing Skills for Nurses—cont’d
STAGE 3: INTERVENTION

Perceptual/Conceptual Skills

Executive Skills

3. Recognize that lack of information of an
educational nature can inhibit the family’s
problem-solving abilities.

3. Provide information to family members that will
enhance their knowledge and facilitate further
problem solving.
For example, the nurse can ask family members
if they would like to hear about some typical reactions of a 3-year-old to a new baby or about
the aging process of an older adult with
Alzheimer’s disease. This type of intervention targets the family’s cognitive domain of functioning.

That is, when given additional information,
many families can provide their own creative
and unique solutions to problems.

4. Recognize that persistent and intense
emotions can often block the family’s
problem-solving abilities.

4. Validate family members’ emotional responses,
when appropriate.
For example, family members suppressing grief
over the loss of another family member may
only need confirmation of the normal grieving
process to work through their bereavement. This
type of intervention targets the family’s affective
domain of functioning.

That is, families who predominantly experience emotions such as sadness or anger
are often unable to deal with problems until
the emotional constraint is removed.

5. Assign tasks or assignments aimed at improving
5. Recognize that suggesting specific tasks or
family functioning.
assignments can often provide a new way
for family members to behave in relation to
one another that will improve problem-solving
abilities.
For example, suggest that the father and son
spend one evening a week together in a common activity; suggest to the mother and father
that one parent put the children to bed on odd
days and the other on even days. This type of
intervention influences the family’s behavioral
domain of functioning.

That is, some tasks can facilitate changes in
the structure of the family or family rules or
rituals.

STAGE 4: TERMINATION

A. If Consultation or Referral Is Necessary:
1. Recognize that families appreciate additional
professional resources when problems are
quite complex.
That is, nurses cannot be expected to have
expertise in all areas.

1. Refer individual family members or the family
for consultation or ongoing treatment.
For example, say, “I feel that your family needs
professional input beyond what I can offer for
Tracey’s learning disability. Therefore, I would
like to refer you to the learning center in the
city. They have more expertise in dealing with
these types of problems.”

B. If Family Interviewing With Nurse Continues:
1. Recognize the importance of evaluating the
family interviews or meetings at regular
intervals.

1. Obtain feedback from family members about
the present status of their problems or level of
suffering and initiate termination when the contracted problems have been resolved or sufficient progress has been made.

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Chapter 5: Family Nursing Interviews: Stages and Skills 191

Table 5-1 | Family Interviewing Skills for Nurses—cont’d
STAGE 4: TERMINATION

B. If Family Interviewing With Nurse Continues:
That is, evaluating the progress of family interviews leads to more focused and purposeful
time spent with the family.
2. Recognize when dependency on the nurse
inadvertently may have been encouraged.
That is, many interviews over a prolonged
period can foster excessive dependency.

3. Recognize family members’ constructive
efforts to solve problems or soften suffering.

Families normally do not lead problem- or
suffering-free lives. Rather, what is important is
their feeling of confidence to cope with life’s
challenges and stresses.
2. Mobilize other supports for the family if necessary, and begin to initiate termination by decreasing the frequency of sessions.
For example, nurses can inadvertently provide
“paid friendship,” with mothers in particular, unless they mobilize other supports such as husbands, friends, or relatives.
3. Summarize positive efforts of family members
to resolve problems and lessen suffering
whether or not significant improvement has
occurred.

That is, the family’s perception of progress is
more significant than the nurse’s perception.

For example, comment, “Your family has made
tremendous efforts to find ways to care for your
elderly father at home while still attending to
your children’s needs.”

4. Recognize that backup support by professional resources is appreciated by individuals
and families in times of stress.

4. End the family interviews with a face-to-face
discussion when possible. If appropriate, extend
an invitation for additional family meetings
should problems recur or if the family desires
consultation.

of interviewing” that allows considerable flexibility in application. The family’s cultural norms for giving and receiving information can provide a guide
for the pacing of the meeting. We cannot emphasize enough the importance
of the nurse and the family developing a collaborative working relationship
during the interview.

CONCLUSIONS
The family interviewing skills (perceptual, conceptual, executive) discussed
in this chapter function as a guide or a map for nurses working with families.
Thus, through the implementation of these skills, beginning family nurse interviewers can progress through the four stages of the interview by engaging
families, assessing strengths and problems, deciding whether to intervene or
to refer families, and terminating with the family. These stages of a family interview, with their accompanying skills, are another useful blueprint for nurses
working with families. We strongly encourage nurses to tailor the use of these
skills to each family’s unique context and their relationship with the family.
The nurse and family converse and collaborate and bring forth old and new
stories of suffering, problems, resiliencies, strengths, competence, and problem

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192 Nurses and Family: A Guide to Family Assessment and Intervention

resolution. The ethnicity, culture, class, sexual orientation, and race of the
nurse and family members will, of course, influence their collaboration.
References
Cleghorn, J.M., & Levin, S. (1973). Training family therapists by setting learning
objectives. American Journal of Orthopsychiatry, 43(3), 439–446.
Duhamel, F. (2010). Implementing family nursing: How do we translate knowledge into
clinical practice? Part II: The evolution of 20 years of teaching, research, and practice to
a center of excellence in family nursing. Journal of Family Nursing, 16(1), 8–25.
Eggenberger, S. (2010). Glen Taylor nursing institute for family and society: Advancing
family nursing. Journal of Family Nursing, 16(2), 234–238.
Gehart, D. (2011). The core competencies and mft education: Practical aspects of
transitioning to a learning-centered, outcome based pedagogy. Journal of Marital and
Family Therapy, 37(3), 344–354.
Harper-Jaques, S., & Houger Limacher, L. (2009). Providing marriage and family
therapy supervision in a multidisciplinary psychiatric setting: Contextual sensitivity
as a cornerstone of supervision. Journal of Systemic Therapies, 28(3), 49–58.
International Council of Nurses. (2002). Nurses Always There for You: Caring for
Families. Geneva, Switzerland: Author.
Leahey, M., & Harper-Jaques, S. (1996). Family-nurse relationships: Core assumptions
and clinical implications. Journal of Family Nursing, 2(2), 133–151.
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),
196–212.
Moules, N., & Johnstone, H. (2010). Commendations, conversations and life-changing
realizations: Teaching and practicing family nursing. Journal of Family Nursing, 16(2),
146–160.
Moules, N.J., & Tapp, D.M. (2003). Family nursing labs: Shifts, changes, and innovations. Journal of Family Nursing, 9(1), 101–117.
Moules, N.J., Bell, J.M., Paton, B.I., et al. (2012). Examining pedagogical practices in
family systems nursing: Intentionality, complexity, and doing well by families. Journal of
Family Nursing, 18(2), 261-295.
Nelmes, T.P., & Eggenberger, S.K. (2010). The essence of the family critical illness
experience and nurse-family meetings. Journal of Family Nursing, 16(4), 462–486.
Schober, M., & Affara, F. (2001). The Family Nurse: Frameworks for Practice. Geneva,
Switzerland: International Council of Nurses.
Southern, L., et al. (2007). Integrating mental health into urgent care in a community
health centre. Canadian Nurse, 1, 29–34.
Tapp, D.M., & Wright, L.M. (1996). Live supervision and family systems nursing:
Postmodern influences and dilemmas. Journal of Psychiatric and Mental Health
Nursing, 3, 225–233.
Tomm, K.M., & Wright, L.M. (1979). Training in family therapy: Perceptual,
conceptual, and executive skills. Family Process, 18(3), 227–250.
Wright, L.M. (1994). Live supervision: Developing therapeutic competence in family
systems nursing. Journal of Nursing Education, 33(7), 325–327.
Wright, L.M., & Bell, J.M. (2009). Beliefs About Illness: A Model for Healing. Calgary,
AB: 4th Floor Press.
Wright, L.M., & Leahey, M. (Producers). (2002). Family Nursing Interviewing Skills:
How to Engage, Assess, Intervene, and Terminate With Families. [DVD]. Calgary, AB.
Available at www.familynursingresources.com.

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Chapter

6

How to Prepare for
Family Interviews
Nurses who work in various types of settings often ask, “How do I prepare
for a family interview?” For many nurses, family meetings happen by chance,
such as when family members are visiting their loved one in the hospital. For
others, family presence in emergency departments or intensive care units is
an accepted practice, and nurses are expected to interact with family members as part of their usual practice and supported by institutional and/or administrative policy. However, only 5% of nurses work in units with a written
family presence protocol (Duran, et al, 2007). For some nurses, interviews
are a planned event and may be initiated by either the family or the nurse.
Foucault and colleagues (2008) found that 43% of individual clients would
have preferred for a family member to join them for a meeting about mental
health issues. Some nurses must overcome the belief that they would be intruding on the family visit if they were present in the patient’s room. For
many nurses, tension caused by the time required to set up an interview, develop a relationship with the family, and intervene effectively is a major challenge to overcome. Time tension is something that health-care professionals
need to learn to manage; otherwise, they can become immobilized by it. We
suggest that nurses cannot not attend to families!
For both the nurse and the family, the first interview or family meeting is
often filled with anxiety often due to lack of experience, skills, or both of
how to involve families. We find this to be a natural reaction of nurses who
desire and are committed to expand their practice and include families as
part of their relational practice. We believe that the less anxious the nurse is,
the more he or she invites confidence in family members, thereby reducing
their anxiety. The purpose of this chapter is to help reduce the nurse’s anxiety
by discussing how to plan for the initial and subsequent interviews. First,
ideas are offered for the nurse to reflect on the type of relationship that is
most desirable to be co-constructed with a family. How to develop hypotheses related to the purpose of the interview is then addressed. Concrete issues
193

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194 Nurses and Family: A Guide to Family Assessment and Intervention

are presented, such as deciding on the interview setting, deciding who will
be present, and contacting the family by telephone.

IDEAS ABOUT THE NURSE-FAMILY RELATIONSHIP
Since the first edition of this book, there has been a steady increase in the
attention paid to the relational aspect of nurse-family encounters. The relationship is actualized through the microcontext of “therapeutic conversations,” meaning the nurse clinician acts with, rather than on, patients.
Madsen (2007) has advocated self-reflection in relation to dominant
societal ideas and practices, intimate relationships past and present, the
client–health-care professional relationship, gender, sexual thoughts, and
strong feelings. We believe that nurses cannot avoid their influence on
families, particularly the potential healing power of their words. Nurses
and families inevitably influence each other, but not always with predictable
results.
Bell (2011) has championed the idea that relationships are the heart of
the matter in family nursing: “What would happen if family nurses would
continue to focus on families but with a keener interest and heightened sensitivity to relationships?” (p. 3) and “What if, in nursing education, we were
to begin instead (of teaching how to do an assessment) to teach about the
ways we enter into relationships with the family?” (p. 5). The idea of nurses
increasing their attention especially to the first few minutes of an encounter
with a client is a powerful one.
We also believe nurses’ positive attitudes toward families encourage them
to engage more frequently in therapeutic conversations with families. The
work of Sveinbjarnardottir, Svavarsdottir, and Saveman (2011) supports
this notion that the attitude psychiatric nurses have is fundamental to the
quality of interventions offered to families. A revealing study of nurses’ attitudes about involving families in nursing care showed that less supportive
attitudes existed among the newly graduated, those having no particular
approach to the care of families in their workplace, and those who were
male nurses (Benzein, Johansson, Arestedt, et al, 2008).
We believe that families and nurses each have their own health-care system. Families provide diagnoses, advice, remedies, and support to their members in both sickness and health. They have constraining and facilitating
beliefs about the illness experience (Wright & Bell, 2009). Nurses also have
their own constraining and facilitating beliefs, theories, opinions, recommendations, and remedies about managing problems or illness that they share
with families. Leahey and Harper-Jaques (1996) have outlined five assumptions relating to the family-nurse relationship and the clinical implications
of each assumption. Emphasis is on both the nurse’s and the family’s contribution to establishing and maintaining the relationship. We believe that it is
useful for a nurse to reflect on his or her potential contribution to the
relationship before meeting with a family. It is also helpful for the nurse to
reflect with the family about their working relationship at the end of their

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Chapter 6: How to Prepare for Family Interviews 195

contract. More ideas on this topic are provided in Chapter 12. The five assumptions related to the family–nurse relationship are detailed in the following sections.
Assumption 1: The Family-Nurse Relationship Is Characterized by Reciprocity.

The family and nurse are connected in a pattern that is quite distinct from
the positivist-based idea of two separate components, either family or nurse.
It is the “fit” between the family and the nurse that is important to foster a
collaborative partnership. Sample questions to ask might include:
■ What are your thoughts on working together? Is it a good fit so far?
What can you imagine will be your preferred way of contributing to
our time together?
■ What direction do you hope we move in over the next few meetings?
■ Is there anything you’d like to know from me to make the conversations
easier? (Madsen, 2007)
Trust is a process that evolves over time. Jonsdottir and Ingadottir (2011)
offer an example of a nurse clinic in Reykjavik where the focal point is unmet
health-care needs of the patients and their families. They stress the importance of recognizing that complementarity of expertise and a holistic approach are essential for success. Collaboration with trust and respect for each
other’s contribution is essential for action to be taken. If the nurse wishes to
foster a reciprocal relationship, he or she can reflect on additional sample
questions in Box 6–1.

Box 6-1

Questions About Reciprocity

For the nurse’s self-reflection:
To what extent will I:
• Elicit the patient’s and family members’ expectations, hopes, questions, and ideas?
• Consider the patient’s and family members’ expectations, knowledge, experience,
and desires when planning nursing care?
• Communicate information, ideas, and recommendations to patients and families on
a regular basis?
• Involve the patient and family to their satisfaction in making decisions for the overall
treatment plan?
To ask the family when evaluating care:
To what extent do you feel that:
• I heard your opinions and ideas?
• I was available and approachable to answer your questions?
• I showed interest in your ideas and experience with illness?
Leahey, M., & Harper-Jaques, S. (1996). Family-nurse relationships: Core assumptions and clinical implications.
Journal of Family Nursing, 2(2), 133–151. Copyright 1996 by M. Leahey and S. Harper-Jaques. Reprinted
by permission of Sage Publications.

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196 Nurses and Family: A Guide to Family Assessment and Intervention

Assumption 2: The Family-Nurse Relationship Is Nonhierarchical. Each

person’s contribution is sought, acknowledged, and valued. A conversation
is a co-construction of ideas and mutual discoveries. However, both the nurse
and the family remain aware that they are bound by moral, legal, and ethical
norms. Tapp’s research (2000) identifies useful practices to counterbalance
hierarchy and expert professional views: “offering commendations,
coevolving a description using the family’s language, exploring the illness
story and the medical story, asking questions that invite reflection, and
initiating conversations about family members’ preferences” (p. 69). Madsen
(2007) suggests that the clinician examine the stance that clients hold toward
problems. Do the clients believe they have some influence over the problem
and want to do something about it? Or, perhaps the clients don’t see
themselves as having a problem? Or, this is a problem, but I have no control
over it? Connecting with clients’ intentions, hopes, and preferred view of self
is a way for the nurse to demonstrate respect and collaboration. (More ideas
on this topic are given in Chapter 7.) Box 6–2 contains some sample
questions that nurses can ask themselves and the family about hierarchy.
Assumption 3: Nurses and Families Each Have Specialized Expertise in
Maintaining Health and Managing Health Problems. Families who live with

chronic conditions develop expertise in managing symptoms, adapting their
environments, and adjusting their lifestyles. They live “near illness,” “alongside
of illness,” and “with illness” (Wright & Bell, 2009). When they meet with
nurses, they bring a wealth of information and personal expertise to the
encounter. Nurses, through their education and experience, also bring expertise
to the relationship with the family. Out of this mutually respectful encounter,
the family members’ confidence in self-managing a disease can be enhanced.
Diabetes management, for example, depends largely on self-regulation.

Box 6-2

Questions About Hierarchy

For the nurse’s self-reflection:
• To what extent am I imposing my beliefs on the family? Allowing the family to impose their beliefs on me?
• How well do the expectations between the family and I match?
• When there is a mismatch, whose opinion usually predominates?
• How frequently are decisions about the patient’s health care made mutually by the
patient, family, and me?
To ask the family when evaluating care:
• Overall, what percentage of time were decisions about your health care made in a
mutual way between you and me?
• To what extent did I help you feel more in control of your health?
Leahey, M., & Harper-Jaques, S. (1996). Family-nurse relationships: Core assumptions and clinical implications.
Journal of Family Nursing, 2(2), 133–151. Copyright 1996 by M. Leahey and S. Harper-Jaques. Reprinted
by permission of Sage Publications.

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Chapter 6: How to Prepare for Family Interviews 197

We believe that more traditional compliance models relying on pressure
to follow recommendations need to be replaced by patient-empowerment
models. Nurses risk starting to believe they really know what the best answers are for a family or a particular problem. We agree with Tapp (2000)
that “these beliefs can become oppressive when the expert has the expectation that their advice must be obeyed” (p. 81). Nurses can think about their
own expertise and the family’s expertise as they prepare to meet with a family to discuss managing a particular health problem. Developing and nurturing a kernel of appreciation and respect for the client is foundational to
a therapeutic alliance. Box 6–3 provides sample questions that the nurse
can consider.
Assumption 4: Nurses and Families Each Bring Strengths and Resources to the
Family–Nurse Relationship. Nurses who use a resource-identification lens

strive to draw forth the family’s cultural, ethnic, spiritual, and other beliefs
that have been helpful in dealing with the health problem. Nurses also bring
to the relationship their own life experience; clinical intuition; and cultural,
ethnic, spiritual/religious, and educational background. Sample questions the
nurse could ask the family in evaluating the effectiveness of their relational
practice include:
■ What have I as a nurse done with you as a family that has made a difference? A positive difference?
■ Looking back, what was your preferred way of contributing to our conversations? Is there something in particular that you feel pleased about
with the outcome?

Box 6-3

Questions About Expertise

For the nurse’s self-reflection:
• What do I know about the family’s ideas and plans for care during this course of
treatment?
• What can I learn from this family about their experiences in living with this health
problem?
• What knowledge and expertise do I have to offer this family?
• How does this family demonstrate its trust in my expertise?
• Who in the family has the most expertise in getting Grandpa to take his medications?
To ask the family:
• What are the things that you or other family members do to help you relieve the
pain?
• What ways have you found most useful to invite your father to take care of his own
personal needs?
Leahey, M., & Harper-Jaques, S. (1996). Family-nurse relationships: Core assumptions and clinical implications.
Journal of Family Nursing, 2(2), 133–151. Copyright 1996 by M. Leahey and S. Harper-Jaques. Reprinted
by permission of Sage Publications.

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198 Nurses and Family: A Guide to Family Assessment and Intervention

Box 6–4 offers sample questions that nurses can ask themselves about
how they would like the relationship with the family to be focused on
strengths.
Assumption 5: Feedback Processes Can Occur Simultaneously at Several
Different Relationship Levels. Nurses have often focused on family dynamics

and interactional patterns within family systems. More recently, however,
they have begun to address family-nurse relationships and reflect on their
own patterns with families (Bergadahl, Benzein, Ternestedt, et al, 2011).
Rarely do nurses address the interactive patterns that can simultaneously
occur at different relational levels. Box 6–5 offers sample questions that the
nurse can consider about the family-nurse relationship.

Box 6-4

Questions About Strengths

For the nurse’s self-reflection:
• Will my actions and comments acknowledge the strengths and abilities of this family?
• What interventions can I use to further enhance this family’s strengths?
• How am I inviting this family to trust my knowledge and skill in helping them with
this health problem?
• What are the strengths that I bring to this relationship?
Leahey, M., & Harper-Jaques, S. (1996). Family-nurse relationships: Core assumptions and clinical implications.
Journal of Family Nursing, 2(2), 133–151. Copyright 1996 by M. Leahey and S. Harper-Jaques. Reprinted
by permission of Sage Publications.

Box 6-5

Questions About the Family–Nurse Relationship

For the nurse’s self-reflection:
To what extent did my relationship with the patient and family help to:
• Increase their knowledge? Insight? Coping?
• Increase my knowledge? Insight?
• Improve or enhance their emotional well-being? My emotional well-being?
• Improve the patient’s physical health?
• Build stronger relationships between the patient and family members?
To ask the family when evaluating care:
To what extent did our meetings together:
• Meet your needs?
• Contribute to your having an increased sense of confidence in living with your illness?
Leahey, M., & Harper-Jaques, S. (1996). Family-nurse relationships: Core assumptions and clinical implications.
Journal of Family Nursing, 2(2), 133–151. Copyright 1996 by M. Leahey and S. Harper-Jaques. Reprinted
by permission of Sage Publications.

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Chapter 6: How to Prepare for Family Interviews 199

HYPOTHESIZING
Before meeting the family for the first time, the nurse should develop an
idea of the purpose of the interview and an understanding of the family’s
context. For example, a nurse in primary care who is conducting an
interview to understand how the family is coping with a chronic or lifethreatening illness will conduct it differently than a nurse who is trying to
assess family violence, abuse, or some other specified problem. In the latter
example, either the family or some other agency may have already identified
the problem. Also, if a family were in crisis—for example, having just received news of an untimely death of a family member—the context for the
interview would be different than if the family were not experiencing a crisis. Another purpose for an interview could be for the nurse to discover parents’ desires about whether they want to remain at their child’s side during
complex invasive procedures and resuscitation. Offering family members a
choice is a practice parents often prefer. Inquiring how family members
would like to be involved in the patient’s home care or hospitalization could
be another reason for a family meeting. Depending on the purpose of the
interview, the types of questions asked and the flow of the therapeutic conversation may be quite different. See Chapters 4, 7, 8, 9, and 10 for clinical
examples of interviews.
We are heartened by the work of Burke and colleagues (2001), who studied the effects of stress-point intervention with families of repeatedly hospitalized children. They hypothesized that each additional hospitalization
has unique challenges and could be more stressful than previous ones. A
family-focused supportive intervention called Stress-Point Intervention by
Nurses (SPIN) was designed to reduce family problems. The findings from
a three-site clinical trial with random assignment of nurses and families to
experimental (SPIN) and control (usual care) groups indicate that parents
who received SPIN were more satisfied with family functioning and had better parental coping after hospitalization than parents who received usual
care. The intervention was based partly on CFAM and CFIM and involved
“ a) identifying the family’s own particular stressful issues surrounding the
expected or anticipated hospitalization, b) developing a plan with the parents
to handle these specific issues and c) following up to praise strengths and
successes, modify, and evaluate the success of the intervention” (Burke, et
al, 2001, p. 138). It is the follow-through on these types of hypotheses that
we find encouraging for the further development of relational family nursing
practice.
In our clinical supervision with nurses, we have encouraged them to
generate hypotheses related to the purpose of the meeting before the interview. Fleuridas, Nelson, and Rosenthal (1986) define hypotheses as “suppositions, hunches, maps, explanations, or alternative explanations about the
family and the ‘problem’ in its relational context” (p. 115). For them, the

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200 Nurses and Family: A Guide to Family Assessment and Intervention

purpose of a hypothesis is to connect family behaviors with meaning and
guide the interviewer’s use of questions. A hypothesis provides order for the
interviewing process. It introduces a systemic view of the family and generates new views of relationships, beliefs, and behaviors. Preferably, the
hypothesis should be circular rather than linear to maximize the therapeutic
potential.
The essence of all these definitions is similar: A hypothesis is a tentative
proposition or hunch that provides a basis for further exploration. For example, we know from stress theories and from our own personal and professional experiences that the time of diagnosis of an illness is generally
stressful, and in many cases, symptoms temporarily become worse.
Using this as a hypothesis, the nurse can arrange a family interview to discuss the impact of the diagnosis on the family, the family’s response to the
illness, and the family’s expectations of the nurse. In this way, the nurse can
explore family patterns of adjusting to the diagnosis and also the family
members’ ideas of the types of relationships they would like to have with
health-care providers. The hypothesis provides general direction for the nurse
interviewer in exploring with this particular family their unique adjustment
to a diagnosis.
The value of curiosity and naïveté for the nurse working with families, especially in immigrant and marginalized populations, cannot be overestimated. Cultural naïveté and respectful curiosity can be as significant as or
more significant than knowledge and skill. It is important for us to point out
how our thinking about hypotheses has changed as we work toward operating within a postmodernist paradigm and shift from a modernist point of
view. Our attention has shifted from what we think about what patients and
families are telling us to trying to grasp what they think about what they are
telling us.

How to Generate Hypotheses
Hypotheses can be formulated from many bases. For example, they can be
based on information the family provided or on ideas about the family gathered during hospital admission, during visiting hours, or from the other staff.
The information may consist of opinions, observations of behavior or interactive patterns, and other data. In considering this information, we encourage nurses to ask themselves what they think the other staff thinks about
what they are saying. We believe the most relevant hypotheses are generally
based on information already provided by the family.
Hypotheses can also be based on the nurse’s previous experience and
knowledge. This experience and knowledge can involve families whom the
nurse believes to have similar ethnic, racial, or religious or spiritual backgrounds. The nurse may recall similar problems, symptoms, or situations
and similar interactive patterns noticed with previous patients and families.
He or she may generate a hypothesis based on knowledge about family

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Chapter 6: How to Prepare for Family Interviews 201

development and life-cycle stages, research literature, or another conceptual
framework that he or she finds most relevant. We encourage nurses to include in their hypotheses ideas about a family’s strong spirit, generosity of
heart, devotion to one another, deep caring, and commitment. These are
enduring qualities that families can draw upon in times of stress.
In addition to formulating hypotheses based on information from or
about the family or from previous experience and knowledge, nurses may
develop hypotheses based on whatever is salient or relevant to them about
the health problem or risk that is encountered at the time. For example, if a
recent tragedy has occurred in the immediate community, the nurse may find
such information relevant in generating a hypothesis about what might be
most meaningful for this particular family at this point.
We believe that it is important for nurses to state (to themselves) their
hypotheses explicitly and consciously before the interview. We do not concur
with those who state that hypotheses are unnecessary. Our belief is that a
nurse cannot not hypothesize or think about a family before the meeting. It
is important for nurses to explicate their hunches so that these thoughts may
be refined and made transparent as nurse and family engage in the interview
process. Hypothesizing before the family meeting is viewed as a way to start
focusing on the family, churning up the gray matter, making connections,
and generating questions. It should not involve preparing an agenda for the
session that is imposed on the family regardless of what the family members
desire and despite changes that may have occurred since the last meeting
(see Chapter 11 for ideas of how to avoid these kind of mistakes).
The guidelines for designing hypotheses, presented in Box 6–6, have
been adapted from the work of Fleuridas, Nelson, and Rosenthal (1986). We
encourage nurses to generate hypotheses that are useful. We do not believe
that there is one “correct” or “right” hypothesis. Rather, the goal is to generate useful explanations that lead to desired outcomes. We believe that stories

Box 6-6

Guidelines for Generating Hypotheses

• Choose hypotheses that are useful.
• Generate the most helpful explanations of the family’s behaviors for this particular
time.
• Understand that there are no “right” or “true” explanations.
• Include all participants in the “problem-organizing system” to make the hypothesis as
systemic as possible.
• Relate the hypothesis to the family’s presenting concerns so the interview can proceed along the lines most relevant to the family (versus those relevant to the nurse).
• Make the hypothesis different from the family’s hypothesis to introduce new information into the system and avoid being entrapped with the family in solutions that
are not working.
• Be as quick to discard unhelpful hypotheses as you are to generate new ones.

