Nurses And Families A Guide To Lorraine M Wright
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- Chapter 1: Family Assessment and Intervention: An Overview
- EVOLUTION OF THE NURSING OF FAMILIES
- FAMILY ASSESSMENT
- CALGARY FAMILY ASSESSMENT MODEL: AN INTEGRATED FRAMEWORK
- INDICATIONS AND CONTRAINDICATIONS FOR A FAMILY ASSESSMENT
- NURSING INTERVENTIONS: A GENERIC DISCUSSION
- NURSING INTERVENTIONS FOR FAMILIES: A SPECIFIC DISCUSSION
- DEVELOPMENT, IDENTIFICATION, AND IMPLEMENTATION OF NURSING INTERVENTIONS WITH FAMILIES
- FAMILY RESPONSES TO INTERVENTIONS
- CALGARY FAMILY INTERVENTION MODEL: AN ORGANIZING FRAMEWORK
- NURSING PRACTICE LEVELS WITH FAMILIES: GENERALIST AND SPECIALIST
- Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models
- SYSTEMS THEORY
- COMMUNICATION THEORY
- CHANGE THEORY
- BIOLOGY OF COGNITION
- Chapter 3: The Calgary Family Assessment Model
- STRUCTURAL ASSESSMENT
- DEVELOPMENTAL ASSESSMENT
- Middle-Class North American Family Life Cycle
- Divorce and Post-Divorce Family Life Cycle
- Remarried Family Life Cycle
- Professional and Low-Income Family Life Cycles
- Adoptive Family Life Cycle
- Lesbian, Gay, Bisexual, Queer, Intersexed, Transgendered,Twin-Spirited Family Life Cycles
- FUNCTIONAL ASSESSMENT
- Chapter 4: The Calgary Family Intervention Model
- DEFINITION AND DESCRIPTION
- INTERVENTIVE QUESTIONS
- INTERVENTIONS TO CHANGE THE COGNITIVE DOMAIN OF FAMILY FUNCTIONING
- INTERVENTIONS TO CHANGE THE AFFECTIVE DOMAIN OF FAMILY FUNCTIONING
- INTERVENTIONS TO CHANGE THE BEHAVIORAL DOMAIN OF FAMILY FUNCTIONING
- CLINICAL EXAMPLES
- Chapter 5: Family Nursing Interviews: Stages and Skills
- Chapter 6: How to Prepare for Family Interviews
- IDEAS ABOUT THE NURSE-FAMILY RELATIONSHIP
- INTERVIEW SETTINGS
- WHO WILL BE PRESENT
- FIRST CONTACT WITH THE FAMILY
- RESISTANCE AND NONCOMPLIANCE
- Chapter 7: How to Conduct Family Interviews
- GUIDELINES FOR FAMILY INTERVIEWS
- GUIDELINES FOR THE REMAINING INTERVIEWING PROCESS
- CLINICAL CASE EXAMPLE
- Chapter 8: How to Use Questions in Family Interviewing
- QUESTIONS IN CONTEXT
- Example 1: Engage All Family Members and Focus the Meeting
- Example 2: Use Questions to Assess the Impact of the Problem/Illness on the Family
- Example 3: Use Questions to Elicit Problem-Solving Skills, Coping Strategies, and Strengths
- Example 4: Use Questions as Interventions and to Invite Change
- Example 5: Use Questions to Request Feedback About the Family Meeting
- QUESTIONS IN CONTEXT
- Chapter 9: How to Do a 15-Minute (or Shorter) Family Interview
- KEY INGREDIENTS
- PERSONAL EXAMPLE OF INVOLVING FAMILY IN NURSING PRACTICE
- PROFESSIONAL EXAMPLE OF A BRIEF FAMILY INTERVIEW WITHOUT FAMILY MEMBERS PRESENT
- Chapter 10: How to Move Beyond Basic Family Nursing Skills
- FAMILY NURSING SKILLS IN CONTEXT
- BEYOND BASIC SKILLS
- CLINICAL VIGNETTES
- Chapter 11: How to Avoid the Three Most Common Errors in Family Nursing
- Chapter 12: How to Terminate With Families
- DECISION TO TERMINATE
- PHASING OUT AND CONCLUDING TREATMENT
- REFERRAL TO OTHER PROFESSIONALS
- The “How to” Family Nursing DVD Series
A Guide to Family Assessment
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Lorraine M. Wright and Maureen Leahey
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
A Guide to Family Assessment
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F. A. Davis Company
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Philadelphia, PA 19103
Copyright © 2013 by F. A. Davis Company
Copyright © 2009, 2005, 2000, 1994, 1984 by F. A. Davis Company. All rights reserved.
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Printed in the United States of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Publisher, Nursing: Joanne Patzek DaCunha, RN, MSN
Director of Content Development: Darlene Pedersen
Project Editor: Echo Gerhart
Manager of Art and Design: Carolyn O’Brien
As new scientific information becomes available through basic and clinical research, rec-
ommended treatments and drug therapies undergo changes. The author(s) and publisher
have done everything possible to make this book accurate, up to date, and in accord with
accepted standards at the time of publication. The author(s), editors, and publisher are
not responsible for errors or omissions or for consequences from application of the book,
and make no warranty, expressed or implied, in regard to the contents of the book. Any
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changes and new information regarding dose and contraindications before administering
any drug. Caution is especially urged when using new or infrequently ordered drugs.
Library of Congress Cataloging-in-Publication Data
Wright, Lorraine M., 1944-
Nurses 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.
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2739_FM_i-xxii 29/08/12 2:41 PM Page iv
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
Lorraine M Wright
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2739_FM_i-xxii 29/08/12 2:41 PM Page vi
Michele D’Arcy-Evans, PhD, CNM
Lewis-Clarke State College
RN, BA, BSN, MA, CNE
Jamie Kane, MS, RN, CNE
Evening/Weekend Program Coordinator
Ellis School of Nursing
Schenectady, New York
Kara E. Keyes, MS, RNC
Department of Nursing
Le Moyne College
Syracuse, New York
Stephanie Langford, RN,
University of Ottawa
Faculty of Health Sciences
School of Nursing
Ottawa, Ontario, Canada
Krista Lussier, RN, MSN
Thompson Rivers University
Kamloops, British Columbia, Canada
M. Star Mahara, RN, BSN, MSN
Thompson Rivers University
Kamloops, British Columbia, Canada
Janet McCabe, PhD, MEd, RN
University of Saskatchewan
Prince Albert, Saskatchewan, Canada
Carol Murphy Moore, MSN, CRNP
Assistant Professor of Nursing
Judith Quaranta, MS, RN, CPN,
AE-C, Doctoral candidate
Clinical Associate Professor
Decker School of Nursing/Binghamton
Binghamton, New York
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Helena Schaefer, RN, MN, NP
University of Alberta
Edmonton, Alberta, Canada
Gisele Thibodeau, BScN, RN
Dalhousie School of Nursing—
Yarmouth, Nova Scotia, Canada
Sharon E. Thompson, MSN, RN
Assistant Clinical Professor
Northern Arizona University
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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
Finally, we are grateful to each other . . . for enduring friendship/
collegiality over some 37 years, for Caffe Beano Saturday morning conver-
sations, fabulous restaurant experiences, and wonderful trips traveling to-
gether in Provence, Germany, Thailand, Iceland, Inle Lake, Luang Prabang,
Lake O’Hara, Pugwash, Nova Scotia . . . and more adventures await!