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202 Nurses and Family: A Guide to Family Assessment and Intervention

are authored through conversations. The story that is co-constructed between
the nurse and the family is uniquely personal. We cannot know which
hypotheses will fit for a particular family or where people’s stories will go.
We can only attune ourselves one piece at a time to the story as it unfolds.
We encourage nurses to design hypotheses that are circular rather than
linear—that is, a hypothesis that includes all the components of the system
(e.g., the family and the nurse) is most likely to be more circular than one
that includes either the nurse or the family. (See Chapters 2 and 3 for a
more in-depth discussion regarding circularity.) The hypothesis should be
related to the family’s concerns. This is important because, as previously
stated, a hypothesis guides the interview. For example, if the nurse develops
a hypothesis that is unrelated to the family’s concerns, he or she will ask
questions that do not relate to the family’s reason for coming to the interview
or health-care facility.
The nurse who is attuned to the family’s concerns will listen for openings,
through questions and reflective discussion, of problem-saturated stories and
unique outcomes (see Chapter 7). These outcomes, or “sparkling events,”
would not have been predicted in light of the problem-saturated story.
We remind ourselves that it is the clinician’s certainty about her beliefs and
opinions that can oppress and constrain opportunities to hear the patient’s
and family’s story as they experience it.
We also encourage nurses to design a hypothesis that is different from the
family’s explanation or hypothesis. For example, a family may have the explanation that Puichun is a “bad daughter” who is shirking her responsibility
by not caring for her elderly mother in her own home. The nurse, on the
other hand, may develop an alternate hypothesis that fits the same data. The
nurse’s hypothesis might be that Puichun is overwhelmed by having to take
care of her two preschool children while maintaining a full-time job. Thus,
she is stretched to the limit in also trying to take responsibility for her elderly
parent. Furthermore, Puichun’s elderly mother may be sensitive to her stress
and thus may be reluctant to live with her.
Once hypotheses have been designed, the nurse can use them to guide the
interview. The nurse can ask questions of each member and note the responses to questions, thus confirming, altering, or rejecting a hypothesis. In
conversation with families, the nurse should be sure to pay attention to the
small and the ordinary. We agree somewhat with the notion that the starting
point for hypotheses is arbitrary and intuitive but that hypotheses are either
validated or invalidated by evidence (i.e., they may be confirmed, rejected,
or modified). We remain acutely aware that our notion of validation and
evidence is just from our “observer perspective.”
Hypothesizing and interviewing constitute a reciprocal cycle and are
interdependent. The nurse develops a hypothesis, asks questions, converses
with the family about the “problem” and its influence on their lives, and
gathers evidence that either confirms or refutes the nurse’s hypothesis.

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Chapter 6: How to Prepare for Family Interviews 203

Box 6–7 illustrates questions that invite hypothesizing about the system and
the problem. As new information is generated, the nurse modifies the previous
hypothesis and evolves a more useful one. The goal of the interview is to bring
forth the family’s resources to deal with the presenting issue. More information about how to conduct family interviews is provided in Chapters 7 to 11.

Box 6-7

Questions That Invite Hypothesizing About the System
and the Problem

Who
Who is in the system? Who are the key players?
Who first noticed the problem?
Who is concerned about the problem?
Who is affected by the problem? (most, least)
Who is interested in keeping things the same? (most, least)
Who referred the system?
What
What is the problem at this time?
What is the meaning that the problem has for the system and for different members
of the system?
What solutions have been attempted?
What question(s) do I feel obliged to ask?
What beliefs perpetuate the problem?
What beliefs might be identified as core beliefs?
What beliefs are perpetuated by the problem?
What problems and solutions perpetuate the beliefs?
Why
Why is the system presenting at this time?
Where
Where has the information about this problem come from?
Where does the system see the problem originating?
Where does the system see the problem and the system going if there is no change
or if there is change?
When
When did the problem begin?
When did the problem begin in relation to another phenomenon of the system?
When does the problem occur?
When does the problem not occur?
How
How might a change in the problem affect other parts of the system (key players, relationships, beliefs)?
How does a change in one part of the system affect another part of the system or the
problem?
How will I know when my work with this system is over?
How might my work with this system constrain the system from finding its solution?

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204 Nurses and Family: A Guide to Family Assessment and Intervention

Leahey and Wright (1987) provide an example of how alternative hypotheses
can be generated before the first family meeting:
A nurse working in an extended-care facility noted that the family,
especially the 9- and 10-year-old children, avoided visiting their
41-year-old mother who had Huntington’s disease, and that the
patient’s symptoms worsened around visiting days. The children
seemed depressed and withdrawn every time they came to the
nursing unit on their monthly visits. During case conferences, the staff
wondered whether there might be a connection between the family’s
avoidance and the patient’s flailing and head banging. They
generated several hypotheses to explain why the family might be
avoiding the patient and why the patient’s symptoms seem to
exacerbate around the time of the family visits.
One hypothesis pertained to the children’s belief that head
banging and flailing were controllable. Perhaps the children felt that
their mother was not trying to control herself so she would not have
to return home to care for them. This made them angry and they
avoided her. An alternate hypothesis concerned the children’s
conflicting loyalties toward their mother and the aunt who took care
of them. Perhaps they felt that if they visited too often, their aunt might
think they did not appreciate her care. Thus they spaced out their visits
and seemed depressed and withdrawn. They demonstrated both
loyalty to their aunt and affection for their mother.
Yet a third hypothesis involved the children’s fears of developing
Huntington’s disease themselves. They avoided visiting and showed
sadness because of their own expectations of contracting the disease
(p. 60).

Having generated several hypotheses about the family and the problem
in its relational context, the nurse arranged a meeting with the family. The
purpose of the interview was to clarify how the family members wanted to
be involved with the patient and how the staff could be most helpful to them.
The nurse’s hypotheses were relevant to the purpose of the interview. She
did not know if the frequency of the family visits was a “problem” for either
the children or the patient. Rather, the staff had identified the problem. Thus,
the nurse chose to frame the purpose of the meeting as one in which the staff
wanted to know how they could be most helpful to both the family and
the patient during the patient’s hospitalization. The patient and family were
collaborating with the staff rather than the family being the object of care.

INTERVIEW SETTINGS
A family interview or meeting can take place anywhere: in the home
(e.g., kitchen, living room, patient’s bedroom), in an institution (e.g., bedside,
urgent care center, nurse’s clinic or office, used treatment room), or in the

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Chapter 6: How to Prepare for Family Interviews 205

community (e.g., interviewing room, school, office, health clinic, on the street
where a homeless family “resides”; on Skype for patients/families in remote
areas). Depending on the purpose of the clinical interview, some settings are
more conducive to beginning a therapeutic conversation than others. Nurses
and families, therefore, need to consider the advantages and disadvantages
of various settings. They should be flexible in choosing a setting that is appropriate for the specific purpose of the interview. We believe families should
be offered a choice of setting whenever possible.

Home Setting
Many nurses interview families in their home setting. There are some concrete advantages to interviewing in the home. Infants, children of all ages,
and older family members are able to be present more easily. Chances are
increased for meeting significant but perhaps elusive family members, such
as boarders, adolescents, or grandparents. Firsthand acquaintance with the
physical environment is also possible. For example, the presence of staircases
and the display of family photographs can be observed. The nurse can also
experience the family’s social environment; for example, rituals of eating,
challenges with mobility, or who answers the doorbell can be noted.
In addition to the concrete advantages to interviewing in the home, there
are also other advantages. These are particularly important if the nurse is
from a different social class or ethnic background than the family. Articulate
middle-class parents may report only the most exemplary family interactions
in the office or school. The nurse may thus have difficulty understanding
how the apparent competence of the parents and the banality of the reported
parent-child incidents are in such sharp contrast to the degree of behavioral
upset manifested by the child.
Lower-class families sometimes have difficulty bridging the gap and explaining their situation to middle-class nurses who are unfamiliar with their
home milieu. For example, a nurse suggests that an older woman prepare
her husband several small meals a day rather than one very large meal, which
he is unable to consume. The nurse did not know (and the family members
were too embarrassed to mention) that the family shared cooking facilities
with other people in their apartment building. A home interview can thus
give the nurse a clearer direction for therapeutic suggestions and can enhance
the relationship between the family and nurse.
However, the disadvantages of using the home setting for family interviews are the increased administrative and personal cost involved in the
nurse’s travel. In addition, the meeting may have far more disruptions and
may require the nurse to structure the interview flexibly. Nurses should also
be aware that a family’s home is their sanctuary. If family members are asked
in their own home to share intense and deep emotions, they are often left
without a retreat. For example, if abuse is an issue, the nurse should anticipate that the family’s affective disclosure would be quite intense. Perhaps

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206 Nurses and Family: A Guide to Family Assessment and Intervention

they will need more physical and psychological space to deal with the issues
than their home permits. On the other hand, if the purpose of the interview
is to facilitate shared grieving over the loss of a family member, the home
setting might be ideal.
Ideas about therapeutic boundaries and hierarchy, confidentiality, and the
timing and pacing of interventions can sometimes be challenged during home
interviews. Doubts and confusion about the usefulness of intervention are
not uncommon after nurses have experienced firsthand the economic deprivation of their clients. Experiencing families in their homes can teach nurses
there are small opportunities even when a client’s world seems to go under.
It can make them more confident and comfortable to hold clients’ hopelessness and helplessness and be with them to develop strategies to get unstuck,
rather than trying to rescue them.
The nurse can tell the family that he or she would like to have an interview
in the home “to get a better feel for their situation.” Explain that, in your
experience, there are frequently interruptions to an interview in the home
(e.g., telephone calls, texting, neighbors dropping in, children wanting to put
on the television or play computer games). Ask, “How should we handle this
if it comes up?” In this way, you have already set the stage for work, rather
than for visiting, and for a specific purpose to the interview. One way to handle social offerings, such as coffee or a cold drink, is to say, “Thanks, but
maybe we could work first and then have coffee afterward.” The work and
social boundaries are thus clearly identified. Keep in mind that although this
boundary might be useful for some nurses working with certain ethnic
groups, such a boundary might be offensive to families from other ethnic
groups or from rural areas.

Office, Hospital, or Other Work Setting
The greatest advantage of using the work setting for the interview is that the
setting is the nurse’s base or territory. Therefore, the nurse can capitalize on
the opportunity and adapt the setting to the needs of the interview. Fewer
telephone calls, mobile phones, and visitor interruptions are also possible.
Furthermore, the nurse has a greater opportunity to obtain consultation from
colleagues when interviewing the family in the work setting.
Disadvantages of interviewing in the work setting concern issues of context. A family might be intimidated by the professional trappings (e.g., large
institution, plush furniture, complicated equipment) of the office and therefore may display anxiety or reluctance to talk. Suggestions for how beginning
interviewers can maximize privacy in hospital settings are given later in this
chapter.
Another disadvantage of using the institution for interviewing can be the
inadvertent fostering of the belief that pathology resides in the individual—
for example, “Mom’s the sick one. We’re only coming to help Mom get over
her depression.” This attitude is particularly evident if the mother has been
hospitalized in a psychiatric unit. This disadvantage can be handled by using

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Chapter 6: How to Prepare for Family Interviews 207

the family’s willingness to “help Mom.” The interviewer can reframe or
discuss the mother’s hospitalization in a positive light, for example, by saying, “Perhaps your mother’s hospitalization has provided the family with an
opportunity to all work together in a new way.”
How to Use the Work Setting

Some hospitals, clinics, or universities have elaborate interviewing rooms,
but most nurses must make do with the usual hospital or clinic facilities.
Therefore, they may have to negotiate with coworkers for space and privacy.
We recommend that you choose a private place where you will not be
interrupted. For example, an unused patient room or an office is often more
quiet and private than a four-bed room with curtains, a visitor’s lounge, or
a waiting area. Remove any important or intimidating equipment (such as
machines and monitors). The discussion area should ideally be sparsely
furnished with movable chairs and no big desks, couches, or examining
tables. This allows family members to control their own space, move closer
or farther away from someone, and not worry about children touching
hospital equipment. A few quiet toys, such as rubber or cloth hand puppets
or paper and crayons, are useful to have readily available in the room. Books
and magazines should not be available during the interview because they give
a mixed message to the family, especially to adolescents. The participants
should expect to discuss issues; they should not expect to read during the
interview.
Acquaint yourself with the physical layout of the room before the session.
This is likely to increase your feelings of comfort when first meeting the family.
At the beginning of the interview, if children are present, you can say to the
parents, “I’d like you to handle the children in whatever way you usually do.
That will give me a better idea of how things go at home.” If the baby starts
to cry, observe who comforts the baby. If the noise level gets beyond your
tolerance, notice what tolerance level the family has. Unless absolutely necessary, try to avoid giving behavioral directives (e.g., “Watch out for that plant,”
or “Don’t touch Dad’s chest tube”) during the first interview unless they are
required for safety. Valuable information can be lost if you impose your standards of behavior upon family members. At the same time, be sure to structure
the interview to avoid chaos and thereby lose your therapeutic leverage.
At the end of the session, assess the influence of the work setting. Ask
family members if they behaved differently than they usually do: for example,
“Did the children behave better or worse today than they usually do at
home?” or “Were family members more or less talkative than usual than
they are at home?”

WHO WILL BE PRESENT
Deciding who will be present for the first and subsequent interviews is
important. The decision is generally determined together by family members
and the nurse. In our early days of working with families, we thought it

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208 Nurses and Family: A Guide to Family Assessment and Intervention

imperative that all family members be present for family interviewing. However, we have significantly changed in our thinking about who should come
to the meetings. We now believe that a nurse can develop hypotheses, assess,
and intervene with a family regardless of who is in the interviewing room.
The number of family members sitting in front of a nurse does not constitute
family nursing. Rather, what is more important is how the nurse conceptualizes human suffering, problems, and solutions. See Chapter 10 for a clinical
vignette where Dr. Lorraine Wright interviews an individual to gain a family
perspective about chronic illness.
We believe that nurses who are beginning to interview families will generally find it easiest to invite everyone living in the household to be present
for the first interview. In this way, the nurse can more easily elicit information
from members who most likely have a description of the problem, concern,
or illness. To begin family work by interviewing just one person reduces the
number of perspectives on the concerns, but it is still possible to inquire
about family functioning even if seeing only one family member. If the problem concerns a couple, we usually try to have both spouses together for the
first meeting. Similarly, if the issue is parenting-related, and it is a heterosexual couple, then the father, mother, and child should all be invited to the
meeting.
The more family members present, the more information it is possible to
gather. In addition, the more viewpoints and descriptions by family members
of the influence of the problem or illness on their lives and relationships can
then be considered by the nurse. Family members at the first interview might
include the young children, the grandparent “who never has much to say,”
and the nephew “who just moved in for the weekend.” Sometimes the most
significant thing that the nurse is able to accomplish in a family interview is
just to bring the whole family together in one spot at one time to discuss an
important issue. When deciding who to invite to the first meeting, we believe
it is very useful to consider the network of professional resources involved
with the family as well as the family members themselves. We believe that
relational family nursing is best practiced in context.
Nurses frequently question whether they should include in the first
interview psychotic family members, those who are mentally or cognitively
handicapped, or elderly family members who are experiencing dementia or
Alzheimer’s disease. Generally, the answer is yes. Including these members
provides the nurse with an opportunity to talk with the family about the impact of the psychosis, mental handicap, or dementia on the family. In addition,
it shows the nurse how the family and individual interact to deal with the presenting problem. A clinical example may help to illustrate this point. A family
requested help for their 6-year-old daughter, who was “regressing, having
imaginary friends, and refusing to play with peers or go to school.” During
the initial interview, the little girl walked over to the door and turned the
doorknob. The nurse asked her not to leave the room. In response, the girl’s
siblings said that she was not leaving but rather “was letting the cat out the

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Chapter 6: How to Prepare for Family Interviews 209

door.” The nurse looked a bit startled because there was no cat in the room.
The nurse then asked the other children how they knew that this was what
the little girl was doing and proceeded to inquire if this was how they usually
responded to the child’s behavior. Had the “psychotic child” not been
present, the nurse would have been unaware of the siblings’ contribution to
perpetuating the presenting problem.
Deciding who should be present for the first meeting is an important indicator of the collaborative nurse–family relationship. It is important for the
nurse to be aware of who is in relevant conversation with whom about the
problem or illness outside the interview room. Given the ever-increasing use
of telecommunication devices such as e-mail, chat rooms, Skype, Facebook,
and text messaging, it is useful for nurses to inquire not just about the family
contacts in the immediate vicinity but also those online. We must respect
family members’ ideas about what is germane to the conversation and who
should be involved in it. We recommend that all decisions about who should
be involved in meetings, when, and what is talked about are determined
collaboratively, one conversation at a time.

FIRST CONTACT WITH THE FAMILY
The way in which the nurse makes the first contact with the family conveys
an important message to the parents and the children. We believe that the
quality of the nurse’s relationship with the family, in addition to manners
and etiquette, are important ingredients for accountable and effective therapeutic engagement. Good manners and etiquette may help manage deep currents of tension and ease potentially awkward situations. Manners such as
respect, tact, and humility can go a long way in establishing the nurse–family
relationship. Madsen (2007) suggests “there is a long history of tension
between professionals and poor and working-class people that is often invisible to professionals but painfully apparent to the poor and working
classes” (p. 98; see Chapter 9 for more ideas about using manners in relational practice). By inviting each person in the household to the family
meeting, the nurse implicitly states that each is a significant family member
and each has a role to play in understanding, describing, and dealing with
the problem.
The rationale for involving as many family members as possible can be
explained in several ways. If a baby is in the intensive care nursery, the nurse
might use the following explanation: “When a baby is in the intensive care
nursery, we frequently find that family members are concerned and often
anxious as well. Bringing family members together results in more information for the whole family on how best to help the baby.” Another idea is for
the nurse to say, “Years ago, fathers and family members were kept out of
the delivery room and out of the hospital units. We’ve learned, though, how
important it is to have family members present for special events such as the
birth of a baby. Now we recognize that it is even more important for family

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210 Nurses and Family: A Guide to Family Assessment and Intervention

members to be present and involved in health care when there is some type
of illness. Family members know and care about each other. In many cases,
they have a lot to offer each other.”
With families experiencing a crisis, such as the diagnosis of a stage 4
glioblastoma in a previously healthy 62-year-old father, nurses may want to
focus on providing physical information relating to the patient. Nurses can
also see if the family is interested in hearing about services for families coping
with the sudden onset of a life-threatening illness. They may state that in
times of crisis, families often find comfort in meeting with health professionals so that they can gain accurate, up-to-date patient information. Nurses
are aware from their knowledge of crisis theory that the time frame for intervention is limited because crises are self-limiting. Assertiveness and a calm
demeanor are generally useful postures for nurses to take when a family is
overwhelmed by a crisis.
Spouses sometimes agree to come for an interview but object to either
having the children present or taking the children out of school. One way to
handle the latter problem is to have meetings before school, during the lunch
hour, after school, or in the evening. If this is not possible because of the
nurse’s work schedule, the nurse may say, “I understand your concern about
the children missing school. In my experience, however, children have a
tremendous amount to contribute to a family interview. They generally feel
quite relieved when they see that the family is dealing with an issue about
which they may have been worrying. Schools also are usually quite agreeable
to children missing an hour.”

How to Set Up an Appointment
On an outpatient basis, the purpose of the initial telephone contact with the
family is to set up an appointment for an interview, explain the rationale for
involving family members, and determine with the family who will be present
at the interview. Naturally, both nurse and family gather much useful information about each other over the telephone. Telephone contact is therefore
part of the development of a collaborative working relationship, and the
nurse should treat it as such.
Generally, the first telephone contact sets the stage for subsequent interviews. Our advice is to pay careful attention to this contact, whether you
call the family to set up an appointment or a family member calls you. The
following is a sample first telephone contact:
Mother: Hello.
Nurse: Mrs. Garcia, this is Amrita Virk. I’m the community
health nurse in your neighborhood.
Mother: Yes.
Nurse: I understand that you have a new baby. It’s our
practice to come out and visit all families with new babies.

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Chapter 6: How to Prepare for Family Interviews 211

Mother: Oh, I didn’t know that.
Nurse: Yes, we usually do a physical examination of the
baby and discuss feeding or other concerns.
Mother: Oh, that seems like a good idea. The doctor didn’t
tell me much about feeding.
Nurse: Sure, we can get into that during our visit. I was just
calling to set up a time that would be convenient for your
family and for me. I would like to see the whole family because usually, when a new baby arrives, the child has a great
impact, not just on the mother but on the father and other
children as well.
Mother: You can say that again! My 2-year-old usually
seems to like his baby sister, but last night I saw him pinch
her.
Nurse: Yes, these are the kinds of things that we can discuss
when the whole family and I get together. The meeting will
probably take about an hour. I have some time available on
Tuesday at 10:00 or on Thursday at 3:00. Which would be
best for you, the baby’s father, and the children?
Mother: Tuesday isn’t good because my son is going to the
doctor that day. Thursday would be better since my husband works shifts and gets off at 2:30. But I should tell you
that my husband didn’t like the last nurse because she made
some negative comments about his tattoos and piercings.
Nurse: Let me reassure you, I’m fine with people expressing
themselves in body art. Would a 3:00 appointment give
him enough time to get home, or should we make the
appointment at 3:15?
Mother: Yes, 3:15 would be better.
Nurse: I look forward to seeing you and the whole family
then.
Mother: Yes, me too.
Nurse: Good-bye.
Mother: ‘Bye.
In the previous selection, the nurse was clear, confident, focused, and accommodating. She set forth the purpose of the interview and who she
thought should be involved. She invited the family to a “meeting” by stating
that this is the clinic’s usual practice. She responded directly to Mrs. Garcia’s
concern about tattoos and piercings. Whether the nurse refers to her collaborative time with a family as a “meeting” or an “interview” is arbitrary; it is
most important that the nurse use the most palatable language with families

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212 Nurses and Family: A Guide to Family Assessment and Intervention

based on the context in which she encounters them. The nurse took charge
by identifying and introducing herself without apologies and offered specific
appointment times. Furthermore, the nurse received much information that
can be useful in the family meeting:
“The doctor didn’t tell me much about feeding.”
“I saw [the 2-year-old] pinch her.”
“My son is going to the doctor . . .”
“My husband works shifts . . .”
It is not possible to provide written guidelines to cover all the various situations that nurses will encounter in trying to set up a family interview. Some
suggestions for involving fathers include:
■ Emphasize the value and importance of fathers’ perceptions and observations.
■ Demonstrate respect for the father’s time by asking if the telephone call
was made at a convenient time.
■ Use positive verbal cues (e.g., common courtesies, personal titles, a
cheerful and interested tone of voice, positive phrases, and affirming
remarks) in order to maintain rapport.
Each family presents different challenges for the nurse, and vice versa.
Therefore, each interview must be approached with flexibility. A unique
approach is always the rule in clinical practice. Each telephone contact
demands a slightly different plan of action to invite family members to an
interview or to elicit the family’s permission for a home visit. We strongly
encourage nurses, especially community health nurses, to plan their
telephone calls and appointments to maximize efficiency and the possibility
of developing a collaborative partnership with the family. We generally do
not recommend that appointments be set up by e-mail or text, as there can
be issues of confidentiality and ambiguity about how promptly the e-mail or
text will be responded to and by whom. However, we do recognize that, in
some rural or very remote areas, setting up and even offering family meetings may be done online via Skype, e-mail, or instant messaging. Online
family meetings may prove to be very useful if a face-to-face meeting is not
possible.

RESISTANCE AND NONCOMPLIANCE
Often in our clinical supervision with nurses, we have been asked how to
deal with resistant, difficult, or noncompliant families. When nurses ask
this, they are generally referring to families whom they perceive to be “in
denial,” oppositional, or noncompliant with ideas and advice that they have
offered or could offer to promote, maintain, or restore health. The family is
designated as noncompliant when they do not respond to particular nursing

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Chapter 6: How to Prepare for Family Interviews 213

interventions; nurses often interpret this behavior as unwillingness or a lack
of readiness to change (Wright & Levac, 1992).
We do not use the terms resistance and noncompliance, because we have
not found them clinically useful in relational family nursing practice. Resistance was initially used to describe a client’s reluctance to uncover or recover
from some anxiety-filled experience. Resistance is still generally viewed as
“located” in the client and is often described as something the client “does.”
This is a linear view that implies that problems with adherence to treatment
regimens reside within individuals and families, not in the interactions or relationships between individuals. However, we see the idea of resistance as a
product of client–interviewer interaction. We believe that resistance and noncompliance are not terms describing a unilateral phenomenon but rather an
interactional phenomenon.
Rather than using these terms, we have found the multidirectional terms
cooperation and collaboration to be very useful clinically. When nurses
think of how they work collaboratively with families, they are less likely to
impose their will on them. They tend to open space for the family and to
be more tentative and receptive to the family’s point of view. For example,
they welcome the opportunity to offer their time (Miller, et al, 2011), respond
to what they might perceive as challenging questions, sit with the client,
not minimize the situation, apologize if indicated, seek solutions (e.g., “What
can we do to move forward on this?”), speak in positive terms (e.g., “I
will have your lab results by . . .” vs. “I can’t get them until . . .”), and
so forth.
The theory behind the “death of resistance” has emerged since our first
edition of Nurses and Families. The result has been a dramatic increase in a
solution-focused, strengths-based, and resiliency orientation to family interviewing (Bell & Wright, 2011; Hougher Limacher & Wright, 2006; Madsen,
2007; Walsh, 2011). With emphasis on a solution comes an increasing emphasis on change, cooperation, and collaboration. They open us to reflect
on conversation, language, and possibilities rather than pathologizing labels.
We are especially partial to the work of Miller and Duncan (2000), who
advocate client-directed, outcome-informed clinical work as compared to a
model-driven focus. The “common factors” (Hubble, Duncan, & Miller,
1999) associated with positive outcomes include:
■ Extra-therapeutic factors, including clients’ beliefs about change,
strengths, resiliencies, and chance-occurring positive events in clients’
lives (40%)
■ The client–therapist relationship experienced as empathic, collaborative,
and affirmative in focusing on goals, methods, and pace of treatment
(30%)
■ Hope and expectancy about the possibility of change (15%)
■ Structure and focus of a model or approach in organizing the treatment
(15%)

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214 Nurses and Family: A Guide to Family Assessment and Intervention

How to Deal With a Hesitant Family Member
A spouse may be hesitant to attend the family session for several possible
reasons. Each requires a different approach on the part of the nurse. The
following are a few common situations that interviewers encounter:
1. “My husband would never come to a family interview. He thinks that
my mother’s stroke and how to handle it are my responsibility.”
Ask what the wife thinks about her husband attending the interview. If
she believes her mother’s chronic illness is her responsibility and has
very little to do with her husband, she will not be interested in inviting
her husband to a family interview. You would need to engage in
conversation with the wife to see if she wants to alter her cognitive set
before you start talking to her about her husband.
2. “My husband wouldn’t want to come to a family interview. Besides, I
wouldn’t know how to get him there.”
If the wife would like her husband to attend but does not know how
to invite him, you can explore with her why she feels her husband might
be hesitant. There could be several reasons:
■ He may view the problem as his wife’s, not his own.
■ The timing of the interview might be inconvenient.
■ The thought of going to a hospital might be repugnant (“seeing all
those sick people”).
■ He may be afraid of being blamed for not taking a more active role
in his mother-in-law’s care.
You can ask the wife if she thinks any of these feelings or thoughts might
be stopping her husband from becoming involved. After she has speculated
on the reasons for her husband’s hesitance and her own desire for him to be
present, you can discuss with her some alternate ways to engage him:
■ She can discuss with her husband how she needs his help to deal with
her mother’s illness.
■
■
■

She can find out convenient times for her husband to come to a halfhour meeting.
She can tell him exactly where the interview will be held (e.g., not in
the patient’s room but in an office).
She can tell him that the nurse is most hesitant to see only parts of the
family for a meeting. That is, if you saw only the wife with her mother,
there could be a danger that the husband would feel left out and perhaps blamed. If he were present, however, this could not happen. He
could help you to understand more fully the relationship between his
wife and her mother. The wife can let him know that he has a unique
view of the family—a view that only he can provide. Most husbands
do not like to be left out of the original planning and decision making.