Lorraine M. Wright
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Chapter 1 Family Assessment and Intervention:
An Overview 1
Chapter 2 Theoretical Foundations of the Calgary
Family Assessment and Intervention Models 23
Chapter 3 The Calgary Family Assessment Model 51
Chapter 4 The Calgary Family Intervention Model 151
Chapter 5 Family Nursing Interviews: Stages and Skills 179
Chapter 6 How to Prepare for Family Interviews 193
Chapter 7 How to Conduct Family Interviews 219
Chapter 8 How to Use Questions in Family
Chapter 9 How to Do a 15-Minute (or Shorter)
Family Interview 263
Chapter 10 How to Move Beyond Basic Family
Nursing Skills 281
Chapter 11 How to Avoid the Three Most Common
Errors in Family Nursing 309
Chapter 12 How to Terminate With Families 321
The “How To” Family Nursing DVD Series 349
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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 bound-
aries of practice, education, and research. Research evidence and clinical nar-
ratives 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
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■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
■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 inter-
viewing skills in action that have either been substantiated with practice-
based 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) con-
tinues 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 frame-
work 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 ever-
changing 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
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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 mem-
ber and nurse see a world that he or she brings forth through interacting
with themselves and with others through language. We encourage an open-
ness in ourselves, our students, and the families with whom we work to the
many “worlds”, differences, and diversity between and among family mem-
bers 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 set-
tings, 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 ac-
cepted in both our text and when presenting them at nursing workshops or
conferences. More important, based on anecdotal reports, the implementa-
tion 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 suf-
fering 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 cele-
bration. There has been progress, and yet there are other areas where nursing
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still needs to put its “shoulder to the wheel.” We believe one of the most far-
reaching 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 pro-
vided 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 confirma-
tion 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 interven-
tions in family work. There exists a solid commitment to focus on knowl-
edge 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
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 confer-
ence 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
The face of families has dramatically changed over the past 30 years as
demographics in North America indicate an ever-increasing aging popula-
tion; 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 popula-
tions 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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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 nurs-
ing has not been immune to these changes, nor have we.
Numerous other paradigm events have influenced families and the devel-
opment 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, in-
stant 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 treat-
ments, 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 “how-
to” basic text for undergraduate, graduate, and practicing nurses. It is the
only textbook, of which we are aware, that provides specific how-to guide-
lines for family assessment and intervention and actual skills for implemen-
tation 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 ap-
proach 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 substan-
tially 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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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 prac-
tices. 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 use-
ful. How to Do a 15-Minute (or Shorter) Family Interview (Chapter 9) re-
mains 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
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 assess-
ment and intervention models, namely the Calgary Family Assessment and In-
tervention Models, for current best practice; (3) provide guidelines for family
interviewing skills; (4) offer detailed ideas and suggestions with clinical exam-
ples of how to prepare, conduct, use questions in, and terminate family inter-
views; 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 inter-
viewing families in various settings and presents two clinical vignettes.
Sample skills for interviewing families of the elderly at times of transi-
tion are highlighted as well as skills for interviewing an individual to
gain a family perspective on chronic illness. Tips are offered, and micro-
skills 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 diver-
sity 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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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 sib-
lings, 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 fos-
ter 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 relation-
ships 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 con-
sulting 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 in-
cluded 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 indica-
tions and contraindications for family assessment and intervention.
Chapter 2 addresses the major concepts of systems, cybernetics, commu-
nication, 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 mod-
els, such as postmodernism and gender sensitivity. Clinical examples of the
application of these concepts are offered.
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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 re-
flect 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 inter-
views are presented to illustrate how to use the model and tools in clinical
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 consider-
ation. Nurses traditionally have primarily focused on family assessment
because there have been no family nursing intervention models within nurs-
ing to draw on.
Chapter 5 describes the family interviewing skills and competencies nec-
essary 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 evalu-
ation 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 set-
ting, and making the first telephone contact with the family.
Chapter 7 delineates the various stages of the first interview and the re-
maining 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 interven-
tions nurses offer to families. Questions to engage, assess, elicit problem-
solving 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 en-
courages nurses to adopt the belief that any time spent with families is better
than no time.
2739_FM_i-xxii 29/08/12 2:41 PM Page xx
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 exam-
ple 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 bed-
side, 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 nurs-
ing 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 trans-
fer to actual clinical practice and supervisory feedback.
We envision this book as a springboard for nursing students, nursing ed-
ucators, 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 pro-
fessionals. 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.
Wright, L.M., & Leahey, M. (Producers). (2000). How to do a 15-minute (or less) fam-
ily 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
Wright, L.M., & Leahey, M. (Producers). (2002). Family nursing interviewing skills:
How to engage, assess, intervene, and terminate with families. [DVD]. Calgary, Canada:
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 inter-
viewing. [DVD]. Calgary, Canada: www.familynursingresources.com.
2739_FM_i-xxii 29/08/12 2:41 PM Page xxi
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,
2739_FM_i-xxii 29/08/12 2:41 PM Page xxii
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 involve-
ment 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
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.
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2Nurses 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 im-
plication 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
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 origi-
nated in patients’ homes, family involvement and family-centered care were nat-
ural 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 contri-
butions to the advancement of family nursing knowledge.
The evolution, development, and practice of family nursing are well estab-
lished 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 ed-
ucational 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 coun-
try that published an impressive report upon completion of the Family Health
Nurse Project initiated by WHO was Scotland, at the University of Stirling
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 ref-
erenced throughout this text are now in their second to sixth editions. Provid-
ing 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.”
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 identi-
fied and described several family assessment models and instruments devel-
oped 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 empha-
sized in each model because no one assessment model explains all family
In any clinical practice setting, nurses benefit from adopting a clear con-
ceptual 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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4Nurses 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 seem-
ingly 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 the-
ory 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 postmod-
ernism, feminism, and biology of cognition. Diversity issues are also empha-
sized 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 baccalau-
reate 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 au-
tomatically be considered for family assessment. Because families now tend
to have increased health-care awareness and knowledge, nurses are encoun-
tering 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,
■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 motiva-
tion 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, par-
ticularly 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 ration-
ale 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 ad-
vantage 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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6Nurses 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, activ-
ity, moves, and micromoves (Bulechek & McCloskey, 1992, 1999; Wright &
Bell, 2009). This textbook prefers the designation intervention. The most rig-
orous 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 consider-
ation 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 treat-
ment based upon clinical judgment that a nurse performs to enhance pa-
tient/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 ther-
apeutic 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, fre-
quently offering something or doing something to someone else.” Interven-
tions 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 (in-
terventions) 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 be-
tween 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, effec-
tive nursing interventions are those to which clients and families respond be-
cause 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
Conceptualization of Interventions With Families
Notions about reality gleaned from postmodernism and social construction-
ism 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 con-
struction of the world. Maturana (1988) presents an intriguing notion of re-
ality by submitting that individuals (living systems) bring forth reality—they
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8Nurses 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 inter-
ventions directed to the family rather than just the individual diagnosed with
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 chil-
dren 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 interven-
tions 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
Evidence has been found for a significant reduction in the use of health-
care 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 interven-
tions with families experiencing physical illness, particularly about the use-
fulness 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
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 effec-
tiveness is evident (Loveland-Cherry & Bomar, 2004). Family health promo-
tion 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 inter-
vention called Parents and Children Together (PACT) (Kendall & Tabacco,
2011). Recognizing that families with children with ADHD have more in-
terpersonal 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 inter-
ventions. Interventions are an integral part of family interviewing, span-
ning 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
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 conse-
quently find themselves wanting to know about the specific practice offered
to families. We have found it heartening to learn about the increased exam-
ples 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 detrimen-
tal 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 exacer-
bates 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 deteri-
oration occurs, family patterns may need restructuring, and intervention
■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 re-
lief, the family might feel a tremendous void when the caregiving role
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 insuf-
ficient 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 fre-
quently 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 terminat-
ing with families. Additional information on termination is discussed in
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 meet-
ings 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
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 & Harper-
Jaques, 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 ac-
tions 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 ac-
knowledge 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 fami-
lies are the most urgent need of the three. Therefore, nurse educators, re-
searchers, 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 psycho -
educational intervention program for family caregivers of seniors. Although
they acknowledge that this program does not address the family from a sys-
temic 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 interven-
tions differently from nurses who predominantly conduct research or en-
gage in theory development. Nurse educators and researchers need to
understand more about the challenges, successes, and difficulties of im-
plementing 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 fam-
ilies often led them to label families’ responses to illness as being “dysfunc-
tional” 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 prima-
rily 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 phe-
nomena (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
■Bringing the family together to engage in new and different conversa-
tions (this fell within the stage of “creating the circumstances for
■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 re-
■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 use-
fulness 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 sig-
nificant 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 un-
dergoing bone marrow transplants (Noiseux & Duhamel, 2003), interven-
tions 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 cerebrovas-
cular 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 inte-
grated 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 stud-
ies 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 of-
fered by nurses (see Chapter 4). It is at this intersection that healing can take
place. The CFIM is a resilience and strength-based, collaborative, nonhier-
archical 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 cog-
nition. 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 clin-
ical 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 baccalau-
reate students begin to conceptualize the family as the unit of care. Special-
ists, 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 re-
quires 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 sys-
tems 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 nurs-
ing 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 be-
come blurred, with upper-level baccalaureate students recognizing the im-
portance 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.