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Once they have a fuller understanding of the purpose of a family interview, they are often quite agreeable to attending.
Although it may involve a little persuasion, when nurse interviewers ask
that the husband attend and state that they need him to be there, they are
likely to have few problems with absent husbands. Conversely, nurses are
likely to have difficulties in this area if they are timid or inconsistent in requesting the husband’s presence.
We believe it is important for nurses to recognize that husbands and wives
may be at different stages in their desire to seek help. Some of this may be
attributable to gender differences, with females generally more likely than
males to utilize social support networks. Women are more than twice as
likely as men to speak to someone about their problems. It seems likely, then,
that wives would lead the discussion regarding assistance and help their husbands along the process.
Another idea for inviting an anxious or a threatened family member to
an interview is to suggest that the person be asked to be present as an observer, just to see what is happening. Also, the person can come whenever
he or she is “in the mood” as a historian, an accuracy checker, or a consultant. If these suggestions are followed, it is important to ask the “observer”
or “historian” to react at the end of the interview to what the family has discussed in the session. Gradually, as the family member continues to observe
sessions, he or she often becomes more comfortable and is willing to participate during the interview. This may be a particularly useful way of engaging
some adolescents. Telling the member not to talk places no direct pressure
on that member to participate. Silent members are often closely attuned to
the process, and when a sensitive area is broached, they forget their defensive
stance and join in the process. Other times, they may remain silent but hear
the information.

How to Deal With Family Nonengagement
and Referral Sources
If you have difficulty engaging the family on the telephone, you may need to
contact the referral source—that is, physicians frequently tell a patient on
discharge, “The nurse will be out to check on you and see how you are
doing.” When you contact the patient, the patient may have forgotten what
the physician said, may be confused about the purpose of the visit, or simply
may not be interested in being “checked on.”
Sometimes in situations of suspected child abuse, the physician may contact the nurse and ask him or her to drop in on the family just to see if there
is any abuse. You may then find yourself in an awkward situation, trying to
explain the purpose of your visit to a family who may be reluctant to have
you come. One way to approach this is to say, “Doctor Fishkin asked me to
set up a visit with your family to discuss issues about raising children.
Dr. Fishkin feels that most families who have infants and preschoolers who

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216 Nurses and Family: A Guide to Family Assessment and Intervention

are close in age sometimes find it helpful to talk to a nurse.” In approaching
the situation this way, you have clearly indicated that it is on Dr. Fishkin’s
request that you are calling, and you have attempted to normalize the purpose of the interview. If, however, the family is still reluctant to have you
visit, initiate contact with the physician and have the physician set the stage
for future work with the family. You should not consider this inability to engage a family your fault or the fault of the family, but rather as a problem of
inadequate preparation by the referral source.
Several other ideas have emerged over the past few years about dealing
with referral sources. We find it best for interviewers to avoid focusing prematurely on family dynamics if the request for the interview comes from another agency or if the interview is compulsory. Treatment failure often ensues
because of powerful conflict between the family and the referral source. In
such situations, we recommend that the nurse engage the family and conceptualize their work together as collaboration to deal not with family issues
per se, but with dynamics between the family and the agency. In this way,
the interviewer can join with the family around a problem such as, “That
school is always making trouble for us.” Thus, the focus of the nurse’s work
would not be on family dynamics but on work with the family to “get the
school off their case.”
We believe that the interviewer must identify and grapple with the expectations of the person referring the “problem family” for assessment. Some
useful questions to ask include:
■ Why is this referral being made to me at this time?
■ What is the relationship between the referral source and my agency?
■ Who is paying? For whom? For what?
■ What are the expectations of the hierarchy within which I work?
■ If the referral source is unhappy with the assessment, who will hear
about it?
■ If I am unhappy about the assessment process, who will hear about it?
In any situation in which nonengagement occurs, the nurse must realize
that the reluctance provides important information about the dynamics between the interviewer and the family. The hypothesized reason that a person
is not present should be explored at the first interview. For example, we
were once asked to consult with the family members of a 59-year-old
woman who had terminal cancer. The hospital staff nurse arranged the interview for a time convenient for the husband and adult daughter. However,
only the daughter and the mother showed up for the interview. In exploring
the reasons that the husband did not attend, we discovered that he was
73 years old and in poor health himself, a fact unknown to the hospital staff.
By asking the adult daughter about the impact of her mother’s illness, we
also discovered information about the father’s absence. The daughter
wept openly about her mother’s impending death. She then stated, “If you

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Chapter 6: How to Prepare for Family Interviews 217

think I’m a basket case, you should see my father. He’s in worse shape
than I am.” Thus, in this situation, the husband’s absence from the interview
provided important information about the family’s emotional state. It is
important for nurses to understand reluctance as a systems phenomenon
rather than an individual issue. In this case, we hypothesized not only that
the father was reluctant to attend but also that the adult daughter was trying
to protect him.

CONCLUSIONS
In preparing for family interviews, it is important for nurses to first remind
themselves of the type of relationship they would like to develop with the
client and the purpose of the family meeting and then to generate hypotheses
related to this purpose. Box 6–8 outlines areas for nurses to consider in
preparing for family interviews. These ideas are the result of striving toward
a collaborative relationship between the nurse and the family.
Box 6-8

Helpful Hints for Planning a Family Meeting

Before initiating a family meeting, the nurse needs to:
• Ascertain the purpose and benefit of a family meeting from the family’s perspective.
• Explain why a family meeting may be beneficial to the family.
• Determine who in the family agrees that a problem exists, and who might be willing
to come to a family meeting.
• Mutually determine with the family when and where a meeting could take place
(home, office, school).
• Read literature about working with families experiencing similar health problems to
better understand the issues, concerns, and lived experiences of that specific population.
• Begin to formulate hypotheses (explanations about the family’s behaviors that connect the family system and the particular problem).
• Prepare linear and circular questions that will elicit relevant data about family structure, development, and function. (See the discussions of CFAM in Chapter 3 and
CFIM in Chapter 4 for examples of questions.)
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.). St. Louis: Mosby,
pp. 10–19. Copyright 2002. Adapted with permission from A.M.C. Levac, L.M. Wright, & M. Leahey.

References
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Bell, J.M., & Wright, L.M. (2011). Creating practice knowledge for families experiencing
illness suffering: The Illness Beliefs Model. In E. Svavarsdottir & H. Jonsdottir (Eds.):
Family Nursing in Action. Reykjavik, Iceland: University of Iceland Press, pp. 15–52.
Benzein, E., Johansson, P., Arenstedt, K., et al. (2008). Nurses’ attitudes towards
families’ importance in nursing care – a survey of Swedish nurses. Journal of Family
Nursing, 14(2), 162-180.

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Bergadahl, E., Benzein, E., Ternestedt, B., et al. (2011). Development of nurses’ abilities
to reflect on how to create good caring relationships with patients in palliative care: An
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Burke, S.O., et al. (2001). Effects of stress-point intervention with families of repeatedly
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Duran, C.R., et al. (2007). Attitudes toward and beliefs about family presence: A survey
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Fleuridas, C., Nelson, T., & Rosenthal, D. (1986). The evolution of circular questions:
Training family therapists. Journal of Marital and Family Therapy, 12(2), 113–127.
Foucault, D., Leahey, M., Harper-Jaques, S., et al. (2008). Perceptions of family involvement
in mental health care: Through the lens of clients and their families. Presentation at Institute
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Hougher Limacher, L., & Wright, L.M. (2006). Exploring the therapeutic intervention
of commendations: Insights from research. Journal of Family Nursing, 12(3), 307–331.
Hubble, M.A., Duncan, B.L., & Miller, S.D. (1999). Introduction. In M.A. Hubble, B.L.
Duncan, & S.D. Miller (Eds.): The Heart & Soul of Change: What Works in Therapy.
Washington, DC: American Psychological Association, pp. 1–19.
Jonsdottir, H., & Ingadottir, T.S. (2011). Nursing practice partnership with families
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Nursing in Action. Reykjavik, University of Iceland Press, pp. 357–375.
Leahey, M., & Harper-Jaques, S. (1996). Family-nurse relationships: Core assumptions
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Leahey, M., & Wright, L.M. (1987). Families and chronic illness: Assumptions,
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Chronic Illness. Springhouse, PA: Springhouse, pp. 55–76.
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.). St. Louis: Mosby, pp. 10–19.
Madsen, W.C. (2007). Collaborative Therapy With Multi-Stressed Families. New York:
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Sveinbjarnadottir, E.K., Svavarsdottir, E.K., & Saveman, B.I. (2011). Nurses attitudes
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Tapp, D.M. (2000). The ethics of relational stance in family nursing: Resisting the view
of “nurse as expert.” Journal of Family Nursing, 6(1), 69–91.
Walsh, F. (2011). Strengthening Family Resilience. 2nd Ed., New York, NY: Guilford
Press.
Wright, L.M., & Bell, J.M. (2009). Belief and Illness: A Model to Invite Healing.
Calgary, AB: 4th Floor Press.
Wright, L.M., & Levac, A.M. (1992). The non-existence of non-compliant families: The
influence of Humberto Maturana. Journal of Advanced Nursing, 17, 913–917.

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Chapter

7

How to Conduct Family
Interviews
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.
In this chapter, we present guidelines for each stage of an initial family interview. Afterward, we address the stages involved in the entire interviewing
process.

GUIDELINES FOR FAMILY INTERVIEWS
The following stages generally occur in initial interviews:
1. Engagement stage: The family is greeted, made comfortable, and the
relationship continues.
2. Assessment stage:
■ Problem identification, in which the nurse explores the family’s
presenting concerns and/or suffering.
■ Relationship between family interaction and health problem, in
which 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, in which the family and nurse talk about the
solutions the family has tried and their effects on the presenting issues.
■ Goal exploration, in which 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 softening in their suffering in the emotional, physical,
and/or spiritual domains).
219

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220 Nurses and Families: A Guide to Family Assessment and Intervention

3. Intervention stage: The nurse and family collaborate on areas for
desired change.
4. Termination stage: The nurse and family conclude the interview.

Engagement Stage
During the engagement, or first stage of the interview, the nurse and family
begin to establish a therapeutic relationship. Engagement has several purposes
(Box 7–1). The goal is for family members and the nurse to develop a mutual
alliance so that they can collaborate on the desired changes. 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. 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. 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 health-care 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. Thorne and Robinson
(1989) state that this reconstructed trust is highly selective and is based on revised expectations of the roles of both patient and provider. They suggest that
there are four relationship types in guarded alliance: hero worship, resignation,
consumerism, and team playing. In hero worship and team playing the trust
dimension is high, whereas in resignation and consumerism it is low. Both team
playing and consumerism place a high value on competence, whereas hero
worship and resignation put a low value on competence. Important guidelines
for the engagement of families with children are provided in Box 7–2.

Box 7-1

Purpose of Engagement

• To promote a positive nurse–family relationship by developing an atmosphere of
comfort, mutual trust, and cooperation between the nurse and the family
• To recognize that the family members bring strengths and resources to this relationship that may have previously gone unnoticed by health-care professionals
• To 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.).
St. Louis: Mosby, p. 11. Copyright 2002. Adapted with permission.

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Chapter 7: How to Conduct Family Interviews 221

Box 7-2

The ABCs of Engaging Families

A
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.

B
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).

C
Create a context of
mutual trust.

Clarify expectations about
your role with the family.

Collaborate in decisionmaking, 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.). St. Louis:
Mosby, p. 11. 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.
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.

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222 Nurses and Families: A Guide to Family Assessment and Intervention

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.
Increased societal, professional, and personal experiences with fear and
suffering have caused nurses to engage clients in more personal, open ways
than ever before, especially since September 11, 2001. The societal experiences of large-scale death, both foreign and domestic terrorism (e.g., the
Virginia Tech massacre), and revolutions such as the Arab Spring have made
nurse relationships with families more human, less clinical, and more transparent. Nurses’ own sufferings and losses of family members and friends
also enhance this transparency. Therapeutic relationships in recent years
have become less formal, more connected as nurses experience similar fears
and suffering when crises erupt or illness or loss occurs.
Wright and Bell (2009) pose a reflective question when they ask, “Are
clinicians to remain neutral and non-hierarchical when confronted with illegal or dangerous behaviors?” They answer this important question by stating that each family functions in the way that members desire and in a way
that they determine most effective. However, being part of a larger system,
nurses are bound by moral, ethical, legal, cultural, and societal norms that
require them to act in accordance with those norms in regard to illegal
or dangerous behavior. Cecchin (1987) assented that, in these situations,
“clinicians may need to take a different position—one which is distinct from
a non-hierarchical, collaborative stance. Confronted by illegal behavior, a
nurse may have to abandon a curious, therapeutic manner and become a
social controller” (p. 409) in order to conform to the moral or legal rules
and their consequences.
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.
Sunder’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

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Chapter 7: How to Conduct Family Interviews 223

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 ex-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 their lives. 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 their family functioning in the
context of illness, loss, or disability.
Nurses should initially attempt to spend an equal amount of time with
each family member. We suggest that the nurse ask the same question or a
similar one 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.
Examples of questions used to foster a collaborative working relationship
and engagement have been offered by Levac, Wright, and Leahey (2002).
These provide an implicit message to family members that the practitioner
cares about them. They also provide opportunities for the family to exert

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224 Nurses and Families: A Guide to Family Assessment and Intervention

more power in the conversation, voice concerns, and clarify the working
arrangement. Some examples are:
■ What was most and least useful in your past relationships with health
professionals like me?
■ If you become frustrated with our work together, would you be open
to having a conversation with me about your concerns?
■ On a scale of 1 to 10 (with 1 being very low and 10 being very high),
how well do you think I understand your situation?
■ In what ways was our discussion useful (or not) to each of you?
Both students and practicing nurses have often asked us for tips on how
to deal with verbose clients. Some ideas we have found helpful include:
■ Letting the person tell his or her illness story or particular concern.
■ Setting 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?”
■ Saying, “I know we only have time to skim the surface today in talking
about your experiences, so what shall we focus on?”
■ Explaining, “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?”
■ Taking a break to pull your thoughts together or to seek a consult.
■ Stopping the discussion and setting 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?”
■ Using humor and interrupting by saying something such as, “Seems like
we could talk all day about this issue, but I’m mindful of the time.”
■ Determining 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?”
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:
1. 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 softening suffering.
2. The health-care provider will try to facilitate change, but the ultimate
agent of change is the patient/family.

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Chapter 7: How to Conduct Family Interviews 225

3. 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 foundations of
the therapeutic process (Bell & Wright, 2011; 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 should feel that the
nurse is willing to listen and witness their voice, 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, ambivalent/low hope, to solid hope.
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, 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 their experience as skilled immigrants who have made tremendous
sacrifices to stand up to oppressive regimes, learn a new language, and make
a significant move to a new country. She could wonder how this stamina might
now serve the family as they stand together against illness.
If the engagement relationship is not going well, we encourage nurses to
recognize this difficulty. For example, the nurse could tune into potential difficulties such as the client’s repetitions or interruptions. The nurse could acknowledge the difficulties to the patient and say, “I’m having trouble
understanding how you’d like me to help.” Or, “It doesn’t seem that this
visit is going the way you had hoped.” Or, “I would like to work with you
even though we see some things differently.”

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, and goals.

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226 Nurses and Families: A Guide to Family Assessment and Intervention

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, preferably at the end of the interview (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” (OQQ) suggested
by Wright (1989): “If you could have only one question answered during
our work together, what would that one question be?” At the end of the
clinical meeting, this is a particularly effective way to elicit the family’s deepest concern or greatest area of suffering (Duhamel, Dupuis, & Wright, 2009).
It provides a focus for the conversation and generates sharing of new information among family members and between the nurse and the family. For
example, the husband of a 44-year-old woman with newly diagnosed multiple myeloma asked, “How can I support my wife and children better during
this time?” The teenage daughter asked, “How can I learn more about my
mother’s illness?” The patient asked, “How long do I have to live?” The
young adult son asked, “Should I avoid having my friends come over to the
house so that the house can be quieter for my mother when she returns
home?” These four very different questions made it clear that each family
member had different concerns and issues, expectations for the interview,
and expectations for the relationship with the nurse. We are drawn to Madsen’s phrase “Honor before helping,” in which he reminds us how important
it is not to attempt to help a family without its authorization to do so (2007).
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.)
Leahey and Wright (1987) give examples of how to elicit the family’s concerns by asking circular questions that focus on the present, past, and future:
Present. The nurse should ask each family member, including the children,
to share their knowledge and understanding of the present situation. For
example, the community health nurse working with a family with teens could
ask such questions as:
■ What is the family’s main concern now about Mobina’s cyber-bullying?
■ How is this concern a problem for the family now as compared with
before?

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Chapter 7: How to Conduct Family Interviews 227
■
■

Who agrees with you that this is a problem? Is this a problem that
Mobina believes she has control over?
What is your explanation for this?

Past. In exploring the past, the nurse can again ask questions pertaining to:
■
■
■

Differences: How was Mobina’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
Mobina’s decision to stop using the family computer for her messaging?

Future. During the initial interview with a new family, the nurse must learn

about the family’s own hypotheses or beliefs about the problems. In asking
the family to explain the present situation, the nurse should attempt to
identify previously unrecognized connections. This might be accomplished
by asking such questions as:
■ 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 Mobina’s
relationship with Mom?
If children or adolescents are reluctant to identify concerns in the family, 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 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, the 8-year-old 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 oldest son, Raja, would have an insulin reaction.
Other ideas for involving children in interviews have also been presented.
For example, having paper, markers, and crayons in the office and using
strategies such as:
■ Art techniques (e.g., drawing a family picture)
■ Verbal techniques (e.g., the “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

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228 Nurses and Families: A Guide to Family Assessment and Intervention
■
■

Puppet and doll techniques to ask the family about interactions
Experiential techniques (e.g., family sculpture or “a can of worms in
action”)

Relationship differences can be explored by providing props, such as
scarves, hats, and glasses, to the children. This role-playing technique using
props enables children and adults to display their perceptions. Another idea
is to give the child an ordered array of pictures ranging from a frowning face
to a smiling face and then ask, “Which one of these is most like how you
and your brothers got along this week?” Engaging children through video
games offers many other possibilities. 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.
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. Box 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. Al-Krenawi (1998) points

Box 7-3

Factors to Consider in Defining the Problem

1. Presenting problem
• Specify
2. Problem identification
• 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)?
3. Problem evolution
• 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.

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Chapter 7: How to Conduct Family Interviews 229

out that Bedouin Arab patients routinely express their personal or family
problems in proverbs. For example, a wife of a husband engaged in
polygamy described how her husband’s multiple marriages affected her
deeply by saying, “My eye is blind and my hand is short.” She meant that
she felt unable to do anything (p. 73). Another example of how a presenting
problem can be described is how some African American couples frequently
use metaphors to describe issues. For example, a couple experiencing major
disagreement and conflict used the metaphor “a glass wall between us, we
can see each other, but we never seem to touch.” The nurse can identify conflict among family members about the problem definition if it arises. When
differences 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. To bring a family focus to the situation when interviewing an individual, the nurse could ask the following family-oriented questions:
1. Has anyone else in the family had this problem? (This addresses family
history.)
2. What do other family members believe caused the problem or could
treat the problem? (This explores the individual’s explanatory model
and health beliefs.)
3. Who in the family is most concerned about the problem? (This helps
to understand the relational context of the concern.)
4. Along with your illness and symptoms, have there been any other recent
changes in your family? (This addresses family stress and change.)
5. How can your family be helpful to you in dealing with this problem?
(This focuses on family support.)
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
thinks 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 Salahuddin has any control over the problem?”
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, “Yael, 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.

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230 Nurses and Families: A Guide to Family Assessment and Intervention

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 7–4 lists
some factors to consider in exploring family interaction related to the presenting problem. The nurse conceptualizes the information that he or she
has already 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.

Box 7-4

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.

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Chapter 7: How to Conduct Family Interviews 231

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 himself or herself and the family to consider.
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
inquire about differences between individuals: “Who is better at getting
Grandmother to make her meals, Shanghi or Puichun?” The nurse can also
inquire about differences between relationships: “Do your ex-husband and
José fight more or less than your ex-husband and Nadiya?” In working with
families with chronic or life-threatening illness, the nurse should explore
differences before or after important events or milestones. For example, the
nurse could ask, “Do you worry more, less, or the same about your wife’s
health since her emergency surgery?”
In addition to exploring areas of difference, the nurse can inquire about
areas of agreement or disagreement: “Who agrees with you that Brandon is
most likely to forget to give your mother her eyedrops three times per day?
Who disagrees with you?“ The nurse should explore the family’s explanation
for the sequence of interaction: “How do you understand Brandon’s tendency to be most forgetful about the eyedrops? 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 types of questions to

explore:
Differences: “How was Brandon’s caregiving different before he had highspeed Internet? How does that differ from now?”
Agreement or disagreement: “Who agrees with Murdock that Dad was
more involved in Genevieve’s exercise program?”
Explanation or 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 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, families 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

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232 Nurses and Families: A Guide to Family Assessment and Intervention

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, he or she 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. The nurse can
ask questions pertaining to:
Differences: “How would it be different if your grandfather did not side
with your mother against your father in managing Paola’s Crohn’s
disease?”
Agreement or disagreement: “Do you think your mother would agree that,
if your grandfather stayed out of the discussions, things would be
better?”
Explanation or meaning: “Dad, if your wife stopped phoning her father for
advice about Paola’s Crohn’s disease, what would that mean to you?”
We believe it is especially important to ask future-oriented questions
when working with families dealing with hereditary disorders such as
Huntington’s disease. For at-risk individuals, the possibility of detecting
the disease-provoking gene exists, but no treatment is available. It is not
so much the test result itself that may be disrupting to family life transitions
but instead the changed expectations and possibilities for the future.
During this part of the interview, the nurse attempts to gain a systemic
view of the situation and a description of the cycle of repeated interactions.
These interactions may be between family members or between family members and the nurse. We stress that it is not important for the nurse to understand or agree with the problem but instead to be curious about the family’s
description of its positive and negative impact. We are drawn to the idea
of using appreciative inquiry, a line of questioning that elicits and builds on
appreciated practices and engages family members in discussion with each
other about what works for them.
Such questions invite members to distinguish, understand, and amplify
the appreciated life-sustaining forces within their family. In this way, families
can take a “both/and” position. For example, they can relate the challenges
of trying to raise a child with Down syndrome and discuss how raising this
child has brought the family closer together and helped them pool their collective strengths and be a stronger family unit. Striking examples of how

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Chapter 7: How to Conduct Family Interviews 233

families have pooled their strengths to cope with a dying family member’s
illness have been recounted on numerous blogs and on Facebook.
During this phase of the interview, the nurse should be able to describe
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.
All of the scenarios previously described relate to clients who believe there
indeed is a problem, who believe they have some control over it, and who
want to see it changed. But, what of those 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. For example, a 16-year-old boy
verbally abused an elderly woman in his high school and then pushed her
off the elevator. When the principal asked what happened, he said, “Oh, it’s
nothing. We got into an argument because I didn’t let her get away with that
‘age stuff’ and let her on the elevator first. It’s no big deal.” His grandmother
whom he lived with stood by helplessly as the principal talked.
In situations where clients and helpers have different agendas for a meeting and different definitions of the problem, we believe it’s important for the
nurse not to inadvertently rigidify the interaction—that is, 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, as this generally
just 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 this typically invites defensiveness and
promotes shame. (Additional ideas on how not to give advice prematurely
are given in Chapter 11.)
Attempted Solutions to Solving Problems

During this next phase of the assessment, the nurse explores the family’s attempted solutions to the problem. Box 7–5 lists some factors to consider
when exploring the family’s attempted solutions. 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 Mandeep’s condition in previous hospitalizations?”
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

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234 Nurses and Families: A Guide to Family Assessment and Intervention

Box 7-5

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.

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.
In our work with families, we have frequently been told that no solutions
have been attempted or that “nothing has worked.” In these circumstances,
we sometimes ask, “How come things aren’t worse? What are you doing to
keep this situation from getting worse?” Then we amplify these problemsolving strategies by asking about their frequency, effectiveness, and so forth.
We also try to expand our view of typical solutions to include complementary
and alternative medical and health approaches.
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 be aware of additional “helping agencies” involved in
health-care delivery. We have found it important to ask questions such as,
“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

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Chapter 7: How to Conduct Family Interviews 235

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, the nurse can simply state to the family that she or he
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. Box 7–6 lists some factors for nurses to consider when exploring goals. Families are pragmatic: They
are seeking practical results when they come to a health-care 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.
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.”
There are many ways in which the nurse can clarify the family’s goals
with future or hypothetical questions such as, “What would your parents do
differently if they did not stay at home every evening with Snanna?” The
nurse can explore future or hypothetical areas of difference (e.g., “How

Box 7-6

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.

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236 Nurses and Families: A Guide to Family Assessment and Intervention

would your parents’ relationship be different if your dad allowed your uncle
to take care of Snanna one evening a week?”), areas of agreement or
disagreement (e.g., “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?”), and explanation or meaning (e.g., “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?”).
We find it useful sometimes 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” phenomena at the same time as inviting a richer
account of the history of the new/old story.
We have found it particularly useful in our clinical work to ask the “miracle question” (de Shazer, 1988) to elicit the family’s goals; de Shazer (1991)
describes the question in 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? (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.”
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 such as this:
Obviously, you want things to be better for your child and so do I.
(Validating the parent)
In order to make the most of this meeting, I’m going to ask you
an unusual question. (Bridging statement)
How will you know by the time you leave here today, that this
meeting has been helpful? (Shifting to the future)
When things are better, what will your son be doing? What will I
be doing? What will you be doing? (Including all the stakeholders in
the solution picture) (p. 192)

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Chapter 7: How to Conduct Family Interviews 237

Nurses working with families of a patient who has a chronic or lifethreatening illness commonly find family members quite vague about the
changes they expect. For example, “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 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.