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 fam-
ilies with our offering of specific knowledge and skills for maximizing family
collaboration and healing.
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Theoretical Foundations of the
Calgary Family Assessment and
Models are useful ways to bring clusters of ideas, notions, and concepts into
awareness. However, models cannot stand alone. For example, nursing prac-
tice 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 ex-
plained. 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
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 theo-
retical perspective gives nurses a sufficiently broad base of knowledge
and understanding for use as a guide to family assessment and interven-
tions 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 inte-
grated approach to practice, research, and education in family nursing”
(Kaakinen & Hanson, 2004, p. 111). We concur with Kaakinen and Hanson
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, commu-
nication theory, change theory, and biology of cognition. Each theory or
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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.
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
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 can-
not 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 prac-
tice of relational family nursing.
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 no-
tions of postmodern thinking is the idea of pluralism, or a belief in multi-
plicity—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 rec-
ognizing that there are as many ways to understand and experience illness
as there are families experiencing it. In an ethical and relational family nurs-
ing practice, it becomes operational by acknowledging the multiplicity of
cultural, ethnic, and religious beliefs and their influence on various complex
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Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models 25
Postmodernism is a debate about knowledge.
Postmodernism is partly a reaction to the modernist claim that knowl-
edge 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 sys-
tems that have formed the foundation of many scientific, religious, and po-
litical 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. Hon-
oring the voices of families about their illness narratives has profound im-
plications for nursing practice with families. It invites collaboration and
consultation between nurses and families to honor the knowledge and ex-
pertise of both nurses and family members. These practices are the corner-
stone of relational nursing. Inviting the illness narratives of families also
enhances the possibilities for healing as their stories are heard, understood,
Some offshoots of postmodernism include constructivism, social construc-
tionism, 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 be-
cause of patriarchy and oppression (Kermode & Brown, 1996). This has
not been our experience in working with families. Evidence for the impor-
tance of acknowledging women’s voices and their illness burden in family
systems nursing practice can be found in Robinson’s 1998 study. She dis-
covered 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 col-
lective “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
For a number of years, health professionals have applied general systems the-
ory, 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 writ-
ten 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 influen-
tial of all the family social science frameworks” (p. 73).
One of the most useful analogies that highlights systems concepts as ap-
plied 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 unbal-
ancing themselves and moving chaotically about for a time. Grad-
ually the whole exerts its influence in the errant part(s) and
balance is reestablished but not before a decided change in direc-
tion 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
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 parent-
child, marital, and sibling subsystems. These subsystems are also composed of
subsystems of individuals. Individuals are extremely complex systems com-
posed of various subsystems, some of which are physical (e.g., the cardiovas-
cular 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 com-
munities. 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 ele-
ments. 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.
FIGURE 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
In addition, within family systems and their subsystems, nurses should
assess the permeability of the boundaries (see Chapter 3 for further un-
derstanding 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 in-
tegrity (e.g., members may be too open to input from the outside environ-
ment, such as extended family, friends, or health professionals) and
therefore does not allow the family to use its own resources in decision-
making. 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.
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 mem-
bers 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. Con-
sider 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 child-
and-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 in-
teraction 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 ex-
ample, the family is the client, but an individual family member is the reason
for initiating care (Schober & Affara, 2001). Any time a family seeks assis-
tance 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. Con-
versely, you cannot grasp how the whole works unless you have an under-
standing 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.)
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 con-
sidering 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 un-
able 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 fa-
ther 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.
The family is able to create a balance between change
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 chang-
ing. The pendulum has now swung to the other end of the continuum. How-
ever, 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; how-
ever, 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 manifest-
ing an observable balance between the two. However, the more experienced
one becomes in family nursing, the greater appreciation one has for the com-
plexity 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 de-
veloped creative solutions to cope with the fluctuations of stability and
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 dis-
cussion 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 pat-
tern. Linearity is heavily rooted in a framework of a continuous pro-
gression 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 an-
other, 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
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 characteris-
tics. 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 relation-
ships 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
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 impor-
tant to the theoretical foundation for working with families.
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.