GUIDELINES FOR THE REMAINING INTERVIEWING
PROCESS
Once the nurse has completed the initial interviews or assessment, he or she
can consider the entire interviewing process. The stages of the interviewing
process generally include:
1. Engagement
2. Assessment
3. Intervention
4. Termination

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, he or she
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.
Level of the Family’s Functioning

The nurse should recognize the complexity of the family situation. 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

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238 Nurses and Families: A Guide to Family Assessment and Intervention

it very idealistic. Community health nurses and mental health nurses, in particular, often work with families who are not referred early. Some of these
families present with several complex physical and emotional problems and
are frequently involved in one crisis after another. These families offer specific
challenges for nurses.
Our recommendation is that nurses 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 such 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.
The nurse must consider ethical issues in deciding who should be treated.
With the popularization of counseling, a surface inspection would seem to
indicate that everyone is in need of psychotherapy in one form or another.
The childless couple, the family with young infants, the family with adolescents, the single-parent family, and the aging family can all be considered
candidates for psychotherapeutic aid. Many people lead psychologically
constricted and difficult lives, but should they be “treated”? This is a troublesome question for helping professionals.
Our recommendation is that nurses ethically weigh two opposing positions when they decide to intervene with, refer, or discharge a family. One
position states that if a person is potentially dangerous to self or others, that
person must receive intervention. On an individual level, a suicidal or homicidal patient is such an example. On a larger system level, a family in which
there is physical, sexual, or emotional abuse or violence is an example.
On a community level, a person who is threatening to the community and
mentally unstable is an example.
Single-parent adoptive families as well as lesbian, gay, bisexual couples or
committed families are entitled to be considered various family forms versus
alternatives to “normal” families. It is our hope that nurses will ethically and
wisely consider the family’s level of functioning and their own legal responsibilities. This is a necessary step before deciding to offer further treatment.
This weighing of alternatives can be particularly challenging for nurses when
dealing with client confidentiality, crisis situations, and non-emancipated
minors. For example, a 16-year-old girl overdosed with 30 tablets of
naproxen and was brought to the emergency room by her boyfriend. She
refused to talk about what had happened and repeatedly said she did not
want to talk with her parents who were in the waiting room; however, she
texted her girlfriend from her bed in the emergency room to say that she had
overdosed. The nurse read the text message and had to weigh several options
in deciding how to proceed with care. In Chapter 12, we present some ideas
that we have used when we have decided not to offer additional treatment
to families.

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Chapter 7: How to Conduct Family Interviews 239

Another ethical consideration for a nurse to weigh is the balance between
his or her own beliefs about a client and his or her respect for the client’s
situation. This is especially important with regard to issues such as sexual
orientation, culture, religion, and ethnic self-determination. For example, we
believe that when discussing decision-making at the end of life, nurses should
recognize and honor that people who are dying are still living and have the
right to be in control of their lives. A real (unflinching) and ethical relationship between the patient, the staff, and the family should be maintained and
valued as end-of-life issues are decided. This is particularly salient when
the nurse may be unfamiliar with the views of Native American groups such
as the Navajo, who hold strong beliefs about spirituality, healing, rituals concerning the end of life, and death practices.
The contrasts between the beliefs of the dominant health-care system and
the views of various religious groups, such as, for example, those who practice
the Islamic and Hindu religions, need to be explored. With regard to homosexuality, Green (2003) has persuasively argued the firm value of respecting
a client’s choices and not trying to “make them” into who they are not.
We believe that nurses should be able to support a client along whatever
sexual-orientation path he or she ultimately takes. Respect for the client’s
and family’s sense of integrity and interpersonal relationships is the most
central goal.
To avoid ethnocentrism and paternalism, some nurses have embraced
certain politically correct ideas with enthusiasm. We advocate that nurses
engage in critical thinking about responsible practice, safeguard human dignity, and not blindly follow injunctions to be politically correct. Nurses are
responsible for their own choices in exercising independent professional judgment and moral agency. We have found it useful in our clinical work with
families to be collaborative, open, and direct with them in discussing ethical
dilemmas involving them.
The Nurse’s Level of Competence

When choosing to work with a family, nurses should consider their personal
and professional capacity. If the nurse has experienced a recent death of a
family member, he or she may not be able to facilitate grieving in family
members. Likewise, a nurse with strong views that people who are on
disability are shirkers would be best advised not to attempt work with such
families. We do not subscribe to the view that a nurse has to have personally
dealt with a situation (e.g., raising teenagers) to help a family. Most noteworthy in a nurse is clinical competence and compassion. However, we do
believe that the nurse should attempt to be well informed and not just offer
advice that might or might not be helpful. We believe that nurses should
consider scope of practice as the care for which they are competent, educated,
and authorized to provide. On a professional level, the nurse needs to evaluate his or her competence by asking self-reflective questions such as, “Am
I at the beginning or the advanced level of family interviewing skill?” and

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240 Nurses and Families: A Guide to Family Assessment and Intervention

“Can I obtain supervision to aid in dealing with families who present with
complex issues?” Each nurse should examine these questions and their
answers before making a decision about intervening with a given family.
The genetic revolution is an explosive area of knowledge for nurses.
Situations resulting from the application of the abundant knowledge gained
from the Human Genome Project (HGP) require decisions for which there
most likely will be limited precedent. Nurses and families alike struggle
with uncertainty and ambiguity as new discoveries are made in the HGP
(VanRiper, 2011). Now is an exciting and meaningful time for nurses to
work alongside families dealing with new information about risk, risk expression, and treatment options.
Work Context

Considerable controversy is sometimes raised about the issue of who is competent to assist clients. 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. For example, if a nurse
is working with a patient who has had a stroke and invites the relatives to
come for an educational class, is the nurse treating a family or a medical
problem? We take the approach that the definition of the problem is less
important than the solution—that is, if the whole family is involved, the definition of the problem is a question of semantics.
The issue of professional territoriality is a very thorny one with no
pat answers. Sometimes the patient sees the psychologist for psychodiagnostic testing and sees the social worker to deal with the family and outside
agencies. The role of the nurse with the family in this situation can become
controversial. If the nurse does a family assessment and decides to intervene
with the family, is the nurse usurping the social worker’s position? Or, perhaps, is the nurse usurping the physician’s position by making the decision
to intervene?
One way around these dilemmas is for the nurse to consider assuming
various roles in his or her work with families. For example, the nurse can
serve as mediator, patient and family advocate, capacity builder for family
health, empowerer, alliance builder, guide, navigator, and so forth.
There are no simple answers to complex professional and territorial issues.
We urge nurses to work cooperatively to ensure the best family care possible.
In general, we believe the best person to intervene in a situation is the one
with the most ready access to the system level in which the problems manifest
themselves. However, we believe that, in the past, nurses have been too quick
to turn over family care to other professionals. Nurses are now reclaiming
their important role in providing relational, family-centered care.
Changes in health-care reimbursement have required all nurses and healthcare 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,

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Chapter 7: How to Conduct Family Interviews 241

and other complex issues have changed the face of nursing practice. The
coming together of the consumer movement, health economics, and technology has huge implications for practice. 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. Strategies to address bureaucratic disentitlement of cultural, ethnic, racial, and other minority groups must be
put forth. Models for access to health care for economically disadvantaged
families need further refinement and implementation.
Accountability structures and practices need to recognize the centrality of
structured power differences in our society. We believe that, as nurses work
with diverse families and are increasingly transparent in this work, they will
find ways to positively influence their employment contexts.

Intervention Stage
Once the nurse has decided to intervene with the family, we recommend that
he or she review the 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 intervention are
offered in Box 7–7.
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. Some factors to consider when devising interventions are outlined
in Box 7–8. First, the intervention should be related to the problem that the

Box 7-7

Helpful Hints About Interventions

• Interventions are the core of clinical work with families.
• They should be devised with sensitivity to the family’s ethnic and 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 as the 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 practitioner should be
open to offering other ideas rather than becoming blameful of self or the family because the intervention was not chosen.
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.).
St. Louis: Mosby, p. 18. Copyright 2002. Adapted with permission.

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242 Nurses and Families: A Guide to Family Assessment and Intervention

Box 7-8

Factors to Consider When Devising Interventions

• 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 and religious beliefs?
• How is the intervention new or different for the family?

nurse and the family have contracted to change. Second, the intervention
should be derived from the nurse’s hypothesis about the problem, what the
family says the problem means to them, and their beliefs about the problem
(Wright & Bell, 2009). Third, the intervention should match the family’s
style of relating. (We have found in our own clinical work that we are sometimes biased toward one particular domain of family functioning, such as
cognitive or affective, and that we have thus erred in devising interventions
that we are most comfortable with rather than ones that the family may
find most useful.) Fourth, the interventions should be linked to the family’s
strengths. We believe that families have inherent resources and that the
nurse’s responsibility is to encourage families to use these resources in new
ways to tackle the problem. Fifth, the interventions should take into consideration the family’s beliefs, which are influenced by ethnicity, spirituality,
race, class, gender, and sexual orientation. Sixth, the nurse should devise
a few interventions so that nurse and family can consider their relative
merits—for example, are these ideas new to the family, or are they more of
the same types of solutions that the family has already tried?
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 is that condoms are available in the
center and clients have the information they need to keep themselves safe.

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Chapter 7: How to Conduct Family Interviews 243

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. For
example, telephone-based skill building can help dementia caregivers’ sense
of social support, reduce their depressive symptoms, and improve their life
satisfaction in the midst of caregiving. Campbell-Grossman and colleagues
(2009) found that providing social support to single, low-income African
American mothers via e-mail was effective. 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.
Once the nurse has devised an intervention, he or she 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 that he or she has confidence in the intervention or task
requested and believes 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 sessions,
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.

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244 Nurses and Families: A Guide to Family Assessment and Intervention

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), in discussing a study conducted by Robinson, cite that families identified interventions within two stages of the therapeutic change process that
they thought were critical to healing: creating the circumstances for change
and 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 outlined 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.

CLINICAL CASE EXAMPLE
The following is an example of how a nurse conducted family interviews
using the guidelines we have given in Chapters 6 and 7. An example of a
15-minute interview is given in Chapter 9.

Pre-Interview
Developing Hypotheses

A home health agency received a referral on the Auerswald family for home
nursing services, physiotherapy, nutrition counseling, and mental health
counseling. Heinz Auerswald, 51, was a paraplegic and in a wheelchair
because of a multiple trauma suffered in an industrial accident. He was
unemployed. Eva Auerswald, 49, a homemaker, was the primary caregiver.
She was reported to be depressed. The home-care nurse hypothesized that
Mrs. Auerswald’s depression could be related to feeling overresponsible 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

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Chapter 7: How to Conduct Family Interviews 245

confirm the usefulness of her initial hypothesis. She used this hypothesis to
provide a framework for her conversation with the couple.
Relation to CFAM. The nurse generated her hypothesis based on knowledge

of and clinical experience with other families in similar situations and with
similar ethnic backgrounds. The nurse also based it on the structural category
of CFAM (internal and external family structure, ethnicity, gender), the
developmental category (middle-aged families), and the functional category
(roles, power or influence, circular communication, beliefs).
Arranging the Interview

The wife 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 CFAM. The nurse thought about family roles and gender. She

speculated that Eva may be protecting her husband, Heinz, from her
problem. In terms of the CFAM category of verbal communication, the nurse
speculated that clear and direct communication between Heinz and Eva
might be absent or infrequent.

Interview
Engagement

The genogram data revealed that:
■ The husband and wife 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 was the husband’s first marriage.
Relation to 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 described the problem as, “Heinz has had such a

hard tragedy, but now I’m the one who is depressed. It doesn’t make sense.”
Mr. Auerswald described the problem as Eva is “worrying too much.”
Relationship Between Family Interaction and Health Problem. By asking

circular questions, the nurse discovered that 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. Mr. Auerswald stated that this would not be a problem for

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246 Nurses and Families: A Guide to Family Assessment and Intervention

him. They both reported that Eva had recently become depressed. She cried
frequently and had difficulty sleeping.
Mrs. Auerswald takes excellent physical care of Heinz and bathes him
daily. He is appreciative of all her nursing care. She feels guilty about asking
for help from his parents.
Attempted Solutions. Eva had recently visited her family doctor, who

prescribed an antidepressant for her. She had requested home-care services
once before, but she said that because “their schedule is unreliable [and she]
never know[s] when they are coming,” she had discontinued treatment with
the nurses. On the advice of her physician, Mrs. Auerswald agreed to try
home care again.
Relation to CFAM. The nurse noted that 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’s desire was to “not feel depressed, [to] feel good about myself.”

The smallest significant change that she was able to describe was to be able
to “go out one afternoon a week without feeling guilty.” Heinz was in
agreement with his wife’s goals.
Intervention
Consideration of 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 Mr. and Mrs. Auerswald in the
cognitive, affective, and behavioral domains of family functioning. The focus
of intervention was Eva’s depression.
Interventions and Outcome. Knowing that Mrs. Auerswald had stayed in a
physically abusive first marriage for 18 years to protect her children, the nurse
asked questions about beliefs and feelings of responsibility. The nurse
encouraged change in Eva’s beliefs by asking both husband and wife
behavioral effect, triadic, and hypothetical questions about responsibility. She
asked the couple to engage in behavioral experiments to try new ways of being
self-responsible. Both Mr. and Mrs. Auerswald challenged their own beliefs
about depression being a solely biological problem and began to take more
responsibility for their own lives. Heinz stated that he wanted a bath only three
times per week. Eva requested caregiving help from her mother-in-law and
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
her 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.

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Chapter 7: How to Conduct Family Interviews 247

CONCLUSIONS
Guidelines for particular stages of family interviews for nurses to consider
during an initial interview and during the whole process of interviewing have
been delineated. We recommend that nurses use these guidelines as ideas and
suggestions for how to maximize the effectiveness of their time with families.
It is not uncommon to move back and forth between the stages of a family
interview to obtain more clarity or additional assessment 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 truly guidelines rather than a rigid prescription for how to conduct
a family interview. We also caution nurses to remember the uniqueness
of every family situation and encourage them to use these guidelines with
sensitivity to each clinical situation, being mindful of the family’s cultural,
religious, spiritual, and ethnic heritage.
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Chapter

8

How to Use Questions
in Family Interviewing
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 clinical examples, we demonstrate and reveal how
questions are used in relational practice. These clinical interviews appear in
our DVD How to Use Questions in Family Interviewing (Wright & Leahey,
2006; available at www.familynursingresources.com). We will discuss the
application of questions in various clinical settings and contexts to:
■
■
■
■
■

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

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
249

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250 Nurses and Families: A Guide to Family Assessment and Intervention

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’ experience 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.
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 or linear questions are meant to inform the nurse; these are
often investigative questions, such as asking a family member to describe the illness experience or problem. We have frequently found that
just telling the story can be therapeutic. For example, talking about developmental transitions, such as the birth of a child or the placement
of a parent in a nursing home, can draw forth remembrances of strength
and meaning that may have been overlooked or forgotten.
■ Interventional, or circular, questions are meant 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. Some clinicians and authors recognize how questions can introduce alternative
possibilities, theories, beliefs, and views, simply in their posing (Katie,
2003; McGee, Del Vento, & Bavelas, 2005; Wright & Bell, 2009).
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.
It can be helpful for the nurse at the start of the family meeting to explain
to the members that she will be asking various kinds of questions to obtain
a thorough understanding of their situation. Also, it 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 he
or she 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
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, “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 student obtains the family’s permission to have a wide-ranging discussion. If conflict among family

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Chapter 8: How to Use Questions in Family Interviewing 251

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 hopefully would result in a
new perspective and new behaviors. (See Chapter 7 for additional ideas
about engagement and assessment.)
In summary, 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. Lorraine 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 Lorraine 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”).
In this first clinical vignette, Lorraine 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. Lorraine paraphrases and clarifies each person’s response so that both
she and the person are in agreement about what has been said. The following
is an example of relational practice, the nurse and the client collaborating in
setting the focus for the meeting:
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?
Husband: I’d like for her (looking at his wife) to deal
differently with her anxiety. Me . . . I’m fine.
Wife: Hmm . . . Oh yes, he wants me to go on tranquilizers.
So . . . sure . . . (Turning away)

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252 Nurses and Families: A Guide to Family Assessment and Intervention

Dr. Wright: (Looking at the husband) So you want to know
how to help your wife deal with her anxiety?
Husband: Oh yeah . . .
Dr. Wright: And for you, Bev, what is the one question you
would most like to get answered?
Wife: 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. . . .
Husband: (Looking down)
Dr. Wright: Is there one question you’d like, Bev . . .
Wife: Well, how can we get him to change his lifestyle?
Dr. Wright: Okay . . .
In reading the transcript of the actual interview, did you notice how
the nurse, Lorraine, persisted in obtaining an answer from Bev? Gentle
persistence can be an important skill in establishing a focus.
There are many other kinds of questions that could also be used in focusing
a conversation. For example, a nurse could ask, “What would you like to see
happen today so that you would know our meeting has been helpful for you?”
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 often telling their illness story or narrative was helpful in their emotional, physical, or spiritual healing as 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 clinical vignette, Dr. Maureen Leahey is meeting with a middleaged 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 eldest, age 26, is married
while the youngest, age 22, lives in the family home.
In this interview, 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

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Chapter 8: How to Use Questions in Family Interviewing 253

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, as 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.
Dr. Leahey: What has been the impact of these illnesses on
the two of you?
Husband: 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.
Wife: (Looking at husband)
Dr. Leahey: (Nodding)
Husband: And it’s a continual, chronic pain . . .
Dr. Leahey: Yes. (Nodding)
Husband: But I try to be as supportive as I possibly can,
but . . .
Wife: 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 . . .
Husband: (Nodding) You were . . . It took you a long time
to adjust . . .
Wife: 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.

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254 Nurses and Families: A Guide to Family Assessment and Intervention

Other kinds of interventive questions that can assess the impact of an
illness are:
■ What changes, if any, have there been in your life since you were diagnosed
with serious illness?
■ What has been the effect of this illness on your family? Your sexual
relations? Your work life?
These types of questions address the suffering the family may be enduring and the systemic effects of that suffering. We find it helpful to remember that talking can be healing, and these kinds of questions have the
potential for simultaneously assessing and intervening. If the couple in
the preceding example 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. Some examples might
include:
■ What has been most helpful for you in adjusting? What do you think
your sons noticed?
■ What has been least helpful?
■ What advice have you been given by family members? Friends? Healthcare providers? Did you try it? What did you discover?
■ What ideas for change have you been considering? What would be a
first step in trying out these ideas? Who would support you in this
change? Who might not support you? How might you resist the temptation to fall back into old habits? How might you reward yourself for
developing new habits?
You can see that these kinds of questions about possible ideas and ways
to change are ones that invite families to reflect on what has and has not
been useful in the past and to develop new ideas for the future.

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
remind families of often 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

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Chapter 8: How to Use Questions in Family Interviewing 255

current situation 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 sweat shop but managed to support her six children and
had great strength. What do you think were her dreams for you, her
daughter’s daughter’s daughter? What do you think she would want
you to do now about your current problem?”
Following is a vignette of a biracial 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 the mother’s
thyroid condition.
In the first section of the example, the husband and father, 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 Lorraine 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.
Husband: 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 . . .
Wife: (Looking over at him)
Dr. Wright: Well, sure . . . you are pooped yourself.
Husband: 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, does not work?
Husband: Mmm . . .

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256 Nurses and Families: A Guide to Family Assessment and Intervention

Wife: 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 . . .
Wife: That allows me to get work done during the day.
Dr. Wright: That’s a good idea . . . a good arrangement.
Wife: It gives me more time in the evening.
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.
In this next section of the vignette, 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 the father 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 wife) Have you been able to find any time
for yourself?
Wife: 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 . . .
Wife: He watches the baby.
Dr. Wright: Very nice.
Husband: 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

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Chapter 8: How to Use Questions in Family Interviewing 257

stated she wanted to increase her problem-solving skills, Lorraine could have
pursued this with her. For instance, they could have discussed possible play
groups in the area, available community resources, and so forth. Other questions that could be asked to bring forth a family’s problem-solving skills and
strengths include:
■ Asking the husband in his wife’s presence: “What do you think your
devotion and caring for your wife during her illness does for your
marriage?”
■ Asking the teenagers in a family meeting: “What do you think other families could learn from your family about coping with a chronic illness?”

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.
The next clinical example is with a couple, Al and Benz. She is a documented
Chinese immigrant, and this is her first marriage. Al is a native Canadian, and
this is his second marriage. Benz is close to being discharged from the hospital
following surgery for breast cancer. The first interventive question in this clinical
vignette is, “Who between the two of you was the most upset with the news of
the diagnosis?” This leads to a very poignant therapeutic conversation about
Benz’s future.
Dr. Wright: (Looking at the wife) Have there been any other
kinds of cancer in your family?
Wife: No . . . we are all pretty healthy.
Dr. Wright: (Looking at the husband) . . . and what about
for you, Al, has there been any history of cancer in your
family?
Husband: 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

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258 Nurses and Families: A Guide to Family Assessment and Intervention

two of you, was most upset about this diagnosis and news
when you got it?
Husband: Oh, Benz was, I think.
Wife: I would say so, too. I cried and cried. I just could not
handle it.
Dr. Wright: Yes . . .
Husband: . . . 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?
Wife: 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 . . .
Husband: 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)
Husband: I really do believe that. I really do believe that.
Dr. Wright: (Looking at husband) . . . You do. (Looking at
wife) And what are your thoughts for the future? Because
I’ve met other women with breast cancer that worry . . .
What are your thoughts?
Wife: 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 . . .
Wife: I think the worst.
Dr Wright: And what do you think about when you think
the worst?
Wife: That Al and our child, Bryan, would be alone without
me. I care about them so much.
Husband: 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?

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Chapter 8: How to Use Questions in Family Interviewing 259

Husband: 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 wife) 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” . . .
Wife: 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 . . .
In this therapeutic conversation, Benz was very concerned about her prognosis. Dr. Wright had asked about Benz’s beliefs about her prognosis when
she said to Benz, “What are your thoughts about your future?”
These are not easy conversations when a nurse “speaks the unspeakable”
by introducing a conversation about their 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 Lorraine taking sides with
either Al or Benz about the best way to handle fears, she asked Benz, “Do
you like this approach (her husband’s optimism), or do you want to say more
about 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 clinical 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.

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260 Nurses and Families: A Guide to Family Assessment and Intervention

Examples of other interventive questions are:
■ How do you make sense of your suffering?
■ In 6 months from now, how do you think your family will have adjusted
to this illness?
In our therapeutic conversations with families, we hope that healing will
be enhanced as new illness beliefs, thoughts, ideas, or solutions come forth,
are pondered, and acted upon. As family members consider how to best live
their lives with illness, change may occur.

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 vignette, 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 Lorraine by saying, “You are
kind.”
But notice how Lorraine’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 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?
Wife: . . . I think you are very kind.
Dr. Wright: (Nodding to the wife and then looking to the
husband) Anything that was helpful for you, Al?
Husband: 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 the wife) I think it is wonderful to
have a husband who wants to cheer you up and make you
feel better . . .

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Chapter 8: How to Use Questions in Family Interviewing 261

Wife: I’m lucky.
Dr. Wright: But there are times when you want him to hear
you out about what you are thinking and feeling.
Other questions that can invite feedback about the usefulness of the therapeutic conversations that nurses have with families are:
■ In what ways was our discussion useful to each of you, or not useful?
■ On a scale of 1 to 10 (with 1 being very low and 10 being very high),
how well do you think I understood your situation?
■ Is there anything you were hoping for in this meeting that did not
happen?
Of course, families do not always convey positive feelings about the meeting with the nurse. If the family expresses 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 for their insights
and ask 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.

CONCLUSIONS
We hope this chapter has given you ideas on how to use questions in family
interviewing—questions that invite possibilities for healing and change. Of
course, there is an unending number of questions that nurses could ask families. But we hope that this sample roadmap for the interview will assist you
to be more selective, skilled, and time-efficient when asking your questions.
We hope you will find that asking families questions will give you an increased understanding and appreciation of their illness experience or concerns and will open possibilities to soften suffering and invite more hope and
healing.
References
Duhamel, F., Dupuis, F., & Wright, L.M. (2009). Families’ and nurses’ responses to the
“one question question”: Reflections for clinical practice, education, and research in
family nursing. Journal of Family Nursing, 15(4), 4–485.
Healing, S., & Bavelas, J.B. (2011). Can questions lead to change? An analogue
experiment. Journal of Systemic Therapies, 30(4), 30–48.
Katie, B. (2003). Loving What Is: Four Questions That Can Change Your Life. New
York: Three Rivers Press.
McGee, D., Del Vento, A., & Bavelas, J.B. (2005). An interactional model of questions
as therapeutic interventions. Journal of Marital and Family Therapy, 31(4), 371–384.

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262 Nurses and Families: A Guide to Family Assessment and Intervention

McGoldrick, M., Carter, B., & Garcia-Preto, N. (Eds.). (2011). A multicultural life cycle
framework for clinical assessment. In M. McGoldrick, B. Carter, & N. Garcia-Preto.
(Eds.). The Expanded Family Life Cycle: Individual, Family, and Social Perspectives
(4th ed.). Boston, MA: Allyn & Bacon, pp. 447–455.
Wright, L.M. (1989). When clients ask questions: Enriching the therapeutic conversation.
Family Therapy Networker, 13(6), 15–16.
Wright, L.M., & Bell, J.M. (2009). Belief and Illness: A Model to Invite Healing. Calgary,
AB: 4th Floor Press.
Wright, L.M., & Leahey, M. (Producers). (2006). How to Use Questions in Family Interviewing. [DVD]. Calgary, Canada. Available at www.familynursingresources.com

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Chapter

9

How to Do a 15-Minute
(or Shorter) Family Interview
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 into their practice and thus how their practice with patients and families has changed in rewarding ways (Goudreau, Duhamel, & Ricard, 2006;
LeGrow & Rossen, 2005; Moules & Johnstone, 2010). Bell (2012) offered
a compelling idea 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
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. To further assist nurse educators and nursing students with implementing these ideas in
practice, we produced an educational DVD titled How to Do a 15-Minute
(or Less) Family Interview (see Family Nursing Resources at www.family
nursingresources.com to view video vignettes of actual family interviews;
Wright and Leahey, 2000).
“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
263

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264 Nurses and Families: A Guide to Family Assessment and Intervention

need to possess sound knowledge of family assessment and intervention models, interviewing skills, and questions. We have witnessed and conducted interviews to know that family nursing knowledge can be applied effectively
even in very brief family meetings. We also claim that a 15-minute, or even
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.
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:
■ “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 (2011) 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, Correia, Bobele, et al, 2011).
In South Calgary Health Center, Calgary, Canada, where Dr. Leahey and
colleagues initiated a single-session walk-in mental health clinic in 2004,
evaluation studies demonstrated ease of access for clients, with 65% being
seen on average within 13 minutes of handing in their forms to the admitting
clerk; clients’ mean presession distress levels (7.9) dropped significantly to
5.4 postsession (Harper-Jaques & Leahey, 2011). Of the 240 clients who answered a written questionnaire about overall satisfaction with the service,

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Chapter 9: How to Do a 15-Minute (or Shorter) Family Interview 265

94% stated they were satisfied or delighted (Harper-Jaques & Leahey, 2011).
The value of having a meaningful conversation with a health professional
stands out as significant.
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, 2005; 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). Examples of family-friendly policies and actions at the
larger system level could include having family members as advisory board
or task force members, focus group participants, program evaluators, and
participants in quality and safety initiatives. Ensuring that parking is available
at health-care facilities for families with limited income is another strategy.
At the department or unit level, examples can include providing familyfriendly visiting hours and space, such as a play area for children; offering
a quiet room for retreat or for family discussion of difficult situations or
moments; and lobbying for routinely providing family nursing therapeutic
conversations when families are suffering. Inviting family members to participate in new staff orientation or volunteering to orient new families to
the inpatient unit and mentor other families are additional options. Nurses
can invite families to patient conferences, accompany patients to tests, support patients during procedures, assist patients with personal care, and so
forth. A combination of administrative support, family-friendly facilities,
and nurses who have the commitment, knowledge, and skills to routinely
involve families in their practice is necessary for nurses to be able to maximize their time with families.
Following are some specific ideas for conducting a 15-minute (or shorter)
family interview. These ideas are the condensed version of the core elements

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266 Nurses and Families: A Guide to Family Assessment and Intervention

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
What are the key ingredients of a healing, productive, and effective 15-minute
family interview? From our observations and experience, they are therapeutic
conversations, manners, a family genogram (and in some situations an
ecomap), therapeutic questions, and commendations. Of course, all of these
elements can be involved only within the context of a therapeutic relationship
between the nurse and family.
Research on and clinical evidence for the usefulness of the 15-minute family interview are now appearing in family nursing’s primary journal, the Journal of Family Nursing. Holtslander (2005) described how the 15-minute
family interview was successfully applied to the needs of families in a postpartum unit. Martinez, D’Artois, & 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.

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.
The conversation in a brief family interview is therapeutic because from
the start it is purposeful and time-limited, as are the relationships. 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; 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, in press).

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Chapter 9: How to Do a 15-Minute (or Shorter) Family Interview 267

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.
The researchers 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/post-test research study that illustrates the possibility for
healing within families was conducted in four acute psychiatric units with
patients and family members (Sveinbjarnardottir, Svavarsdottir, & Wright,
[in press]). 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 conversation 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, 2005). 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 & Wright, 2011;

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268 Nurses and Families: A Guide to Family Assessment and Intervention

Bohn, Wright, & Moules, 2003; Hougher Limacher, 2003, 2008; Hougher
Limacher & Wright, 2003; Moules, 2002; Moules & Johnstone, 2010;
Wright & Bell, 2009).
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:
■ 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 two decades in North America, social
behavior has dramatically shifted from formal to casual social interaction;
some would say it has even progressed to being rude or occasionally abusive.
Style of dress has been altered from “Sunday Best” to “Casual Friday.”
Martin and Kamen’s (2005) Miss Manners’ Guide to Excruciatingly Correct
Behavior offers their 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.

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Chapter 9: How to Do a 15-Minute (or Shorter) Family Interview 269

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 Hispanic man,
was seen in an outpatient clinic in a large metropolitan hospital after openheart surgery. He reported that the nurse did not introduce herself but began
touching his body and adjusting his intravenous 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 inhibits the establishment of therapeutic relationships is 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.
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, nurses might introduce themselves 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 waiter who says, ‘Hi, my name is Josh, and I’m your
waiter tonight.’” We encourage nurses always to introduce themselves by
their full names, except in unique circumstances when there might be concerns for 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? 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, et al, 1995).

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270 Nurses and Families: A Guide to Family Assessment and Intervention

Good manners also instill trust in family members. Examples of good
manners that invite a trusting relationship are:
1. Always call patients and family members by name.
2. Always tell the patient and family members your name.
3. Explain your role for that shift or meeting or any encounter with the
patient and/or family.
4. Explain a procedure before coming into the room with the equipment
to do it.
5. 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 were given in Chapter 3
in the discussion about 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 ages, 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.”

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Chapter 9: How to Do a 15-Minute (or Shorter) Family Interview 271

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) and
in the discussion of family nursing skills (see Chapter 5) and were given 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.
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. The following are some examples of
questions that address these particular topics:
■

■

■

■

■
■

■

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, 2005].)
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].)

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272 Nurses and Families: A Guide to Family Assessment and Intervention
■

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.)

Key Ingredient 5: Commending Family and Individual
Strengths
The important intervention of offering commendations (Bell & Wright, 2011;
Hougher Limacher, 2003, 2008; Hougher Limacher & Wright, 2006; Moules
& Johnstone, 2010; Wright, 2005; Wright & Bell, 2009) was 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 of 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.”
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
& Wright, 2011; Bohn, Wright, & Moules, 2003; Hougher Limacher, 2003,
2008; Hougher Limacher & Wright, 2003, 2006; Moules, 2002; Moules &
Johnstone, 2010; Wright & Bell, 2009). Robinson’s (1998) study explored
the processes and outcomes of nursing interventions with families experiencing difficulties with chronic illness. The families reported the clinical nursing
team’s “orientation to strengths, resources, and possibilities to be an extremely important facet of the process” (p. 284). 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 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.

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Chapter 9: How to Do a 15-Minute (or Shorter) Family Interview 273

PERSONAL EXAMPLE OF INVOLVING FAMILY
IN NURSING PRACTICE
To illustrate how involving family members in health care can be ef fective 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 Dr. Wright accompanied 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

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274 Nurses and Families: A Guide to Family Assessment and Intervention

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.

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Chapter 9: How to Do a 15-Minute (or Shorter) Family Interview 275

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.

PROFESSIONAL EXAMPLE OF A BRIEF FAMILY INTERVIEW
WITHOUT FAMILY MEMBERS PRESENT
Dr. Leahey offers an example of a situation she was involved in while consulting with staff nurses on a medical unit:
Greta, a 32-year-old woman, was admitted to a medical unit with a
questionable diagnosis of influenza. Her weight had dropped to
82 pounds, a loss of 10 pounds in the week before admission.

Greta also had a genetic disease involving weakness and wasting of
skeletal muscles. The nursing staff perceived her to be angry and abrupt;
they also wondered what the medical problem was. They felt sorry for
Greta and thought of her as “very dependent.” A brief interview was scheduled to explore Greta’s expectations, beliefs, and resources. Her family was
invited to the meeting, which was held on the unit, but they did not come.
In a 15-minute interview with Greta alone, the nurse initially drew a quick
genogram. She learned that Greta lived with her two younger brothers and
their mother, all of whom had what Greta called “the disease” (wasting of
the muscles). She was the only family member who was able to drive, and
this was why the others did not attend the meeting. (This was new information for the nurse.)
The nurse then asked Greta about her expectations for the hospitalization
and how the nurses could be most helpful. Greta responded to the circular
questions 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 stated that she needed to be strong to care
for her brothers and mother, “who depend on me.”
The nurse asked Greta what hopes and expectations the other family
members had for Greta’s hospitalization. She replied that, when her mother
had previously been hospitalized, the staff had “pushed her to eat.” Greta
found this very disrespectful. The nurse asked how the current staff was
treating Greta’s reluctance to eat. Greta described that they offered her food
choices and reported that she found this quite satisfactory. The interview
concluded with the nurse inviting Greta to talk more with her if she had any
concerns about her care.

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276 Nurses and Families: A Guide to Family Assessment and Intervention

From this interview, the nurse revised her opinion of Greta being “very
dependent” to thinking of her as someone who needed to be commended for
her independence and caregiving. She now saw Greta as a “strong person”
and passed this message on to her nursing colleagues.
A few days after the 15-minute interview, Greta commented to the nurse
during morning care, “Remember when you told me to tell you if something
wasn’t going right?” She then related that the evening staff was “pushing me
to eat and not respecting my choices.” She had lost 1 pound. The nurse listened and remembered that, in the morning report, Greta was talked about
as being “manipulative.” The staff members were concerned with her weight
loss and therefore “pushed her” to eat more. In turn, Greta ate less. The nurse
conceptualized the problem as a vicious circular interaction (see Chapter 3)
between the patient and the evening staff. She decided to intervene by:
■ Inviting the dietitian to talk with the staff regarding food groups and
choices
■ Putting a note in the record system that Greta could “eat on demand”
■ Encouraging individual members of the nursing staff to give Greta more
choices of various types of food
The outcome of this brief, family-oriented interview and interventions
was that Greta gained some weight over the course of hospitalization.
The other staff nurses said that they felt “less responsible for making
Greta eat” and more responsible for offering her choices and promoting her independence. Most significant to the primary nurse was
the intervention used in the unit documentation system in which she
identified the problem, provided a rationale, and recommended direction for other staff members.

From our perspective, an important outcome was that Greta’s skills and
competencies to manage and live with her chronic illness were reinforced.
She went home stronger, both physically and emotionally. In addition, she
was able to assist herself and other family members with ongoing health issues. This 15-minute interview also indicates how nurses can include other
family members in the therapeutic conversation even if the members are not
present. Involving family members in relational nursing practice includes
inquiring about them whether they are present or not.

CONCLUSION
In conclusion, an overall framework for ritualizing a 15-minute (or shorter)
family interview is:
1. Begin a therapeutic conversation with a particular purpose in mind that
can be accomplished in 15 minutes or less.
2. 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.

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Chapter 9: How to Do a 15-Minute (or Shorter) Family Interview 277

3. Assess key areas of internal and external structure and function—
obtain genogram information and key external support data.
4. Ask three key questions of family members.
5. Commend the family on one or two strengths.
6. Evaluate usefulness and conclude.
We generally find this framework to be a useful guide when conducting
15-minute (or shorter) family interviews. However, these key ingredients
of a brief family interview need to be adapted according to the competence
of the nurse, the practice context in which nurses and families encounter
one another, and the appropriateness and purpose of the family meeting.
We are confident that, if the interview is suitably implemented, both nurses
and families will be satisfied with the usefulness of a brief family interview.
Short therapeutic conversations are not intended, nor is it possible to
resolve all of the issues that may be of concern to a family experiencing
illness. Brief meetings are intended to address the most pressing and immediate concerns of families and to empower nurses so they can soften
and/or relieve families’ physical, emotional, and spiritual suffering in just
15 minutes (or even in one sentence) in the micro-context of a therapeutic
conversation!
References
Bell, J.M. (2012). Making ideas “stick”: The 15-minute family interview [Editorial].
Journal of Family Nursing, 18(2), 171-174.
Bell, J.M., & Wright, L.M. (2011). Creating practice knowledge for families experiencing illness suffering: The Illness Beliefs Model. In E. Svavarsdottir & H. Jonsdottir
(Eds.): Family Nursing in Action. Reykjavik, Iceland: University of Iceland Press,
pp. 15–52.
Bohn, U., Wright, L.M., & Moules, N.J. (2003). A family systems nursing interview
following a myocardial infarction: The power of commendations. Journal of Family
Nursing, 9(2), 151–165.
Duhamel, F., Dupuis, F., & Wright, L.M. (2009). Families’ and nurses’ responses to the
“one question question”: Reflections for clinical practice, education, and research in
family nursing. Journal of Family Nursing, 15(4), 461–485.
Frank, A.W. (1998). Just listening: Narrative and deep illness. Families, Systems and
Health, 16(3), 197–212.
Goudreau, J., Duhamel, F., & Ricard, N. (2006). The impact of a family systems nursing educational program on the practice of psychiatric nurses: A pilot study. Journal of
Family Nursing, 12(3), 292–306.
Green, K., Correia, T., Bobele, M., et al. (2011). The research case for walk-in single
sessions. In A. Slive & M. Bobele (Eds.): When One Hour Is All You Have: Effective
Therapy for Walk-in Clients. Phoenix, AZ: Zeig, Tucker & Theisen, pp. 23–36.
Harper-Jaques, S., & Leahey, M. (2011). From imagination to reality: Mental health
walk-in at South Calgary health centre. In A. Slive & M. Bobele (Eds.): When
One Hour Is All You Have: Effective Therapy for Walk-in Clients. Phoenix, AZ:
Zeig, Tucker & Theisen, pp. 167–184.
Holtslander, L. (2005). Clinical application of the 15-minute family interview: Addressing the needs of postpartum families. Journal of Family Nursing, 11(2), 5–18.

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Hougher Limacher, L. (2003). Commendations: The Healing Potential of One Family
Systems Nursing Intervention [Unpublished doctoral thesis]. Calgary, Alberta, Canada:
University of Calgary.
Houger Limacher, L. (2008). Locating relationships at the heart of commending practices. Journal of Systemic Therapies, 27(4), 90–105.
Hougher Limacher, L., & Wright, L.M. (2003). Commendations: Listening to the silent
side of a family intervention. Journal of Family Nursing, 9(2), 130–135.
Hougher Limacher, L., & Wright, L.M. (2006). Exploring the therapeutic family intervention of commendations: Insights from research. Journal of Family Nursing, 12(8),
307–331.
International Council of Nurses. (2002). Nurses always there for you: Caring for families. Information and Action Tool Kit. Geneva: Switzerland.
Leahey, M., et al. (1995). The impact of a family systems nursing approach: Nurses’
perceptions. Journal of Continuing Education in Nursing, 26(5), 219–225.
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),
196–212.
Leahey, M., & Svavarsdottir, E.K. (2009). Implementing family nursing: How do
we translate knowledge into clinical practice? Journal of Family Nursing, 15(4),
445–460.
Martin, J., & Kamen, J. (2005). Miss Manners’ Guide to Excruciatingly Correct Behavior, Freshly Updated. New York: WW Norton.
LeGrow, K., & Rossen, B.E. (2005). Development of professional practice based on a
Family Systems Nursing Framework: Nurses’ and families’ experiences. Journal of
Family Nursing, 11, 38–58.
Martinez, A., D’Artois, D., & Rennick, J.E. (2007). Does the 15 minute (or less) family
interview influence nursing practice? Journal of Family Nursing, 13(2), 1–22.
McLeod, D.L. (2003). Opening Space for the Spiritual: Therapeutic Conversations
With Families Living With Serious Illness [Unpublished doctoral thesis]. University of
Calgary, Alberta, Canada.
Moules, N.J. (2002). Nursing on paper: Therapeutic letters in nursing practice. Nursing
Inquiry, 9(2), 104–113.
Moules, N., & Johnstone, H. (2010). Commendations, conversations, and life-changing
realizations: Teaching and practicing family nursing. Journal of Family Nursing, 16(2),
146–160.
Robinson, C.A. (1998). Women, families, chronic illness, and nursing interventions:
From burden to balance. Journal of Family Nursing, 4(3), 271–290.
Robinson, C.A., & Wright, L.M. (1995). Family nursing interventions: What families
say makes a difference. Journal of Family Nursing, 1(3), 327–345.
Slive, A., & Bobele, M. (Eds.). (2011). When One Hour Is All You Have: Effective
Therapy for Walk-in Clients. Phoenix, AZ: Zeig, Tucker & Theisen.
Svavarsdottir, E.K., Tryggvadottir, G.B., & Sigurdardottir, A.O. (In press). Does a shortterm therapeutic conversation intervention benefit families of children or adolescents
within a hospital setting? Journal of Family Nursing.
Sveinbjarnardottir, E.K., Svavarsdottir, E.K., & Wright, L.M. (In press). What are the
benefits of a short therapeutic conversation intervention with acute psychiatric patients
and their families? A controlled before and after study. International Journal of Nursing
Studies.
Wright, L.M. (1989). When clients ask questions: Enriching the therapeutic conversation. Family Therapy Networker, 13(6), 15–16.

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Wright, L.M. (2005). Spirituality, Suffering, and Illness: Ideas for Healing. Philadelphia:
F.A. Davis.
Wright, L.M., & Bell, J.M. (2009). Beliefs and Illness: A Model to Invite Healing.
Calgary, AB: 4th Floor Press.
Wright, L.M., & Leahey, M. (Producers). (2000). How to Do a 15 Minute (or Less)
Family Interview. [DVD]. Calgary, Canada. Available at www.familynursingresources.com.
Wright, L.M., & Leahey, M. (Producers). (2006). How to Use Questions in Family
Interviewing. [DVD]. Calgary, Canada. Available at www.familynursingresources.com.

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Chapter

10

How to Move Beyond Basic
Family Nursing Skills
Researchers and clinicians have identified the needs of family members when
illness arises. Family interventions that enhance the possibility of support and
healing with serious illness have also been well documented (see Chapters 4,
5, and 8). Yet, there still remains a gap between knowledge and relational
practice. The circularity between knowledge and practice remains underappreciated. Graham and colleagues (2006) articulated the value of two cycles
in thinking circularly about knowledge exchange. The first cycle involves inquiry, synthesis, and development of tools. The second cycle involves action
and leads to application of knowledge through problem identification, selection of knowledge, implementation of change, and evaluation of outcomes.
Knowledge exchange between nurses and families involves skills, basic and
advanced, that enhance and promote healing.
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—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 discussed basic essential skills and stages in family nursing
interviews. In this chapter we discuss the more advanced 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 will also be offered. The
two educational family nursing DVDs that we have produced that are most
relevant to this chapter are Tips and Microskills for Interviewing Families of
281

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282 Nurses and Families: A Guide to Family Assessment and Intervention

the Elderly (Wright & Leahey, 2010b) and Interviewing an Individual to Gain
a Family Perspective With Chronic Illness: A Clinical Demonstration (Wright
& Leahey, 2010a). See the section following the Index for a full description
of each DVD and ordering information.

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 is 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 and colleagues (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 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.

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Chapter 10: How to Move Beyond Basic Family Nursing Skills 283

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.

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.
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.

BEYOND BASIC SKILLS
Differentiating basic and advanced skills in family nursing is a challenge. 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

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284 Nurses and Families: A Guide to Family Assessment and Intervention

articulated as expounded knowledge” (p. 1). More conceptual knowledge
aims to lead to more advanced skill level, but as Chesla (2008) points out,
awareness of information does not necessarily lead to implementation or
executive skills.
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 to the needs and concerns of the family.
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.
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 VIGNETTES
Number 1: Interviewing Families of the Elderly at
Time of Transition
Setting, Family Composition, and Purpose of the Interview

Dr. Leahey interviews two siblings whose mother is entering a long-term care
facility. The two senior children being interviewed are Ross, age 72, and
Myrna, age 70. 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.

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Chapter 10: How to Move Beyond Basic Family Nursing Skills 285

Myrna is a widow with two sons and four grandchildren, and she continues to work three days a week. Ross and Myrna’s father died 15 years ago,
and their mother has recently been admitted to the care facility. Myrna and
Ross have a photo of their mother at her 99th birthday party.
The purpose of this clinical vignette 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.
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
clients 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—

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286 Nurses and Families: A Guide to Family Assessment and Intervention

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’ 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.

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Chapter 10: How to Move Beyond Basic Family Nursing Skills 287

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 a 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
seven 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.

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288 Nurses and Families: A Guide to Family Assessment and Intervention

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
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 client’s language
Commending
Asking for others’ advice to client
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.

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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.

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290 Nurses and Families: A Guide to Family Assessment and Intervention

Clinical Skill:
■

Asking clients 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

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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 suggestions how they could better help her and it 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.

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292 Nurses and Families: A Guide to Family Assessment and Intervention

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:

Some tips and micro-skills for working with elderly persons and their families
include:
■ Draw forth the family’s illness experience
■ Ask difference questions such as, “What do you think your sons are
most concerned 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 vignette, Maureen demonstrated the following clinical
skills:
■ 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 to be a
very helpful and healing practice. Inviting reflections about what family

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Chapter 10: How to Move Beyond Basic Family Nursing Skills 293

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.

Number 2: Interviewing an Individual to Gain a Family
Perspective on Chronic Illness
Setting, Family Composition, and Purpose of the Interview

Dr. Wright interviews Ralph, age 55. He 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.
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 these excerpts from a clinical interview, 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.
We begin with the first excerpt of the therapeutic conversation, which has
been transcribed verbatim. Dr. Wright asks, “What are you most hoping can
happen from this meeting?” This is an example of collaborative interaction
where Ralph and Lorraine 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?

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294 Nurses and Families: A Guide to Family Assessment and Intervention

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.

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Clinical Skill:
■

Inquiring about the best/worst advice 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 Skills:
■
■

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—

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296 Nurses and Families: A Guide to Family Assessment and Intervention

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

In reading the transcript of this 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 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 vignette, 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.
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?

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Chapter 10: How to Move Beyond Basic Family Nursing Skills 297

Ralph: I . . .
Dr. Wright: What percent do you control now?
Ralph: I have to be able to control the pain at least 75 percent
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 percent 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?
Dr. Wright: Like, what would be your ideal percent that you
would say, wow.
Ralph: It would be nice to be 90 percent.
Dr. Wright: 90 percent.
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 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 percent more?
Ralph: That’s right.

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298 Nurses and Families: A Guide to Family Assessment and Intervention

Dr. Wright: That’s amazing. So you’re willing to live with
at least 10 percent 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 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 differently that your family
could be doing 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.

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Chapter 10: How to Move Beyond Basic Family Nursing Skills 299

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—

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300 Nurses and Families: A Guide to Family Assessment and Intervention

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 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
six foot one, 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.
Dr. Wright: 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.

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Chapter 10: How to Move Beyond Basic Family Nursing Skills 301

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?

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302 Nurses and Families: A Guide to Family Assessment and Intervention

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 was 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.

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Chapter 10: How to Move Beyond Basic Family Nursing Skills 303

Comments

Let us review what we have just read. Dr. Wright asked the “one question
question” (Duhamel, Dupuis, & Wright, 2009; Wright, 1989) “If there were
just one question that you would like to have answered today, what might
that be?” The “one question question” is an interventive question that assists
individuals and the nurse to focus on the issue of most concern. It helps to
identify where the greatest concerns, problems, or suffering lie. Duhamel,
Dupuis, and Wright (2009) have documented the usefulness of the ‘one question question’ and illustrate how frequently nurses and families differ in their
perspective of what is important in a therapeutic conversation.
Also in the last segment Dr. Wright 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
of fulfilling that need.
Afterward, 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. 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 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.
Clinical Skill:
■

Offering interventions of prescribing a ritual, and 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 and you said learn more coping strategies. I’d just like
to throw out one idea that I have utilized with some clients
and families.
Ralph: Okay.
Dr. Wright: You’ve been at this so long. You only want to
improve 15 more percent. You’ve already done 75 percent.

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304 Nurses and Families: A Guide to Family Assessment and Intervention

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.”
Dr. Wright: 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 percent is just really remarkable and really incredible.
Ralph: Thank you.
Dr. Wright: Because there is 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 percent, especially with people experiencing chronic

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Chapter 10: How to Move Beyond Basic Family Nursing Skills 305

pain. I have met many people, like I said, and some of them
would just be thrilled if they could get to 30 percent 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 a hundred percent 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 percent. 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.

CONCLUSIONS
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 and knowledge about families while simultaneously offering interventions to promote health and/or to address
concerns or soften 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 “evidenced based practice” and “practice based evidence” that
enhances the care offered to families.
We hope that by presenting these clinical vignettes that you can appreciate
how family nursing skills, whether basic or advanced, are not cookie-cutter
clinical skills but rather are fluid, relevant, and tailored to each family in
each unique interview and relationship situation with a competent and compassionate nurse.
References
Astedt-Kurki, P., & Kaunonen, M. (2011). Family nursing interventions in Finland:
Benefits for families. In E.K. Svavarsdottir & H. Jonsdottir, (Eds.): Family Nursing in
Action. Reykjavik, University of Iceland Press, pp. 115–132.

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Benner, P. (2001). From Novice to Expert: Excellence and Power in Clinical Nursing
Practice. New Jersey: Prentice-Hall.
Chesla, C. (2008). Translational research: Essential contributions from interpretive
nursing science. Research in Nursing & Health, 31(4), 381–390.
Duhamel, F. (2010). Implementing family nursing: How do we translate knowledge into
clinical practice? Part II: The evolution of 20 years of teaching, research, and practice to
a center of excellence in family nursing. Journal of Family Nursing, 16(1), 8–25.
Duhamel, F., & Dupuis, F. (2011). Toward a trilogy model of family systems nursing.
Knowledge utilization: Fostering circularity between practice, education and research.
In E.K. Svavarsdottir & H. Jonsdottir (Eds.): Family Nursing in Action. Reykjavik,
Iceland. University of Iceland Press, pp. 53–68.
Duhamel, F., Dupuis, F., & Wright, L. (2009). Families’ and nurses’ responses to the
“one question question”: Reflections for clinical practice, education, and research in
family nursing. Journal of Family Nursing, 15(4), 461–485.
Ericsson, K.A. (2006). The influence of experience and deliberate practice on the development of superior expert performance. In K.A. Ericsson, N. Charness, P. Feltovich, and
R.R. Hoffman, (Eds.): Cambridge Handbook of Expertise and Expert Performance.
Cambridge, UK: Cambridge University Press, pp. 685–706.
Ericsson, K.A., Whyte, J., & Ward, P. (2007). Expert performance in nursing: Reviewing
research on expertise in nursing within the framework of the expert-performance
approach. Advances in Nursing Science, 30(1), E58–E71.
Gladwell, M. (2008). Outliers: The Story of Success. New York: Penguin Books.
Graham, I.D., Logan, J., Harrison, M.B., et al. (2006). Lost in knowledge translation:
time for a map? Journal of Continuing Education in the Health Professions, 26(1),
13–24.
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),
196–212.
Leahey, M., & Svavarsdottir, E. (2009). Implementing family nursing: How do
we translate knowledge into clinical practice? Journal of Family Nursing, 15(4),
445–460.
Litchfield, M.C. (2011). Family nursing: A practice and systemic approach to innovation
in health care. In E.K. Svavarsdottir & H. Jonsdottir (Eds.): Family Nursing in Action.
Reykjavik, University of Iceland Press, pp. 285–308.
McLeod, D.L., Tapp, D.M., Moules, N.J., et al. (2010). Knowing the family: Interpretations of family nursing in oncology and palliative care. European Journal of Oncology
Nursing, 14(2), 93–100.
Moules, N.J., Bell, J.M., Paton, B.I., et al. (2012). Examining pedagogical practices in
family systems nursing: Intentionality, complexity, and doing well by families. Journal of
Family Nursing, 18(2), 261–295.
Moules, N.J., Laing, C., Morck, A., et al. (2011). Family research in pediatric oncology
—Connecting research and practice. In E.K. Svavarsdottir & H. Jonsdottir (Eds.):
Family Nursing in Action. Reykjavik, Iceland: University of Iceland Press, pp. 271–284.
Southern, L., Leahey, M., Harper-Jaques, S., et al. (2007). Integrating mental health into
urgent care in a community mental health centre. Canadian Nurse, 130(1), 29–34.
Svavarsdottir, E.K., & Sigurdardottir, A.O. (2011). Implementing family nursing in
general pediatric nursing practice: The circularity between knowledge translation and
clinical practice. In E.K. Svavarsdottir & H. Jonsdottir (Eds.): Family Nursing in Action.
Reykjavik, Iceland: University of Iceland Press, pp. 161–184.
Vandall-Walker, V., Jensen, L., & Oberle, K. (2007). Nursing support for family members
of critically ill adults. Qualitative Health Research, 17(9), 1207–1218.

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White, M. (1989). The externalization of the problem and the re-authoring of lives and
relationships. In M. White (Ed.): Selected Papers. Adelaide, Australia. Dulwich Centre
Publications, pp. 5–28.
Wright, L.M. (1989). When clients ask questions: Enriching the therapeutic conversation.
Family Therapy Networker, 13(6), 15–16.
Wright, L.M., & Leahey, M. (Producers). (2010a). Interviewing an Individual to Gain a
Family Perspective With Chronic Illness: A Clinical Demonstration. (DVD). Calgary,
AB. Available at www.familynursingresources.com.
Wright, L.M., & Leahey, M. (Producers). (2010b). Tips and Microskills for Interviewing
Families of the Elderly. (DVD). Calgary, AB. Available at
www.familynursingresources.com.