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 mem-
bers 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 sub-
stantial change to occur in a relationship, the regulatory limits must be ad-
justed 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 dis-
cussed in Chapter 3.
Feedback processes can simultaneously occur at several sys-
tems 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 feed-
back and change of change). Maturana and Varela (1980) suggest a
higher-order cybernetics that links the organization of living process and
Therefore, the simple feedback phenomenon observed in the interac-
tional pattern of criticizing wife—withdrawing husband may also be un-
derstood to be part of a larger feedback loop involving the couple’s
relationship to their families of origin, which may recalibrate the lower-
order loop of the couple’s interaction. This concept can be especially help-
ful 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
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 im-
portant book on communication and have been updated by the research
studies of Dr. Janet Beavin Bavelas in 1992.
All nonverbal communication is meaningful.
This concept helps us to realize that there is no such thing as not commu-
nicating because all nonverbal communication by a person carries a message
in the presence of another (Watzlawick, Beavin, & Jackson, 1967). In per-
sonal communications and in her 1992 publication, Dr. Beavin Bavelas states
that she now distinguishes between nonverbal behavior (NVB) and nonver-
bal communication (NVC). NVC is viewed as a subset of NVB. NVB
involves an “inference-making observer,” whereas NVC involves a “com-
municating 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 exam-
ple, if a mother complains to a CHN that she has been experiencing in-
somnia for 2 months and finds herself irritable because of the prolonged
sleep deprivation, the mother’s behavior must be understood in her imme-
diate 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 in-
formation, the mother’s insomnia can be more fully understood and treated
by the CHN.
All communication has two major channels for
transmission: digital and analog.
Digital communication is commonly referred to as verbal communica-
tion. 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.” How-
ever, 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 cumber-
some 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 signifi-
cance of the analogical communication. More suggestions for operational-
izing this concept are included in the CFAM in Chapter 3.
A dyadic relationship has varying degrees of symmetry
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 fol-
low 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 be-
tween two people who behave as if they have equal status. Each per-
son 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 equal-
ity 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 pre-
dominantly 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 relation-
ship is one between spouses, who may, for instance, debate where to spend
their next vacation.
In family relationships, predominance of either complementary or sym-
metrical 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 re-
lationship to a more symmetrical, egalitarian relationship as the child moves
into the teenage and young adult years.
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 ex-
ample, 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 differ-
ent relationship. The first statement could be viewed as part of a loving re-
lationship, 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).
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 main-
taining 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 accom-
panied 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 sug-
gest 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 first-
order change. It is a change in quantity, not quality. First-order change in-
volves 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 vigor-
ously applied. An example of first-order change is the learning of a new be-
havioral 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 dis-
continuity or jump and can be sudden and radical. Other times, second-
order 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 reso-
lution occurs in daily living without the input of professionals or sophisti-
cated 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 envi-
ronment 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 mem-
ber) exists or is a result of the system’s (family member’s) own internal
Our own view of change in family work draws from the above authors
and from our clinical experience in working with families. Change is con-
stantly 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 in-
terventions 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 fam-
ily, 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
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Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models 39
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 implica-
tions 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 “real-
ities” 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 va-
lidity. 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 dif-
ferent 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 cy-
bernetics 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
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 determin-
ism (Maturana & Varela, 1992) offers the notion that each individual’s
biopsychosocial-spiritual structure is unique and is a product of that per-
son’s genetic history (phylogeny) and his or her history of interactions over
The implication for nursing practice is that an individual’s present struc-
ture determines the interpersonal, intrapersonal, and environmental influ-
ences that are experienced as perturbations (i.e., that trigger structural
changes). Therefore, we cannot say beforehand which family nursing inter-
ventions will be useful in promoting change for this particular family member
at this time and which will not. Consequently, individuals are selectively per-
turbed 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 standard-
ized 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, re-
sistant, 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.
Change is dependent on context.
Efforts to promote change in a family system must always take into ac-
count the important variable of context. Interventions must be planned with
sufficient knowledge of the contextual constraints and resources. This is par-
ticularly 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
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 com-
monly tend to go beyond the immediate concerns. The end result is that pa-
tients 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 set-
ting 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
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.
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 inappropri-
ate 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 fam-
ily’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
The task of setting specific goals for treatment is accomplished in collab-
oration with the family. Part of the assessment process is to identify the cur-
rent 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
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 prob-
lems 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.