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Chapter

11

How to Avoid the Three
Most Common Errors in
Family Nursing
Nurses working with families want to be helpful and to soften or alleviate
emotional, physical, or spiritual suffering whenever possible (Wright, 2005).
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:
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 practice 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 vignette for each error. It is our hope
that by sidestepping the most prevalent mistakes, nurses can sustain and
improve their nursing care of families. We have also produced an educational
DVD entitled Common Errors in Family Interviewing: How to Avoid &
Correct (Wright & Leahey, 2010) that demonstrates skills in actual clinical
vignettes to avoid mistakes or errors.
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.
309

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310 Nurses and Families: A Guide to Family Assessment and Intervention

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. From the first meeting, the nurse and family co-evolve together, with
both the family and the nurse changing in response to the other and according to their own individual biopsychosocial-spiritual structures, which have
been influenced by their history of interactions and their genetic makeup
(Maturana & Varela, 1992).
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, et al, 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.
Preliminary results of this study provided 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.
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.

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Chapter 11: How to Avoid the Three Most Common Errors in Family Nursing 311

These findings draw attention to the importance of the “common factors”
Hubble, Duncan, and Miller (1999) discovered were associated with positive
clinical outcomes. These included:
■ Extratherapeutic factors, including client beliefs about change,
strengths, resiliencies, and chance-occurring positive events in clients’
lives (40%). Such events could include obtaining a new job, moving to
a new city, and so on
■ The client-therapist relationship experienced as empathic, collaborative,
and affirmative in focusing on goals, methods, and pace of treatment
(30%)
■ Hope and expectancy about the possibility of change (15%)
■ Structure and focus of a model or approach organizing the treatment
(15%)
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.” We believe that this same thought 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 clinician and the family is one of the best predictors of
success and therapeutic change (Garfield, 2004; Hubble, Duncan, & Miller,
1999; Martin, Garske, & Davis, 2000).

How to Avoid Failing to Create a Context for Change
1. 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 his or her 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. A nurse will find this task easier to accomplish if
he or she embraces the belief that all families have strengths that are
often unrealized or unappreciated (Wright & Bell, 2009).
2. Obtain a clear understanding of the most pressing concern or greatest
suffering. Seek each family member’s perspective on the problem/illness

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312 Nurses and Families: A Guide to Family Assessment and Intervention

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.
3. 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.
4. Acknowledge suffering and the sufferer. Health providers’ acknowledgment of clients’ suffering can be a powerful starting point to begin
understanding the family’s situation and for healing to occur (Wright,
2005; Wright & Bell, 2009). Through these efforts to understand,
the nurse–family relationship is enhanced and strengthened. When nurses
acknowledge their clients’ 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

Creating a context for change is often begun in the same manner as meeting
a stranger for the first time. However, in the example that follows, the nurse
excludes an introduction that is usually part of the greeting ritual with
strangers. She also neglects to determine the goals for this meeting. Therefore,
some of the important aspects of establishing a new relationship are omitted,
and the therapeutic relationship starts down a slow, slippery slope to the
point where the family is not interested in any further meetings.
The nurse first met the family at the patient’s bedside on a busy medical
unit in a large, urban hospital. Mr. Garcia had been admitted to the hospital
because of his chronic obstructive pulmonary disease. A woman visited
frequently and was usually crying during visits. On one occasion, the primary
nurse asked the husband, “Do you know why your wife is crying?” Unfortunately, the nurse did not introduce herself to the woman who was visiting
and made the assumption that it was the patient’s wife. 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 made a premature conceptualization and offered her
assessment by saying, “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

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Chapter 11: How to Avoid the Three Most Common Errors in Family Nursing 313

discuss the issue with them more fully, at this point addressing the sister
for the first time. However, 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.
This encounter illustrates many missed opportunities to create a context
for change. First, the nurse should have introduced herself to the sister, clarifying the sister’s relationship to the patient. By acknowledging the sister
right at the start, the nurse may have encouraged the sister to be more forthcoming and more willing to have another meeting. In addition, the nurse
could have asked Mr. Garcia and his sister if they had any questions about
the patient’s condition or if they had any worries or concerns. This would
have given the nurse an opportunity to validate or acknowledge any concerns
or sufferings they might have. The sister’s weeping on each visit indicates
that she may be suffering; however, the nature of her suffering and its cause
is unclear. Finally, the nurse offers a quick conceptualization of the problem
by assuming that the sister is worried about the brother’s smoking habit and
its relationship to his recovery. But the sister denies this conceptualization of
her suffering, and, unfortunately, the nurse does not ask any therapeutic
questions to ascertain the nature of the sister’s distress.
The findings of the previously mentioned study by Bell and Wright
(Bell, 1999) are clearly evident in this clinical example. There was no clear
identification of the presenting concern or suffering, no acknowledgment of
their suffering, and a conceptualization of suffering is offered too quickly
without obtaining the perspective of each family member. Without these
ingredients to create a context for change, there was no opportunity for
healing to occur. Sadly, good manners were also missing.

ERROR 2: TAKING SIDES
One of the most common errors in family work is for the nurse to take sides
or form 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.

How to Avoid Taking Sides
1. 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

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314 Nurses and Families: A Guide to Family Assessment and Intervention

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.
2. 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 understanding from as many family
members as possible, the more possible options for resolution. However, we wish to emphasize that we do not condone violence, and we
do not fail to act in dangerous, illegal, or unethical situations.
3. 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].)
4. 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, 2005).
5. 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.
6. Remember that information is, as Bateson (1972) described it, “news
of a difference.” Treat all information as new discoveries; maintain a
systems or interactional perspective regarding your understanding of
the illness and family dynamics.
7. 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 Examples

A clinical example often encountered by community health nurses and nurse
practitioners involves families and the eating habits of children. In our culture and worldwide, there is a tremendous concern about obesity and, in

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Chapter 11: How to Avoid the Three Most Common Errors in Family Nursing 315

particular, childhood obesity. Given this situation, it is not uncommon for
the nurse to believe wholeheartedly a mother’s report about a school-age
child’s poor eating habits. In particular, the mother describes how the father
is laid back about their son’s eating habits. “It is like I have two children!”
she says, referring to her husband’s behavior as childlike. However, listening
to the father’s viewpoint, the nurse hears an entirely different story about
how his son readily eats well in his presence. He describes how his wife
becomes tense, screams, and gets “stressed out” by the boy’s continuous
eating of what she calls junk food.
The nurse then asks herself, “Who should I believe? Who is telling the
truth?” If she sides with one parent, then she alienates the other. She misses
opportunities to work with the entire family on helping them adjust to normal
developmental child-care issues. This trap is especially easy to fall into if
one parent negatively labels the other. For example, the husband may say,
“You know my wife gets hysterical” or the wife may say, “My husband is so
irresponsible; he struggles with depression. And furthermore, I think he may
be addicted to watching porn. I can never get him away from the computer.”
To address this situation, the nurse practitioner could (1) ask the mother,
“When your husband shows you indifference, what do you find yourself
doing?” (2) ask the father, “When your wife starts to scream at your son,
what do you do?” and (3) invite both parents to a meeting together to talk
about the challenges involved in raising a child to have healthy eating habits.
Having obtained a circular view of the interaction, the nurse can look at
them both and ask, “Which do you think would be harder: for your wife to
give up screaming or for your husband to show more responsibility? Who,
between the two of you, would find it easier to believe the other might
change?”
Another clinical example concerns a family with a teenager dealing with
anorexia. Sheena, age 16, is being seen by the unit nurse, Karin Johnson,
age 51, to receive help developing more appropriate eating habits and to
increase her socialization. Sheena has begun successfully to 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 “fashionable clothes my mother never would wear.” Karin believes
she and Sheena have an “excellent” working relationship and is pleased that
Sheena likes her taste in clothes.
Karin has agreed to alternate individual meetings with Sheena with family
interviews that include both parents. During a family meeting in which Karin
proudly described Sheena’s recent accomplishments on the unit, Sheena’s
mom starts to downplay her daughter’s successes. She tells Karin of the various “bad behaviors” Sheena engaged in during a recent pass home. Following this, Sheena bursts out to her mother, “How come you do not treat me
as an adult like Karin does?”
By inadvertently aligning too much with Sheena (e.g., around clothes and
a special relationship) and not sufficiently aligning with Sheena’s parents

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316 Nurses and Families: A Guide to Family Assessment and Intervention

(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 Sheena’s mother to acknowledge her daughter’s changes.
Rather, Sheena’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.

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 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
1. 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, patronizing, or
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.
2. 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, 2005, p. 102). Specifically, nurses should
ask themselves, “What do family members believe, and what meaning

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Chapter 11: How to Avoid the Three Most Common Errors in Family Nursing 317

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 seniors 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.”
3. Ask more questions than offering advice during initial conversations
with families. Asking therapeutic or reflexive questions (Tomm, 1987;
Wright & Bell, 2009) invites a person to explore and reflect on their
own meanings of their health concerns or suffering, not the nurse’s.
Everyone, especially the elderly, has accumulated over the years a vast
reservoir of personal local wisdom and knowledge about health and
wellness. 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, 2005).
4. 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 Examples

Nurses commonly encounter families who are experiencing deep suffering
and grief due to the anticipated or recent loss of a family member. One such
family had recently experienced the loss of their 88-year-old father, William
Li, 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 and son’s
family. Just 3 weeks after the death of the elderly father, his daughter-in-law,
Ming-mei, presented with her husband, Shen, 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

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318 Nurses and Families: A Guide to Family Assessment and Intervention

of her loss and suffering, prematurely offered the following advice to the
couple. 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 since he was
not your father, but your husband’s, you will get over his passing more
quickly.”
Understandably, the Li family did not find this advice helpful or comforting. If the nurse had asked a few assessment questions, even some structural
assessment questions within the CFAM (see Chapter 3), she 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 had with her father-in-law.
By offering premature, albeit well-intentioned, advice, the nurse missed
the opportunity to offer opinions and recommendations that would have
been more healing. By not being more curious (through the asking of pertinent questions) and more interested in understanding the daughter-in-law’s
beliefs about the loss of her father-in-law, the nurse offered her own “best”
ideas and advice, but the recommendations did not “fit” with this couple.
Also, the nurse did not recognize the Chinese culture of the Li family and
their sense of honoring and caring for their elderly family member. Sadly,
this 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.)

CONCLUSIONS
Working with families in relational practice offers nurses many opportunities
for helping them to live alongside and manage illness and increase their sense
of wellness. Similar to other professionals, at times we make errors in our practice and are less helpful than we desire. It is our hope that by describing what
we consider to be the three most common errors in relational family nursing
practice, nurses will either avoid the errors, or if they do make a mistake, will
find ways to rectify the situation and recoup with the family. The process
of collaborating with families is rich with opportunities for creative healing
despite the making of errors. By sidestepping the most frequent mistakes,
nurses can offer a context for healing that is more likely to be helpful.
References
Bateson, G. (1972). Steps to an Ecology of Mind: Collected Essays in Anthropology,
Psychiatry, Evolution, and Epistemology. New York: Ballantine Books.
Bell, J.M. (1999). Therapeutic failure: Exploring uncharted territory in family nursing.
[Editorial]. Journal of Family Nursing, 5(4), 371–373.
Block-Lerner, J., et al. (2007). The case for mindfulness-based approaches in the
cultivation of empathy: Does nonjudgmental, present-moment awareness increase
capacity for perspective-taking and empathic concerns? Journal of Marital and Family
Therapy, 33(4), 501–516.

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Chapter 11: How to Avoid the Three Most Common Errors in Family Nursing 319

Blow, A.J., Sprenkle, D.H., & Davis, S.D. (2007). Is who delivers the treatment more
important than the treatment itself? The role of the therapist in common factors. Journal
of Marital and Family Therapy, 33(3), 298–317.
Couture, S.J., & Sutherland, O. (2006). Giving advice on advice-giving: A conversation
analysis of Karl Tomm’s practice. Journal of Marital and Family Therapy, 32(3), 329–344.
Garfield, R. (2004). The therapeutic alliance in couples therapy: Clinical considerations.
Family Process, 43(4), 457–465.
Hubble, M.A., Duncan, B.L., & Miller, S.D. (1999). Introduction. In M.A. Hubble,
B.L. Duncan, & S.D. Miller (Eds.): The Heart & Soul of Change: What Works in
Therapy. Washington, DC: American Psychological Association, pp. 1–19.
Martin, D.J., Garske, J.P., & Davis, K.M. (2000). Relation of the therapeutic alliance
with outcome and other variables: A meta-analytic review. Journal of Consulting and
Clinical Psychology, 68, 438–450.
Maturana, H.R., & Varela, F.G. (1992). The Tree of Knowledge: The Biological Roots
of Human Understanding (rev. ed.). Boston: Shambhala.
Miller, S., Hubble, M., & Duncan, B. (2007). Supershrinks: Why do some therapists
clearly stand out above the rest, consistently getting far better results than most of their
colleagues? Psychotherapy Networker, 31(6), 26–35.
Tomm, K. (1987). Interventive interviewing—part ii. Reflexive questioning as a means
to enable self-healing. Family Process, 26, 167–183.
Wright, L.M. (2005). Spirituality, Suffering, and Illness: Ideas for Healing. Philadelphia:
F.A. Davis Co.
Wright, L.M., & Bell, J.M. (2009). Belief and Illness: A Model to Invite Healing.
Calgary, AB: 4th Floor Press.
Wright, L.M., & Leahey, M. (Producers). (2010). Common Errors in Family
Interviewing: How to Avoid & Correct. [DVD]. Calgary, Canada. Available
at www.FamilyNursingResources.com.

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Chapter

12

How to Terminate
With Families
Knowing how to successfully conclude or terminate clinical work with families
is as important as knowing how to begin—perhaps even more so. When nurses
part with families, they should do so in a manner that leaves the families with
hope and confidence in their new and rediscovered strengths, resources, and
abilities to manage their health and/or illness and relationships. If the family
has been suffering with illness, loss, or disability, then at the conclusion of
the clinical work, a highly desired outcome would be softened or alleviated
suffering and increased healing.
To end professional relationships with families in a therapeutic fashion is
one of the most challenging aspects of the family interviewing process for
nurses. Reed and Tarko (2004) make the interesting observation that, in
nursing, “the issue of termination has been often discussed in psychiatric
nursing texts, making it seem as if no other nursing situations have issues
surrounding termination” (p. 266). Termination continues to be the least
examined of the treatment phases in clinical work with families.
Two important aspects of concluding with families is to end the nurse–
family relationship therapeutically and to do so in a manner that will sustain
the progress and foster hope for the future. Nurses commonly establish very
intense and meaningful relationships with families and therefore may feel
guilty or fearful about initiating termination. This is especially evident in
nursing practice when the relationship has been a long-standing one, over
months or even years, such as in nursing homes, extended-care facilities, and
clients’ homes.
In this chapter, we review the process of termination by examining the
decision to terminate when it is initiated by the family or the nurse or as a
result of the context in which the family members find themselves. In many
cases, the nurse’s decision to conclude with a family does not necessarily
mean that the family will cease contact with all professionals. Therefore, we
also discuss the process of referring families to other health professionals.
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322 Nurses and Families: A Guide to Family Assessment and Intervention

We provide specific suggestions for phasing out and concluding treatment
and for evaluating the effects of the treatment process. We must emphasize
that, just as other aspects of family interviewing are conducted in a collaborative manner, so, too, should the termination phase. Termination should
occur with full participation and input from the family whenever possible.

DECISION TO TERMINATE
Nurse-Initiated Termination
It is important to emphasize that termination may occur before the presenting
problem or illness is completely “cured” or resolved. However, it is the family’s
ability to master or live alongside problems or illness, although hopefully with
softened emotional, physical, and spiritual suffering, that is the impetus for
initiating termination. In most cases, it is unrealistic for nurses to attempt to
completely eliminate the presenting concern or illness, and such a goal can frequently leave families feeling more discouraged and hopeless and nurses feeling
inadequate or unhelpful. It is by softening suffering or increasing healing and
awareness that enables a family to live with their problems or illness in a more
peaceful and manageable way. If the family’s presenting concern is related to
health promotion, then greater knowledge or increased expertise by the family
might be an indicator for termination.
The termination stage evolves easily if the beginning and middle phases
of engagement and treatment have progressed successfully. However, the
most difficult decision for any nurse to make in regard to termination relates
to time. When is the right time for termination? This question is directly
related to the new views, beliefs, ideas, and solutions that the family and
nurse have generated to resolve current problems. If new solution options
have been discovered and consequently the family functions differently, particularly with the presenting concern, it is time to terminate, because change
has occurred. The skills necessary for nurse-initiated termination are given
in the “Phasing Out and Concluding Treatment” section of this chapter and
in Chapter 5.
In contexts where family meetings have occurred over time, then the nurse
and family may collaboratively decide that additional meetings are not
necessary. In these situations, the termination phase of treatment has begun.
First and most importantly during this phase, we prefer to help families
expand their perspectives to focus on strengths, positive behaviors, and
changes in beliefs or feelings that have occurred or reemerged rather than
focus exclusively on troublesome or problematic behaviors. We encourage
families not to associate these new behaviors with our work but instead with
their own efforts. For example, we would ask a family what positive changes
they have noticed over the last 3 months rather than ask what positive
changes they have noticed since working with a nurse.
White and Epston (1990) offer another useful clinical idea for nurses
terminating with families; they recommend that the interviewer “expand the

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Chapter 12: How to Terminate With Families 323

audience” to describe and acknowledge the family’s unique outcomes and
progress. For example, we commonly ask families to tell us what advice they
would have for other families confronting similar health problems. Sometimes we have families write letters to other families to offer suggestions regarding what has or has not worked in coping with a particular illness. (It is
essential that the family that receives the letter has given permission for the
letter to be sent.) For example, one woman, who was experiencing multiple
sclerosis (MS) but was successfully living with her illness, wrote a letter to a
younger woman who was not yet as successful in managing her illness. The
younger woman found that it gave her hope and encouragement. The older
woman expressed that writing the letter was a very “cathartic” experience
for her. She went on to say, “MS is still here, but it does not dominate our
lives and occupies only a small space over in the corner. I did experience a
minor flare-up after Christmas but it cleared quickly. I remain optimistic.”
The nurse should highlight and become enthusiastic about the family’s
ideas and advice as a way of both reinforcing positive ideas for change and
the family’s new beliefs about themselves and generating useful information
for other families. Thus, the family’s competencies, resources, and strengths
are overtly acknowledged.
When the nurse initiates termination of the therapeutic relationship, the
emphasis throughout this process is to identify, affirm, amplify, and solidify
the changes that have taken place within and between family members.
Consequently, it is essential that change be distinguished to become a reality
(Bell & Wright, 2011; Wright & Bell, 2009). One way to distinguish change
is to obtain the perspective of family members. The nurse can accomplish
this by asking questions such as, “What changes do you notice in your wife
since she has adopted this new idea that ‘illness is a family affair’?” or “What
else would your family or friends notice that is different in you since your
depression about experiencing cancer has dissipated?”
Initiating rituals at the time of termination can also emphasize change and
give families courage to live their lives without the involvement of healthcare professionals. If the initial concern involves a child, we have had parties
(balloons, cake, and all) to celebrate the child’s mastery of the particular
problem, whether it be enuresis, fighting fears, or putting chronic pain in its
place. In addition, we have given children a certificate indicating that he or
she has overcome the problem. This practice helps families to acknowledge
change through celebration.
Some clinical settings send a closing letter at the end of the clinical work
to each family highlighting what the clinical nursing team has learned from
the family and what ideas the team offered the family (Bell, Moules, &
Wright, 2010; Moules, 2002, 2003, 2009; Wright & Bell, 2009). These therapeutic letters serve as closing rituals. They provide the opportunity to highlight the family’s strengths and document in a personal way the family and
individual interventions that were offered. The letters also acknowledge that
family nursing is not a one-way street with nurses assisting families. Rather,

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324 Nurses and Families: A Guide to Family Assessment and Intervention

by stating what the nurse and clinical team have learned from the family, the
nurse honors the reciprocal and relational influence between the family and
the clinical nursing team. More information about closing letters is provided
in Chapter 4.

Family-Initiated Termination
When a family takes the initiative to terminate, it is very important for the
nurse to acknowledge their desire and then to gain more explicit information
in a nonjudgmental fashion regarding their reasons for wanting to terminate.
This information helps the nurse to understand the family’s responses to the
interviewing process. Has the family discovered new solutions to their problems or challenged their beliefs to soften their suffering? For example, have
they found a way to have respite from caring for their ill child without feeling
excessive guilt? Has the family challenged some of their constraining beliefs
about the illness experience (Bell & Wright, 2011; Wright & Bell, 2009)?
For example, have they now stopped blaming themselves for the husband
suffering a coronary in part because of having to work two jobs? Are the
family and nurse able to identify and agree on significant changes that have
occurred in both individual and family functioning? Is the family also aware
of how to sustain these changes? For example, if a son refuses to give his
own insulin injections in the future, what will the family do differently?
If the family specifically states that they wish to terminate but the nurse
believes this would be premature or even enhance their suffering, it is important for the nurse to take the initiative to review the family’s decision. In
so doing, the nurse reconceptualizes the progress the family has made and
recognizes what problems remain and what goals and solutions might yet be
achieved.
One way to do this is to have family members discuss with one another
their desires to continue or discontinue sessions and explore who most
disfavors termination. Also, the specifics of the decision may be helpful,
such as when the family decided to terminate and what prompted the
decision. After establishing who is most eager to continue, the nurse can
invite that family member to share with the other family members the
anticipated benefit of further sessions. It is helpful for families to be specific
and emphasize the benefits that could be achieved if family interviewing
were to continue. However, there are times when termination is inevitable.
At such a point, it is reasonable and ethical to accept the family’s initiative
to terminate and to do so without applying undue pressure, even though
the nurse may disagree with their decision.
We strongly urge nurses not to engage in linear blame of either families
or themselves when they believe that families have prematurely or abruptly
left treatment. Rather, we encourage nurses to hypothesize about the factors
that may have contributed to the termination. These factors may include
such nurse-related behaviors as being too aligned with children, too slow to
intervene, or too “married” to a particular hypothesis about the family’s

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Chapter 12: How to Terminate With Families 325

functioning, or not attending to the family’s main concern (see Chapter 11
for errors to avoid). Family-related behaviors such as concurrent involvement
with other agencies should also be considered.
Nurses may also encounter cases in which a family states that they want to
continue treatment but initiate termination indirectly. Indications include late
arrivals for meetings, missed appointments, and the absence from sessions of
certain family members who were asked to attend. Another indicator that families are perhaps considering termination is their expression of dissatisfaction
with the course of treatment or complaints about the logistical difficulties of
attending or the loss of time from work. In these situations, we suggest that
the same steps be taken as when the family initiates termination directly.
The challenge of family-initiated termination is to determine whether it is
premature. It could be, as Slive and Bobele (2011) suggest, that the family
has received all the assistance they needed and choose not to return for meetings. In the nursing literature, there is a dearth of research to provide insights
into reasons for premature termination. Therefore, nurses must rely on their
own clinical judgment to ascertain if termination is premature. Future research studies should address this area in nursing practice with families who
are seen on an outpatient basis.
In our clinical experience, we have found that families who miss the first
meeting are at high risk for dropping out over the course of treatment. The
implication of missed appointments refers back to the importance of the engagement stage and even to the initial contact with families on the telephone.
We have also found that the referral source has a direct correlation with the
family’s continuing treatment. Families who are referred by institutions (such
as a school or court) are more likely to discontinue treatment before achieving treatment goals than families who were individually referred (such as by
physicians or mental health professionals). Families who are self-referred
tend to complete the treatment process.
It is critically important to help families understand the nature of the treatment contract. Many families’ understandings of what takes place in family
interviewing are markedly different than the understandings held by nurses.
Therefore, these families may relate to nurses as they do to physicians,
imams, or clergy, whereby they use the services as they wish and discontinue
when they desire. For this reason, we find it particularly useful when seeing
families on an outpatient basis to contract for a certain number of sessions
and then reevaluate as progress occurs. This approach may help to prevent
premature or abrupt termination. It also keeps the focus on time-effective,
change-oriented conversation.

Context-Initiated Termination
In some settings, such as hospitals (particularly those in managed health-care
systems), it is not the nurse or the family who initiates termination but the
health-care system or insurance company. In these situations, it is very important for the nurse to assess whether the family needs further treatment

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326 Nurses and Families: A Guide to Family Assessment and Intervention

on an outpatient basis or can continue to resolve problems and discover
solutions on their own. If the family needs to be referred, the nurse requires
some specific skills in this area. The referral process will be discussed in a
later section of this chapter.

PHASING OUT AND CONCLUDING TREATMENT
In Chapter 5, we highlighted some of the specific skills required for therapeutic
termination in the form of learning objectives. We will now expand on these
particular skills.

Review Contracts
For families seen on an outpatient basis, we strongly encourage periodic
review of the present status of the family’s problems and changes. The use
of a contract for a specific number of sessions provides a built-in way to set
a time limit to the meetings and to ensure periodic review. In one outpatient
clinic, all families contracted for four sessions and then evaluated change
(Wright & Bell, 2009). In some cases, four sessions were not necessary; families could save unused sessions to be used at a later time if desired. If the
family required additional sessions at the conclusion of the four-session contract, then another contract was made between the family and the nurse, and
reevaluation occurred again at the end of those sessions. Interestingly, families who contracted for more sessions rarely wanted another 5 or 10 sessions
but usually requested just 1 or 2 more sessions. This finding is consistent
with the literature that posits change occurs early in treatment and improvement declines as the number of therapy sessions increase (Bloom, 2001).
Contracts help nurse interviewers to be mindful of the progress and direction
of their work with families rather than seeing families endlessly and without
purpose beyond the vague good intention of “helping.” We prefer a designated
number of sessions to open-ended sessions. However, nurses need to be flexible
about the frequency and duration of sessions. Normally, the frequency decreases
as problems improve, suffering has softened, and confidence and hopefulness has increased. Periodic reviews allow family members the opportunity to
express their pleasure or displeasure with the progress that is being made.

Decrease Frequency of Sessions
When adequate progress has been made, as evidenced by reduced suffering,
the time is ideal to begin to decrease the frequency of sessions. In our experience, we have found that families are able to work toward termination
more readily and with more confidence when they recognize the improvement in their own ability to solve problems. However, many families find it
difficult to acknowledge changes. In these circumstances, we suggest the use
of a question such as, “What would each of you have to do to bring the
problem back?” to elicit a more explicit understanding or statement from
family members regarding the changes that have been made.

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Another significant time to decrease the frequency of sessions is when the
nurse has inadvertently fostered undue dependency. We have had many family situations presented to us in which nursing students or professional nurses
provide “paid friendship” with mothers. These nurses have become the
mother’s major support system because they have failed to mobilize other
supports, such as husbands, friends, or relatives. In situations in which this
dependency has occurred and is recognized, we strongly suggest that the
nurse help foster other supports for the family and decrease the frequency
of sessions. Regular consultation with colleagues or a supervisor will assist
the nurse to ascertain if a dependent relationship has occurred between the
nurse and the family.
If a nurse encounters hesitancy or reluctance to decrease the frequency of
sessions or to terminate completely, the nurse should encourage a discussion
of the fears related to termination and solicit support from other family members. It has been our experience that family members commonly fear that if
sessions are decreased or discontinued, they will not be able to cope with
their problems or their problems will become worse. Thus, asking a question
such as, “What are you most concerned would happen if we discontinued
our meetings now?” can get to the core of the matter very quickly. By clarifying family members’ fears openly, other family members (who may be less
fearful) have an opportunity to provide support.

Give Credit for Change
Nurses often choose the nursing profession because they have a strong desire
to help individuals and families obtain optimal health and soften their suffering. Their efforts are usually helpful, and they are commonly given all or
much of the credit for the changes and improvements. However, it has been
our experience in family work that it is vitally important that the family receive the credit for change. There are several reasons for this:
1. Families experience the tension, conflict, suffering, and anxiety of working through problems related to their health or illness and relationships;
therefore, they deserve the credit for improvement.
2. If the identified patient is a child and the nurse accepts credit for change,
the nurse can be seen to be in a competitive relationship with the parents.
3. Perhaps the most important reason for giving the family credit for
change is that doing so increases the chance that the positive effects of
treatment will last. Otherwise, the nurse may inadvertently convey the
message that the family cannot manage without him or her, and they
will become indebted or too dependent. Termination provides an opportune time to comment on the positive changes that have already
happened during the course of treatment.
4. Praising the family for their accomplishments in having helped or corrected the original presenting problem provides them with confidence
to handle future problems. Statements such as “You did the work” or

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328 Nurses and Families: A Guide to Family Assessment and Intervention

“You people are being far too modest” can reinforce to family members
the idea that their efforts were essential in making the change.
It is never possible to know for certain what precipitated, perturbed, or
initiated the change that occurs within families. In many cases, nurses create
a context for change by helping family members explore solution options to
their difficulties or suffering. Wright and Bell (2009) suggest that creating a
context for change constitutes the central and enduring foundation of the
therapeutic process. They further propose that it is not just a necessary prerequisite to the process of therapeutic change; it is therapeutic change in and
of itself. Sometimes the very effort of bringing a family together in a room to
discuss important family issues and their suffering can be the most significant
intervention (Robinson & Wright, 1995).
If families present themselves at termination with concerns about progress,
nurses must express their appreciation for the family’s positive efforts to
solve problems constructively, even when no significant improvement has
occurred. In such cases, we strongly recommend that nurses discuss with
their clinical supervisors some hypotheses about why the interview sessions
did not seem to be effective. Perhaps the goals of the family or the nurse were
too high or demanding. If a family does not progress, it is usually the result
of our inability to discover an intervention that “fits” or “meshes” with the
family. Too often, nurses excuse themselves from making further efforts to
intervene by labeling families as noncompliant, unmotivated, or resistant
(Wright & Levac, 1992). But it is very important that nurses believe that
families have worked hard despite minimal progress, and it is important to
praise them for having done so.
However, we do not mean to imply that because we are encouraging
nurses to give families the credit for change that the nurse cannot enjoy the
change. Family work can be very rewarding, and certainly the nurse is part
of the change process.

Evaluate Family Interviews
It is important to provide a formal closure to the end of the treatment process
with a face-to-face discussion, whenever possible. Madsen (2007) refers to
this part of the termination process as a consolidation interview. In a
consolidation or termination interview, the nurse asks particular questions
to review the process of the work that the family and clinician have done
together and then discusses the work the family seeks to accomplish on its
own in the future. This kind of interview is a way to reduce feelings of
anxiety, fear, or loss on the part of the clinician, family, or both.
During this final session, it is very valuable to evaluate the effectiveness
of the treatment process and the effect of changes on various family members. We recommend evaluating the impact not only on the whole-family
system but also on various subsystems, such as the marital subsystem and
individual family member functions. Questions such as “What have you

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Chapter 12: How to Terminate With Families 329

learned about yourself and ALS?” or “What have you come to appreciate
about your marriage?” or “What have you come to understand is the most
effective way you can live with your grief?” invite reflections from the family
about its changes.
We also believe in sharing the family’s wisdom and will frequently ask,
“When you meet with other families with chronic illness, from what you
know now, what would you advise them or offer them?”
An even more dramatic evaluation can occur by having each family member and the nurse write about their reflections on the family meetings, emphasizing what they learned, what has changed, and what new ideas or
beliefs they have about their problems or illness. One such family clinical
nursing team wrote poignant descriptions about dealing with their grief
(Levac, et al, 1998).
We also suggest asking family members the following questions: “What
things did you find most and least helpful during our work together?” and
“What things did you wish or were hoping would happen during our work
together that did not?” or “Based on what you’ve accomplished and learned,
what suggestions do you have for me or other nurses in trying to help other
families suffering with similar issues?” This behavior demonstrates that the
nurse is also open and receptive to feedback. It is important at this time that
the nurse not become defensive to any of the feedback. Rather, he or she can
express appreciation to the family and inform them that this feedback will
assist and educate him or her to be even more helpful in work with future
families. Participatory evaluation research turns the traditional evaluation
process on its head. Outsiders are no longer the “experts” but instead empower families to become leaders in evaluation and change throughout the
interviewing process (Duhamel & Talbot, 2004).

Extend an Invitation for Follow-Up
Nurses often place themselves or are placed in situations of “follow-up.”
However, follow-up is frequently a negative experience for both the nurse
and the family. For example, community health nurses (CHNs) have reported
that they are often requested to “check” on family members to assess their
functioning. However, those who request the visit (be they physicians or
Departments of Child Welfare) often make no clear statement to the family
about the purpose of the visit. Follow-up in this manner can give a very unfortunate and unpleasant message to the family that further problems are
anticipated. Therefore, the nurse is in a very awkward position. We strongly
discourage nurses from placing themselves in these kinds of situations unless
there has been clear, direct communication with the family by the requesting
party. It is better to make clear to the family that progress has been made
and that the sessions are finished. However, if they would like input again in
the future, indicate that you would be willing to see them. Families usually
appreciate knowing that backup support by professionals is available to them
in times of stress.

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330 Nurses and Families: A Guide to Family Assessment and Intervention

For nurses employed in hospitals, a follow-up session is usually not possible, but referral can be made to a CHN, emergency room outreach worker,
or home-care nurse if deemed appropriate. Our experience has been that
families do appreciate knowing whether they will have future contact with
the nurse who has worked intimately with them.

Closing Letters
Another way to punctuate the end of treatment positively is to send the family
a letter giving a summary of the family sessions. This letter provides the opportunity to highlight the family strengths, reinforce the changes made, offer
the family a review of their efforts and what they have accomplished, and list
the ideas (interventions) that were offered to them (Bell, Moules, & Wright,
2009; Hougher Limacher & Wright, 2006; Moules, 2002, 2003, 2009;
Wright, 2005; Wright & Bell, 2009). Many families have commented about
how much they appreciate the letters and how they frequently refer to them.
Additional information about closing letters is provided in Chapter 4.
The following example illustrates a typical closing letter:
Dear Family Barbosa:
Greetings from the Family Nursing Unit. We had the opportunity to meet with various members of your family on
eight occasions. I have also had several phone conversations
with both Venicio and Fatima in recent months.
What Our Team Offered Your Family. Throughout our
work together, our clinical nursing team has been very impressed with your family. Although a great many challenges
have been presented to all of you over the past years, your
family was able to overcome many obstacles and search for
ways of helping each other through these difficult times.
1. We offered you the idea that most families find it very
difficult to talk openly about an impending loss or death
of a family member but that talking can be very healing.
You have shown us that this was the case in your family.
2. We offered you a few books to read about other families
who have experienced a similar tragedy as yours.
3. We offered you the idea that resolving issues in a relationship that has been conflictual can bring great peace and
comfort, particularly following the death of a loved one.
What Our Team Learned From Your Family. Our experience with your family has taught our clinical nursing team a
great deal. The following is a synthesis:
1. Families that have a member dealing with a life-shortening
illness have the strength to deal with unresolved issues of

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Chapter 12: How to Terminate With Families 331

blame, guilt, and shame. Even though there has been a
great deal of pain and hurt in a family, they can heal their
relationships and move on.
2. Although it can be a common response for family members to distance themselves from the possibility of death
with a life-shortening illness and to be afraid of dying, it is
possible for them to make peace with each other and find
peace in themselves, giving them the courage to go on.
3. Although a mother and son may reside in different places
and may not see each other often, they can still play a
significant part in each other’s lives. No matter how old
a child and parent are, the knowledge that they love and
accept each other for who they are can make a significant
difference in their lives.
4. The uncertainty involved with a life-shortening illness
can be the most difficult thing for families to handle.
Family members can help each other with the uncertainty
by discussing the situation openly among themselves.
5. Grandparents and grandsons have very special relationships that are different from those of parents and sons.
As you all continue to face the many challenges that are
ahead, we trust that you will draw on your own special
strengths as well as on more open communication to help
you meet these challenges. It was truly a privilege to work
with you. We wish you continued strength for the future.
Should you desire further consultation at any time, you
can arrange this by contacting the Family Nursing Unit’s
secretary. A research assistant will be in contact with you in
approximately 6 months to ask you to participate in our outcome study to ascertain your satisfaction with the Family
Nursing Unit.
Sincerely,
Jane Nagy, RN Lorraine M. Wright, RN, PhD
Masters Student Director, Family Nursing Unit
Professor, Faculty of Nursing
Therapeutic letters, whether sent during clinical work with families or at
the end of treatment, have proved a very useful and often potent intervention
to invite families to reflect on ideas offered within the session and on changes
they have made over the course of sessions (Bell, Moules, & Wright 2009;
Hougher Limacher & Wright, 2006; Levac, et al, 1998; Moules, 2002, 2003;
Watson & Lee, 1993; White & Epston, 1990; Wright, 2005; Wright & Bell,
2009; Wright & Nagy, 1993; Wright & Watson, 1988).

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332 Nurses and Families: A Guide to Family Assessment and Intervention

REFERRAL TO OTHER PROFESSIONALS
Referral to other professionals may be advisable for various reasons. We will
list some specific tasks that are required to make a smooth transition for the
family from one professional to another. First, however, we will discuss some
of the more common reasons for nurses to refer families to other professionals.
With the expanding specialty areas within nursing, it is becoming impossible
and totally unrealistic to expect nurses to be experts in all areas. Therefore,
when problems are quite complex, it may be appropriate for nurses to seek
the input of additional professional resources. A nurse may refer families or
specific family members for consultation or ongoing treatment. For example,
if a senior within a family is experiencing temporal headaches, it is very important that any organic or biological origin of this problem be ruled out.
Therefore, a nurse might refer the family for consultation with a neurologist
and may suspend treatment until the consultation is complete. Similarly, the
nurse may discover that a particular child has a learning disability that is out
of the realm of the nurse’s expertise. The nurse may suggest referring the child
to an education center where personnel have greater expertise in dealing with
children with learning difficulties. Nurses need to be open to referring individuals or entire families for consultation without perceiving this as an inadequacy
in their repertoire of skills. To refer wisely, nurses need an extensive knowledge
of professional resources within the community.
Although not as common, other situations nurses may encounter that
require them to refer families to other professionals include when the family
moves, is transferred to another setting, or is discharged before treatment is
over. It is very important that the nurse, especially in hospital settings, maximize opportunities to do family work. A beautiful illustration of this was
given by one of our graduate nursing students. After some university seminars
on the importance of family involvement, this student, who was working parttime in a rural hospital, invited the parents of an asthmatic child to a family
interview. The student obtained much valuable information regarding the interrelationship of the child’s asthmatic problem with other family dynamics.
Shortly thereafter, the child was discharged. The nursing student ascertained
that the family was interested in changing the recurring problem of frequent
admissions for this young child. The student made an appropriate referral
to the mental health services within the community. This highlights the point
that with only one family interview, an assessment can be made and a significant intervention completed through referral for a recurring problem. Some
of the specific skills required in making appropriate referrals are described in
the following paragraphs.

Prepare Families
Nurses must adequately prepare families so that they understand the nature
of the referral to a new professional. Useful referrals can be done by explaining to families the reason for the referral and why the nurse feels that the

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Chapter 12: How to Terminate With Families 333

family would benefit from it. Another method that can be useful for ensuring
openness and clarity about the nature of the referral is for the nurse to write
a summary and then to review this summary with the family. This summary
can then be sent to the new professional and a copy made available to the
family. In this way, the family is not left wondering what information will
be shared with the new professional. Also, an important implicit message is
given that this information is confidential and private about them, so they
have a right to know what is shared.
Selecting a new professional can sometimes pose a challenge. If a nurse is
known in the community, it is wise to solicit the help of colleagues for ideas
and advice on which agencies or professionals are best for the type of treatment needed or to seek information from community information directories,
booklets, and online resources.

Meet the New Professional
It has been our experience that the transition to the new professional is much
more effective and efficient if the nurse can be present with the family at the
first meeting. In this way, a more personal referral is made. It often reduces
the fears and anxieties that families may have about starting “fresh” with
someone new. Before the referral, opportunities should be given to the family
to express concerns or ask questions about the referral. At the first meeting,
the family may wish to clarify with the new professional their expectations
and understanding of the reason for the referral, and any misconceptions can
be dealt with at that time. A conjoint meeting with the family, nurse, and new
professional can also serve as a “marker” for the end of the nurse’s relationship
with the family.

Keep Appropriate Boundaries
Despite increased interdisciplinary collaboration in health care, it is still very
important that when a family has been referred, boundaries of responsibility
are clear. Otherwise, there is a potential for the nurse to inadvertently become
triangulated between the family and the new professional. For example, a
home-care nurse regularly visited an elderly patient who lived with her adult
daughter. The purpose of the visits by the home-care nurse was to assist with
colostomy care. The nurse observed and assessed a severe and long-standing
conflict between the elderly parent and the adult daughter. This conflict was
having a negative effect, deterring the elderly patient from assuming more responsibility for her physical care. Because of her family assessment skills, the
nurse was able to make an important referral to a family therapy program
where more in-depth work on the intergenerational conflict began. However,
in future visits, the elderly patient expressed to the nurse complaints about the
adult daughter that the patient was not discussing in the family meetings. Also,
the family therapist called the nurse and asked the nurse to apply pressure on
the elderly parent to be more cooperative in attending sessions. Thus, very

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334 Nurses and Families: A Guide to Family Assessment and Intervention

quickly the nurse had become “caught in the middle” between the family and
the therapist. The nurse dealt with the situation by requesting to join in a
meeting with the family and the therapist to clarify expectations of all parties.
In this one session, the nurse was able to “detriangulate” herself from any
alliance by clarifying her present role with the family and the new professional.
See Chapter 3 for more discussion about alliances and coalitions.

Transfers
In our more than 35 years of clinical experience, we have not found the practice of transferring families from one clinician to another to be very successful.
We view the process of transfers as very different from referrals. A referral is
usually made to another health-care professional with different expertise. A
transfer, on the other hand, is usually made to another colleague of similar
expertise and competence. We recommend, if possible, that nurses conclude
treatment with the families they are working with rather than transfer them
to another colleague. In our experience, families frequently disengage with
the new nurse in various ways (e.g., by missing appointments, not showing
up, or not stating any particular concern). It is understandable that families
do not wish to “start over” with another nurse. We hypothesize that transfers
are frequently made to assuage the nurse’s feelings about leaving versus the
family’s desires about continuing treatment.
If, however, a transfer is necessary, we recommend that the “old” nurse
use language indicating an ending of her relationship with the family. For
example, she can say, “Now that my work with you is coming to an end,
what would you like to work on with Sanjeshna, the new nurse?” In addition, we encourage the new nurse to directly ask the family about their relationship with previous nurses. Such questions as “What do you anticipate
will be different in our work together versus your work with Li?” are useful.
This type of conversation punctuates a change rather than a continuance of
the same work. It fosters engagement and is important for the new nurse and
the family in establishing a collaborative relationship.
Another way to increase engagement is for the current nurse to ask the
family to take a break before the family initiates setting up an appointment
with the new nurse. This again emphasizes the change in the working relationship and encourages the family to be self-directive in initiating the new
contact rather than simply responding to the professionals.

Success of Treatment in Family Work
Although interventions may obtain positive and possibly dramatic results
during treatment, the real success of family work is the positive changes that
are maintained or continue to evolve weeks and months after nurses have
terminated treatment with particular families. We strongly encourage professional nurses and nursing students to make it a pattern of practice to
obtain data from the family regarding outcomes in order to determine best

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Chapter 12: How to Terminate With Families 335

practices. When nurses focus on outcomes, they orient their work toward
change, focus on problems that can be changed, and think about how families will cope without them in the future. We also suggest that nurses explain
to families that follow-up is a normal pattern of practice (e.g., by saying,
“We normally contact families with whom we have worked within 6 months
to gain information on how things are evolving”). It is also important to use
this follow-up contact and have specific goals in mind. A very useful reason
for follow-up can be for research purposes. In our experience, beginning
family nurse interviewers tend to be more focused on what is going on in the
family, whereas more experienced nurses focus on more specific goals for
treatment.
To facilitate evaluation, we suggest formalizing follow-up of families,
particularly those seen on an outpatient basis, by live interview, questionnaire, telephone, e-mail, or online survey. At present, we favor the use of a
face-to-face discussion and questionnaire that is answered by all available
family members.
One outcome study at an outpatient education and research clinic,
namely the Family Nursing Unit, University of Calgary (Bell, 2008; Wright
& Bell, 2009), was designed to evaluate the services provided to families.
The variables examined by this study were the family’s satisfaction with the
services provided, satisfaction with the nurse interviewer, and change in the
presenting problem and family relationships. A semistructured questionnaire
designed for this study asked for each family member’s perspective on each
of the variables. Questions were asked in relation to two periods: at the conclusion of the family sessions and at the time of the survey. Results from the
survey indicated that the most helpful aspects of family sessions were the
opportunity to ventilate family concerns, thereby increasing communication
among family members, and to obtain support from the clinical nursing
team. Families ranked the interview process and the suggestions from the
clinical nursing team as the second most helpful aspects.
Family members reported satisfaction with nurse interviewers, who were
either master’s or doctoral students or faculty members specializing in family
systems nursing. They indicated that the friendly, professional, and nonthreatening manner of the graduate nursing students made them comfortable.
More than 75% of the family members reported that the presenting problem
was better at the time of the survey. Regardless of the presenting problem,
positive changes in the marital relationship, such as increased communication, improved relationships, and decreased tension, were also reported, suggesting support for the systems-theory tenet that change in one part of the
system affects change in other parts.
This type of outcome study suggests that change should be evaluated at
the individual, parent–child, marital, and family system levels. We believe
that a higher level of positive change has occurred when improvement is
evidenced in systemic (total family) or relationship (dyadic) interactions than
when it is evidenced in individuals alone—that is, individual change does not

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336 Nurses and Families: A Guide to Family Assessment and Intervention

logically require system change, but stable system change does require individual change and relationship change, and relationship change requires
individual changes.
Nurses can contribute significantly to family outcome research by focusing
on follow-up with families in which particular family members experience a
health problem. This area of family work is just beginning to be researched
and lends itself beautifully to the active involvement of nurses in its evolution.

CONCLUSIONS
Concluding treatment in a therapeutic and constructive way is a challenge
for any nurse working with families. Unfortunately, much more has been
written in the literature about how to begin with and treat families than how
to effectively and therapeutically terminate with them. However, we want to
emphasize the extreme importance of terminating contact with families in a
manner that will increase the likelihood that diminished suffering will be
sustained and that changes and hopefulness in family relationships will be
maintained, celebrated, and expanded.
References
Bell, J.M. (2008). The Family Nursing Unit, University of Calgary: Reflections on 25 Years
of Clinical Scholarship (1982–2007) and Closure Announcement. Journal of Family
Nursing, 14(3), 275–288.
Bell, J.M., Moules, N.J., & Wright, L.M. (2009). Therapeutic letters and the Family
Nursing Unit: A legacy of advanced nursing practice. Journal of Family Nursing, 15(1),
6–30.
Bell, J.M., & Wright, L.M. (2011). Creating practice knowledge for families experiencing
illness suffering: The Illness Beliefs Model. In E. Svavarsdottir & H. Jonsdottir (Eds.):
Family Nursing in Action. Reykjavik, Iceland: University of Iceland Press.
Bloom, B.L. (2001). Focused single-session psychotherapy: A review of the clinical and
research literature. Brief Treatment and Crisis Intervention, 1, 75–86.
Duhamel, F., & Talbot, L. (2004). A constructivist evaluation of family interventions in
cardiovascular nursing practice. Journal of Family Nursing, 10(1), 12–32.
Hougher Limacher, L.H., & Wright, L.M. (2006). Exploring the therapeutic family
intervention of commendations: Insights from research. Journal of Family Nursing,
12, 307–331.
Levac, A.M., et al. (1998). A “Reader’s Theater” intervention to managing grief:
Posttherapy reflections by a family and a clinical team. Journal of Marital and Family
Therapy, 24(1), 81–93.
Madsen, W. (2007). Working within traditional structures to support a collaborative
clinical practice. International Journal of Narrative Therapy and Community Work,
2, 51–61.
Moules, N.J. (2002). Nursing on paper: Therapeutic letters in nursing practice. Nursing
Inquiry, 9(2), 104–113.
Moules, N.J. (2003). Therapy on paper: Therapeutic letters and the tone of the
relationship. Journal of Systemic Therapies, 22(1), 33–49.

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Moules, N.J. (2009). Therapeutic letters in nursing: Examining the character and influence
of the written word in clinical work with families experiencing illness. Journal of Family
Nursing, 15(1), 31–49.
Reed, K., & Tarko, M.A. (2004). Using the nursing process with families. In P.J. Bomar
(Ed.): Promoting Health in Families: Applying Family Research and Theory to Nursing
Practice (3rd ed.). Philadelphia: Saunders.
Robinson, C.A., & Wright, L.M. (1995). Family nursing interventions: What families
say makes a difference. Journal of Family Nursing, 1(2), 327–345.
Slive, A., & Bobele, M. (Eds.). (2011). When One Hour Is All You Have: Effective
Therapy for Walk-in Clients. Phoenix, AZ: Zeig, Tucker & Theisen.
Watson, W.L., & Lee, D. (1993). Is there life after suicide? The systemic belief approach
for “survivors” of suicide. Archives of Psychiatric Nursing, 7(1), 37–43.
White, M., & Epston, D. (1990). Narrative Means to Therapeutic Ends. New York:
Norton.
Wright, L.M. (2005). Spirituality, Suffering, and Illness: Ideas for Healing. Philadelphia:
F.A. Davis.
Wright, L.M., & Bell, J.M. (2009). Beliefs and Illness: A Model for Healing. Calgary,
AB: 4th Floor Press.
Wright, L.M., & Levac, A.M. (1992). The non-existence of non-compliant families: The
influence of Humberto Maturana. Journal of Advanced Nursing, 17(8), 913–917.
Wright, L.M., & Nagy, J. (1993). Death: The most troublesome family secret of all. In
E. Imber-Black (Ed.): Secrets in Families and Family Therapy. New York: W.W. Norton
& Co., pp. 121–137.
Wright, L.M., & Watson, W.L. (1988). Systemic family therapy and family development.
In C.J. Falicov (Ed.): Family Transitions: Continuity and Change Over the Life Cycle.
New York: Guilford Press, pp. 407–430.

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2739_Index_339-348 29/08/12 2:32 PM Page 339

INDEX
A
Adolescents, families with, 104–106, 106f
attachments, 106, 106f
questions to ask the family, 106
tasks, 105–106
Adoptive family life cycle, 118–121
aspects of the adoption to
consider, 120
Advice, giving too much prematurely,
316–318
clinical examples, 317–318
how to avoid, 316–317
Affective domain, interventions to change,
161–163
drawing forth family support, 162–163
encouraging the telling of illness
narratives, 162
validating, acknowledging, or normalizing
emotional responses, 161–162
Alliances and coalitions, 141–143
questions to ask the family, 141
triangles, 141
Analog communication, 34–35
“Angry associates” divorced
couples, 117
Appointments, setting up, 210–212
Assessment (linear) questions, 250
Assessment stage of family interviews, 182,
219, 225–237
attempted solutions to solving problems,
233–235
factors to consider, 234
goal exploration, 235–237
factors to consider, 235
problem identification, 226–230
factors to consider, 228
future, 227
past, 227
present, 226–227
relationship between family interaction
and the health problem, 230–233
factors to consider, 230
future, 232–233
past, 231–232
present, 231
Attachment, 93–95
diagrams, 94, 94f

B
Balance between change and stability,
created by family, 30–31

Behavioral domain, interventions to
change, 163–165
devising rituals, 164–165
encouraging family members to be
caregivers and offering caregiver
support, 163
encouraging respite, 164
Beliefs, 138–141
questions to ask the family, 140–141
Binuclear families, 117
Biology of cognition, 25, 46–48
Biopsychosocial-spiritual structures, 45–46
Bisexual family life cycle, 121–123
Bonding, 94
Boundaries, 62–64, 333–334
questions to ask the family, 64

C
Calgary Family Assessment and Intervention
Models, theoretical foundations of, 23–48
biology of cognition, 46–48
concept 1: Two possible avenues for explaining our world are objectivity
and objectivity-in-parentheses, 46–47
concept 2: We bring forth our realities
through interacting with the world,
ourselves, and others through
language, 47–48
change theory, 36–46
concept 1: Change is dependent on the
perception of the problem, 39–40
concept 2: Change is determined by
structure, 40
concept 3: Change is dependent on
context, 40–42
concept 4: Change is dependent on coevolving goals for treatment, 42–43
concept 5: Understanding alone does
not lead to change, 43
concept 6: Change does not necessarily occur equally in all family
members, 44
concept 7: Facilitating change is the
nurse’s responsibility, 44–45
concept 8: Change requires a “fit”
between nursing interventions and
family biopsychosocial-spiritual
structures, 45–46
concept 9: Change can be the result of
a myriad of causes or reasons, 46
communication theory, 34–36
339

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340 Index
concept 1: All nonverbal communication is meaningful, 34
concept 2: All communication has
two major transmission channels—
digital and analog, 34–35
concept 3: A dyadic relationship has
varying degrees of symmetry and
complementarity, 35–36
concept 4: All communication has two
levels—content and relationship, 36
cybernetics, 32–33
concept 1: Family systems possess
self-regulating ability, 33
concept 2: Feedback processes can
simultaneously occur at several
systems levels with families, 33
overview, 23–24, 48
postmodernism, 24–25
concept 1: Pluralism is a key focus of
postmodernism, 24
concept 2: Postmodernism is a debate
about knowledge, 25
systems theory, 26–32
concept 1: Family system as part of
suprasystem and composed of
subsystems, 27–28, 27f
concept 2: Family as a whole is greater
than the sum of its parts, 28–29
concept 3: A change in one family
member affects all family members,
29–30
concept 4: The family is able to create
a balance between change and
stability, 30–31
concept 5: Family members’ behaviors
are best understood using circular
rather than linear causality, 31–32
Calgary Family Assessment Model
(CFAM), 51–143
developmental assessment. See Developmental assessment, Calgary Family
Assessment Model
functional assessment. See Functional
assessment, Calgary Family Assessment Model
overview, 4, 51–53, 52f, 143
structural assessment. See Structural
assessment, Calgary Family Assessment Model
theoretical foundations. See Calgary
Family Assessment and Intervention
Models, theoretical foundations of
Calgary Family Intervention Model
(CFIM), 151–174

clinical examples, 165–173
example 1: difficulty putting 3-year-old
to bed, 165
example 2: elderly father complains
his children do not visit often
enough, 166–167
example 3: enuresis and discipline
problems with child, 167–170, 169f
example 4: social isolation and
physical complaints of elderly
woman, 170–173
definition and description, 152–154,
152f
interventions to change the affective
domain, 161–163
drawing forth family support,
162–163
encouraging the telling of illness
narratives, 162
validating, acknowledging, or
normalizing emotional responses,
161–162
interventions to change the behavioral
domain of family functioning,
163–165
devising rituals, 164–165
encouraging family members to be
caregivers and offering caregiver
support, 163
encouraging respite, 164
interventions to change the cognitive
domain, 158–161
commending family and individual
strengths, 158–159
offering information and opinions,
160–161
interventive questions, 154–158
linear versus circular questions,
154–157, 157f
miscellaneous examples of interventions, 157–158, 158f
overview, 15, 151–152, 152f, 173–174
theoretical foundations. See Calgary
Family Assessment and Intervention
Models, theoretical foundations of
Caregivers, family members as, 163
Care provider and supervisor, nurse as,
180
Case finder and epidemiologist, nurse as,
180
CFAM. See Calgary Family Assessment
Model (CFAM)
CFIM. See Calgary Family Intervention
Model (CFIM)

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Index 341
Change
credit for, 327–328
failing to create a context for, 310–313
clinical example, 312–313
how to avoid, 311–312
in one family member affects all family
members, 29–30
spontaneous, 37–38
Change theory, 36–46
concept 1: Change is dependent on the
perception of the problem, 39–40
concept 2: Change is determined by
structure, 40
concept 3: Change is dependent on
context, 40–42
concept 4: Change is dependent on
co-evolving goals for treatment, 42–43
concept 5: Understanding alone does not
lead to change, 43
concept 6: Change does not necessarily
occur equally in all family members,
44
concept 7: Facilitating change is the
nurse’s responsibility, 44–45
concept 8: Change requires a “fit”
between nursing interventions and
family biopsychosocial-spiritual
structures, 45–46
concept 9: Change can be the result of a
myriad of causes or reasons, 46
Children
families with, 102–104, 104f
attachments, 103–104, 104f
questions to ask the family, 104
tasks, 102–103
launching children and moving on,
106–108, 108f
attachments, 108, 108f
questions to ask the family, 108
tasks, 107–108
Chronic illness and its effects on other
family members, 10
Circular causality, 31–32
Circular communication, 128–133,
129f–133f, 250
circular pattern diagrams (CPDs),
128–130, 129f–133f
Clinical examples
advice, giving too much prematurely,
317–318
Calgary Family Intervention Model
(CFIM), 165–173
example 1: difficulty putting 3-year-old
to bed, 165

example 2: elderly father complains
his children do not visit often
enough, 166–167
example 3: enuresis and discipline
problems with child, 167–170, 169f
example 4: social isolation and physical
complaints of elderly woman,
170–173
change, failing to create a context for,
312–313
family interview, 244–246
giving too much advice prematurely,
317–318
taking sides, 314–316
Closing letters, 330–331
Coalitions and alliances, 141–143
questions to ask the family, 141
triangles, 141
Cognition, biology of, 25, 46–48
concept 1: Two possible avenues for
explaining our world are objectivity
and objectivity-in-parentheses,
46–47
concept 2: We bring forth our realities
through interacting with the world,
ourselves, and others through language,
47–48
Cognitive domain, interventions to change,
158–161
commending family and individual
strengths, 158–159
offering information and opinions,
160–161
Collaboration, 213
Commending family and individual
strengths, 272
helpful hints for, 160
Communication theory, 34–36
concept 1: All nonverbal communication
is meaningful, 34
concept 2: All communication has two
major transmission channels—digital
and analog, 34–35
concept 3: A dyadic relationship has
varying degrees of symmetry and
complementarity, 35–36
concept 4: All communication has two
levels—content and relationship, 36
Complementarity, 35–36
Complementary two-person relationship,
141
Complexity, planning and dealing with,
237–241
level of family functioning, 237–239

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342 Index
nurse’s level of competence, 239–240
work context, 240–241
Conceptual skills, 184
Constructivism, 25
Consultant, nurse as, 181
Context (CFAM), 67–75
environment, 74–75
ethnicity, 67–69
race, 69–71
social class, 71–73
spirituality and/or religion, 73–74
Context-initiated termination, 325–326
Contracts, reviewing, 326
Cooperation, 213
“Cooperative colleagues” divorced
couples, 117
Coordinator, nurse as, 180
Counselor, nurse as, 180
Cybernetics, 32–33
concept 1: Family systems possess
self-regulating ability, 33
concept 2: Feedback processes can
simultaneously occur at several
systems levels with families, 33

D
Developmental assessment, Calgary Family
Assessment Model, 90–123
adoptive family life cycle, 118–121
divorce and post-divorce family life
cycle, 111–116
lesbian, gay, bisexual, queer, intersexed,
transgendered, twin-spirited
(LGBQITT) family life cycles,
121–123
middle-class North American family life
cycle, 95–110
stage one: launching of the single
young adult, 95, 98–99, 99f
stage two: marriage—the joining of
families, 100–102, 101f
stage three: families with young
children, 102–104, 104f
stage four: families with adolescents,
104–106, 106f
stage five: launching children and
moving on, 106–108, 108f
stage six: families in later life,
108–110, 110f
overview, 90–95, 94f
professional and low-income family life
cycles, 118
remarried family life cycle, 116–118
Developmental milestones, missing, 10

Digital communication, 34–35
Divorce and post-divorce family life cycle,
111–116
questions to ask the family, 115–116
sample phases, 113–115
Dyadic relationship, 35–36

E
Ecomaps, 270
examples, 75, 88–90, 89f
helpful hints for drawing, 90
Emotional communication, 126–127
questions to ask the family, 126–127
Emotional responses, validating, acknowledging, or normalizing, 161–162
Engagement stage of family interviews,
181–182, 220–225
ABCs of engaging families, 221
purpose of engagement, 220
questions used to foster collaborative
working relationship, 223–224
Environment, 74–75
questions to ask the family, 75
Environmental modifier, nurse as, 181
Epidemiologist, nurse as, 180
Errors in family nursing, avoiding,
309–318
error 1: failing to create a context for
change, 310–313
clinical example, 312–313
how to avoid, 311–312
error 2: taking sides, 313–316
clinical examples, 314–316
how to avoid, 313–314
error 3: giving too much advice
prematurely, 316–318
clinical examples, 317–318
how to avoid, 316–317
overview, 309, 318
Ethnicity, 67–69
questions to ask the family, 67–69
Evaluating family interviews, 328–329
Examples, clinical. See Clinical examples
Executive skills, 184
Expertise in maintaining health and managing health problems is present on both
sides of the nurse–family relationship,
196–197
questions about expertise, 197
Expressive functioning, 124–143
alliances and coalitions, 141–143
beliefs, 138–141
circular communication, 128–133,
129f–133f

2739_Index_339-348 29/08/12 2:32 PM Page 343

Index 343
emotional communication, 126–127
influence and power, 136–138
nonverbal communication, 127–128
overview, 124–126
problem solving, 133–134
roles, 134–136
verbal communication, 127
Extended family, 64–65
questions to ask the family, 65
External structure (CFAM), 64–67
extended family, 64–65
larger systems, 65–67

F
Facilitating change, 44–45
Family, definition of, 54–55
Family advocate, nurse as, 180
Family assessment and intervention,
introduction to, 1–16
Calgary Family Assessment Model: an
integrated framework, 4, 52f
Calgary Family Intervention Model: an
organizing framework, 15
evolution of the nursing of families, 2–3
family assessment, 3–4
indications and contraindications for a
family assessment, 4–6
nursing interventions, 6–7, 7–11
conceptualization, 7–9
context, 6–7
contraindications, 11
definition, 6
development, identification, and
implementation, 11–13
family responses to, 13–15
indications, 10–11
intent, 7
nursing practice levels with families,
15–16
generalists, 15–16
specialists, 15–16
overview, 1–2, 16
Family biopsychosocial-spiritual structures,
45–46
Family composition, 54–57
questions to ask the family, 56–57
Family development, definition of, 91
Family genograms and ecomaps. See
Ecomaps; Genograms
Family-initiated termination, 324–325
Family interviews, conducting, 219–247
assessment stage, 225–237
attempted solutions to solving
problems, 233–235

goal exploration, 235–237
problem identification, 226–230
relationship between family interaction
and the health problem,
230–233
future, 232–233
past, 231–232
present, 231
clinical case example, 244–246
engagement stage, 220–225
intervention stage, 241–244
overview, 219–220, 247
planning and dealing with complexity,
237–241
level of family functioning, 237–239
nurse’s level of competence, 239–240
work context, 240–241
termination stage, 244
Family interviews, preparing for, 193–217
first contact with family, 209–212
how to set up an appointment,
210–212
helpful hints, 217
hypothesizing, 199–204
how to generate hypotheses, 200–204
ideas about the nurse–family relationship,
194–198
assumption 1: the family–nurse
relationship is characterized by
reciprocity, 195
assumption 2: the family –nurse
relationship is nonhierarchical, 196
assumption 3: nurses and families
each have specialized expertise in
maintaining health and managing
health problems, 196–197
assumption 4: nurses and families
each bring strengths and resources
to the family–nurse relationship,
197–198
assumption 5: feedback processes
can occur simultaneously at several
different relationship levels, 198
interview settings, 204–207
home setting, 205–206
office, hospital, or other work setting,
206–207
overview, 193–194, 217
resistance and noncompliance, 212–217
how to deal with a hesitant family
member, 214–215
how to deal with family nonengagement
and referral sources, 215–217
who will be present, 207–209

2739_Index_339-348 29/08/12 2:32 PM Page 344

344 Index
Family interviews, stages and skills,
179–192
development of family nursing interviewing skills, 184–191
evolving stages of family nursing interviews, 181–183
assessment, 182
engagement, 181–182
intervention, 183
termination, 183
nine-star family nurse, 180–181
care provider and supervisor, 180
case finder and epidemiologist, 180
consultant, 181
counselor, 180
environmental modifier, 181
family advocate, 180
health educator, 180
manager and coordinator, 180
researcher, 180
overview, 179–180, 187t–191t, 191–192
types of skills, 183–184
conceptual, 184
executive, 184
perceptual, 183–184
Family interviews in 15 minutes or less,
263–277
examples
brief family interview without family
members present, 275–276
involving family in nursing practice,
273–275
key ingredients, 266–272
1: therapeutic conversations, 266–268
2: manners, 268–270
3: family genograms and ecomaps,
270
4: therapeutic questions, 271–272
5: commending family and individual
strengths, 272
overview, 263–266, 276–277
Family life cycle, definition of, 91
Family Nurse, The: Frameworks for
Practice, 1, 180
Family support, 162–163
Feedback, 33, 198
“Fiery foes” divorced couples, 117
First-order change, 37
Follow-up, 329–330
Functional assessment, Calgary Family
Assessment Model, 123–143
expressive functioning, 124–143
alliances and coalitions, 141–143
beliefs, 138–141

circular communication, 128–133,
129f–133f
emotional communication, 126–127
influence and power, 136–138
nonverbal communication, 127–128
overview, 124–126
problem solving, 133–134
roles, 134–136
verbal communication, 127
instrumental functioning, 123–124
overview, 123

G
Gay family life cycle, 121–123
Gender, 57–58
questions to ask the family, 58
Generalists, 15–16
Genograms, 75–88, 270
artificial insemination and lesbian
couple, 80, 80f
blank, 77f
helpful hints for constructing, 83
samples, 79f–80f, 82f, 84f, 86f–87f
stepfamily, 84f, 86f
symbols used in, 77–79, 78f
Goal exploration, 235–237

H
Health educator, nurse as, 180
Heterosexism, 58
History of family nursing, 2–3
Homeplace, 92
Home setting for interviews, 205–206
Hospital setting for interviews, 206–207
Hypothesizing, 199–204
guidelines for generating, 201
how to generate hypotheses, 201–204
questions that invite hypothesizing about
the system and the problem, 203

I
Iceland-Expressive Family Functioning
Questionnaire (ICE-EFFQ), 4
Iceland-Family Perceived Support
Questionnaire (ICE-FPSQ), 4
Illness and its effects on other family
members, 10
Illness narratives, 162
Influence and power, 136–138
questions to ask the family, 138
Instrumental functioning, 123–124
Internal structure (CFAM), 54–64
boundaries, 62–64

2739_Index_339-348 29/08/12 2:32 PM Page 345

Index 345
family composition, 54–57
gender, 57–58
rank order, 60–61
sexual orientation, 58–60
subsystems, 61–62
Intersexed, definition of, 59
Intersexed family life cycle, 121–123
Intervention, definition of, 6
Interventional (circular) questions, 250
Intervention stage of family interviews,
183, 220, 241–244
factors to consider when devising
interventions, 242
helpful hints, 241
Interventions to change the affective
domain, 161–163
drawing forth family support, 162–163
encouraging the telling of illness
narratives, 162
validating, acknowledging, or normalizing
emotional responses, 161–162
Interventions to change the behavioral
domain, 163–165
devising rituals, 164–165
encouraging family members to be caregivers and offering caregiver support,
163
encouraging respite, 164
Interventions to change the cognitive
domain, 158–161
commending family and individual
strengths, 158–159
offering information and opinions,
160–161
Interventive questions, 154–158
linear versus circular questions,
154–157, 157f
Interviews. See Family interviews

L
Language, 47–48
Larger systems, 65–67
questions to ask the family, 67
Later life, families in, 108–110, 110f
attachments, 110, 110f
questions to ask the family, 110
tasks, 109–110
Launching children and moving on,
106–108, 108f
attachments, 108, 108f
questions to ask the family, 108
tasks, 107–108
Launching of the single young adult, 95,
98–99, 99f

attachments, 99, 99f
questions to ask the family, 99
tasks, 98–99
LGBQITT (lesbian, gay, bisexual, queer,
intersexed, transgendered, twin-spirited)
family life cycles, 121–123
questions to ask the family, 122
Linear blame, 41
Linear causality, 31
Linear questions, 154–157, 250
Listening, importance of, 267
Low-income family life cycle, 118

M
Manager and coordinator, nurse as, 180
Manners, important in family interviews,
268–270
examples, 270
Marriage, 100–102, 101f
attachments, 101, 101f
questions to ask the family, 101–102
tasks, 100–101
Mental health urgent care practice
framework elements and ladders, 283t
Middle-class North American family life
cycle, 95–110
overview, 95–97
stage one: launching of the single young
adult, 95, 98–99, 99f
stage two: marriage—the joining of
families, 100–102, 101f
stage three: families with young children,
102–104, 104f
stage four: families with adolescents,
104–106, 106f
stage five: launching children and
moving on, 106–108, 108f
stage six: families in later life, 108–110,
110f

N
Nine-star family nurse, 180–181
care provider and supervisor, 180
case finder and epidemiologist, 180
consultant, 181
counselor, 180
environmental modifier, 181
family advocate, 180
health educator, 180
manager and coordinator, 180
researcher, 180
Noncompliance and resistance, 212–217
Nonengagement, family, 215–217

2739_Index_339-348 29/08/12 2:32 PM Page 346

346 Index
Nonhierarchical family –nurse relationship,
196
questions about hierarchy, 196
Nonverbal communication, 34, 127–128
questions to ask the family, 128
Nurse-initiated termination, 322–324
“Nurses Always There for You: Caring for
Families,” 180
Nursing interventions. See Intervention
entries
Nursing practice levels with families,
15–16
generalists, 15–16
specialists, 15–16

example 3: Use questions to elicit
problem-solving skills, coping
strategies, and strengths, 254–257
example 4: Use questions as interventions and to invite change, 257–260
example 5: Use questions to request
feedback about the family meeting,
260–261
overview, 249, 261
questions in context, 249–261
linear versus circular, 154–157, 157f,
250
therapeutic, 271–272
“why” questions, 43

O

R

Objectivity and objectivity-in-parentheses,
46–47
Office setting for interviews, 206–207
Opinions and information, offering,
160–161
helpful hints, 161

Race, 69–71
questions to ask the family, 71
Rank order in families, 60–61
questions to ask the family, 61
Reciprocity characterizes family–nurse
relationship, 195
questions about reciprocity, 195
Referral, 215–217, 332–334
Religion and/or spirituality, 73–74
questions to ask the family, 74
Remarried family life cycle, 116–118
attachment theory, 117
questions to ask the family, 118
Researcher, nurse as, 180
Resistance and noncompliance, 212–217
how to deal with a hesitant family
member, 214–215
how to deal with family nonengagement
and referral sources, 215–217
Respite, encouraging, 164
Rigid boundaries, 63
Rituals, devising, 164–165
Roles in expressive functioning, 134–136
questions to ask the family, 136

P
Perceptual skills, 183–184
“Perfect pals” divorced couples, 117
Pluralism, 24
Post-divorce family life cycle, 111–116
questions to ask the family, 115–116
sample phases, 113–115
Postmodernism, 24–25
concept 1: Pluralism is a key focus of
postmodernism, 24
concept 2: Postmodernism is a debate
about knowledge, 25
Power, 136–138
questions to ask the family, 138
Pragmatics of Human Communication, 34
Problem solving, 133–134
Professional and low-income family life
cycles, 118

Q
Queer, definition of, 58–59
Queer family life cycle, 121–123
Questions
how to use in family interviews,
249–261
example 1: Engage all family members
and focus the meeting, 251–252
example 2: Use questions to assess the
impact of the problem/illness on the
family, 252–254

S
Second-order change, 37
Self-regulating ability of families, 33
Sexual orientation, 58–60
questions to ask the family, 60
Sides, taking, 313–316
clinical examples, 314–316
how to avoid, 313–314
Skills, types of, 183–184
conceptual, 184
executive, 184
perceptual, 183–184

2739_Index_339-348 29/08/12 2:32 PM Page 347

Index 347
Skills in family nursing, 281–305
beyond basic skills, 283–284
clinical vignettes, 284–305
1: interviewing families of the elderly
at time of transition, 284–293
2: interviewing an individual to gain a
family perspective on chronic
illness, 293–305
interviewing skills, 184–191
overview, 281–282, 283t, 305
skills in context, 282–283, 283t
Social class, 71–73
questions to ask the family, 73
Social constructionism, 25
Specialists, 15–16
SPIN (Stress-Point Intervention by Nurses),
199
Spirituality and/or religion, 73–74
questions to ask the family, 74
Spontaneous change, 37–38
Strengths, commending, 158–159
Strengths and resources are brought by
each side of the nurse–family relationship,
197–198
questions about strengths, 198
Stress-Point Intervention by Nurses (SPIN),
199
Structural assessment, Calgary Family
Assessment Model, 53–90
context, 67–75
environment, 74–75
ethnicity, 67–69
race, 69–71
social class, 71–73
spirituality and/or religion, 73–74
external structure, 64–67
extended family, 64–65
larger systems, 65–67
internal structure, 54–64
boundaries, 62–64
family composition, 54–57
gender, 57–58
rank order, 60–61
sexual orientation, 58–60
subsystems, 61–62
overview, 53–54
tools, 75–90
ecomap, 88–90, 89f
genogram, 77–88
Subsystems, 27–28, 27f, 61–62
questions to ask the family, 62
Supervisor, nurse as, 180
Suprasystem, 27–28, 27f
Symmetrical two-person relationship, 141

Symmetry, 35–36
System, definition of, 26
Systems, larger, 65–67
questions to ask the family, 67
Systems theory, 26–32
concept 1: Family system as part of
suprasystem and composed of
subsystems, 27–28, 27f
concept 2: Family as a whole is greater
than the sum of its parts, 28–29
concept 3: A change in one family member affects all family members, 29–30
concept 4: The family is able to create a
balance between change and stability,
30–31
concept 5: Family members’ behaviors
are best understood using circular
rather than linear causality, 31–32

T
Taking sides, 313–316
clinical examples, 314–316
how to avoid, 313–314
“10,000-hour rule,” 284
Terminating clinical work with families,
321–336
decision to terminate, 322–326
context-initiated termination, 325–326
family-initiated termination, 324–325
nurse-initiated termination, 322–324
overview, 321–322, 336
phasing out and concluding treatment,
326–331
closing letters, 330–331
decrease frequency of sessions,
326–327
evaluate family interviews, 328–329
extend an invitation for follow-up,
329–330
give credit for change, 327–328
review contracts, 326
referral to other professionals, 332–334
keep appropriate boundaries, 333–334
meet the new professional, 333
prepare families, 332–333
transfers, 334
success of treatment in family work,
334–336
Termination stage of family interviews,
183, 220, 244
Therapeutic conversations, 266–268
Therapeutic questions, 271–272
examples, 271–272
Threesomes, 141

2739_Index_339-348 29/08/12 2:32 PM Page 348

348 Index
Transfers, 334
difference from referrals, 334
Transgendered family life cycle, 121–123
Tree of Knowledge, The: The Biological
Roots of Human Understanding, 46
Triangles, 141
Twin-spirited family life cycle, 121–123
Two-spirited, definition of, 59

W

V

Young adult, launching, 95, 98–99, 99f
attachments, 99, 99f
questions to ask the family, 99
tasks, 98–99

Validating emotional responses, 161–162
Verbal communication, 127
questions to ask the family, 127

Whole greater than the sum of its parts,
28–29
“Why” questions, 43
World Health Organization (WHO) Family
Health Nurse Multinational Study, 3

Y

2739_Author DVD.Ad_1-3 31/08/12 10:53 AM Page 349

The “How to” Family
Nursing DVD Series
www.familynursingresources.com
Available in DVD and/or .mov files, streaming video format
Developed and demonstrated by:
Lorraine M. Wright, RN, PhD, and Maureen Leahey, RN, PhD
Produced by FamilyNursingResources.com
This series presents live clinical scenarios that demonstrate how to practice
family nursing. Interviews are with a family with young children, middleaged families, and later-life families. The health problems and health-care
settings are varied as are the ethnic and racial groups. Intended for practicing
nurses, educators, undergraduate students, and graduate nursing students,
these educational programs will increase nurses’ skills in assisting families
experiencing illness.
These actual family nursing interviews are a perfect accompaniment
to Wright and Leahey’s highly acclaimed, award-winning text, Nurses and
Families: A Guide to Family Assessment and Intervention.
#1: How to Do a 15-Minute (or Less) Family Interview (length 23:18)

Featuring real-life clinical scenarios, Wright and Leahey demonstrate key
family nursing skills such as how to use manners to engage families in a short
period, how to start therapeutic conversations with families, and how to routinely ask key therapeutic questions of families.
#2: Calgary Family Assessment Model: How to Apply in Clinical Practice
(length 26:47)

Wright and Leahey, co-developers of the Calgary Family Assessment Model
(CFAM), demonstrate the model in clinical practice. Highlighting the structural, developmental, and functional categories of CFAM in clinical interviews, they present examples of specific questions the nurse can ask the
family, illustrate the helpfulness of the genogram and ecomap, and demonstrate how to construct circular interactional diagrams in clinical settings.
#3: Family Nursing Interviewing Skills: How to Engage, Assess,
Intervene, and Terminate With Families (length 22:32)

Observe the four stages of a family nursing interview, from engagement
through termination. Wright and Leahey define and demonstrate key perceptual, conceptual, and executive skills; show how to apply these skills in family
nursing clinical practice; offer sample questions for nurses to explore family
concerns/solutions; and show key interventions to help families change.
#4: How to Intervene With Families With Health Concerns (length 27:54)

Focus on intervention and change! Wright and Leahey demonstrate interventions in new clinical interviews: encouraging the telling of illness narratives,
349

2739_Author DVD.Ad_1-3 31/08/12 10:53 AM Page 350

350 Nurses and Families: A Guide to Family Assessment and Intervention

validating affect, drawing forth family strengths/support, encouraging respite,
offering commendations, and offering information/opinions. These interventions focus on strengthening, promoting and/or sustaining effective family
functioning in cognitive, emotional, and behavioral domains.
#5: How to Use Questions in Family Interviewing (length 26:45)

Increase your interviewing skills by using questions that are effective and
time-efficient! Wright and Leahey demonstrate how to use questions that
engage all family members and focus the meeting, assess the impact of the
illness/problem on the family, elicit family coping strategies/strengths, intervene and invite change, and request family feedback.
#6: Common Errors in Family Interviewing: How to Avoid and Correct
(length 27:04)

How to avoid and correct errors in family interviewing is essential for
relational practice and for healing to occur. Interviewing skills are demonstrated in new actual clinical vignettes. Specifically shown is how to create
a context for change and work collaboratively with all family members in
the room without taking sides. Both physical and mental health issues are
explored.
#7: Tips and Microskills for Interviewing Families of the Elderly (length
27:22)

An interview with a clinician and two senior children at the time of their
mother’s transition to a care facility demonstrates the microskills for assisting
families of the elderly with a potentially difficult life transition. Tips for how
to engage with family members quickly, obtain a brief relevant history, and
discuss caregiver impact and burden are provided. Interviewing skills for
how to collaborate with senior children and respond to suggestions about
their mother’s care are also demonstrated in new clinical vignettes.
#8: Interviewing an Individual to Gain a Family Perspective With Chronic
Illness: A Clinical Demonstration (length 28:15)

A brief clinical interview honors the notion that illness is a family affair and
demonstrates skills for how to assess the impact of chronic illness on one’s
life and relationships (work, family, marriage, and children). Interventions
of commendations and rituals are also illustrated.

PURCHASE INFORMATION
Products are available in DVD format. For information about licensing agreements, .mov files, and streaming video, see www.familynursingresources.com.
These DVDs have been translated into Japanese and are available at
www.igakueizou.co.jp
$329 per DVD includes shipping and handling. Additional charge if
courier delivery is requested.

2739_Author DVD.Ad_1-3 31/08/12 10:53 AM Page 351

The “How to” Family Nursing Series 351

Canadian residents pay in Canadian funds and add GST/HST.
United States and international residents pay in U.S. funds.
Payment can be made by: check, money order, or bank wire transfer.
Institutional purchase orders are accepted.
Make check payable to: efamilynursing.com
To order by phone: North America 902-243-3454 or 403-830-3445
(12 noon to 3 p.m. Monday–Friday)
To order by email: mleahey@bellaliant.net or lmwright@ucalgary.ca
To order by Internet: www.FamilyNursingResources.com
To order by mail: efamilynursing.com, 291 Pugwash Point Road, Pugwash,
Nova Scotia, Canada, B0K 1L0
Name:_______________________________Dept./Title:____________
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PROGRAM NAME
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QUANTITY

UNIT PRICE

2. CFAM
3. Family Nursing Skills
4. Interventions
5. Questions
6. Common Errors
7. Tips and Microskills—
Elderly
8. Interviewing Individual
Total
(Revised 11/1/12; price subject to change without notice)
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