Understanding alone does not lead to change.
Changes in family work rarely occur by increasing a family’s understand-
ing 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 sys-
tems 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 dis-
ability 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 ef-
fect a change. The search for causes should be avoided because it inadver-
tently 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
Change does not necessarily occur equally in all family
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.
Facilitating change is the nurse’s responsibility.
We believe that it is the nurse’s responsibility to facilitate change in collab-
oration 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 out-
come. However, there is a distinct difference between facilitating change, di-
recting 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 per-
ceives 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 responsi-
bility 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 con-
text 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.
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 struc-
ture, 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 of-
fered. (For more information on this, see Chapter 4 and the discussion of
the CFIM.) This includes nurse sensitivity to the family’s race, ethnicity, sex-
ual orientation, and social class.
The concept of “fit” allows nurses to be nonblaming of patients and them-
selves when nonfit—and consequently nonadherence and non-follow-
through—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 over-
looked, 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.
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 neurobi-
ologists, 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.
Two possible avenues for explaining our world are objectiv-
ity 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 ex-
ists for explaining the world. Within this domain, entities are assumed to
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Chapter 2: Theoretical Foundations of the Calgary Family Assessment and Intervention Models 47
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,
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 inter-
action 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 ab-
solutely 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 explana-
tion 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.
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 be-
tween the theoretical framework, the intervention, and the outcome meas-
ure” (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.
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The Calgary Family
The Calgary Family Assessment Model (CFAM) is an integrated, multidi-
mensional framework based on the foundations of systems, cybernetics, com-
munication, 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 de-
veloped 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:
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 subcate-
gories need to be assessed at a first meeting with a family, and some subcat-
egories 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
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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 sub-
categories 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.
Religion and/or spirituality
Activities of daily living
Influence and power
FIGURE 3-1: Branching diagram of CFAM.
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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 clin-
ical 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 in-
volves 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 subcat-
egories of CFAM, he or she can use CFAM as a clinical organizing frame-
work 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 cop-
ing with their teenager’s unexpected illness. The nurse, being reminded of
family developmental stages by using CFAM, will draw forth those resilien-
cies. 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 “as-
sessed.” Rather, they present themselves or are encountered by nurses while
coping or suffering with an illness, loss, and/or disability or are seeking as-
sistance to improve their quality of life. CFAM helps guide nurses in helping
In this chapter, each assessment category is discussed separately. Terms
are defined, and sample questions relevant to each CFAM category are pro-
posed 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 ques-
tions 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 inter-
action among all of the individuals within the family.
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 ad-
Internal structure includes six subcategories:
1. Family composition
3. Sexual orientation
4. Rank order
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 be-
longing, 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
3. The unit may or may not contain children.
4. There is commitment and attachment among unit members that include
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 emo-
tional ties, a sense of belonging, and durability of membership determine
Nurses need to find a definition of family that moves beyond the tradi-
tional boundaries that limit membership using the criteria of blood, adop-
tion, 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 same-
sex 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 grand-
parent, 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
Some authors, such as Penn (2007), have questioned the commonly held
belief that all couples want to live together. He discusses “commuter cou-
ples,” 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 defini-
tion 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, stepfam-
ilies 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 tem-
porarily 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 oc-
curred, 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 num-
ber 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 exam-
ple, 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 arrange-
ments can occur when one parent is in a rehab facility owing to military
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). Re-
search by Bowse and colleagues (2003) indicates that the extent of HIV risk-
taking 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
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 pat-
terns 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 our-
selves 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
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 refer-
ence. 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 dif-
ferences between women and men can be changed, discarding unhelpful cul-
tural scripts for women and men, and recognizing and attending to hidden
power and influence issues. We think it is also important to consider friend-
ship 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 com-
monly 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 cul-
tural, 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
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 sig-
nificant 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
Levac, Wright, and Leahey (2002) recommend that assessment of the gen-
der’s influence is especially important when societal, cultural, or family be-
liefs about male and female roles are creating family tension. In this situation,
couples may desire to establish more equal relationships, with characteristics
■Partners hold equal status (e.g., equal entitlement to personal goals,
needs, and wishes).
■Accommodation in the relationship is mutual (e.g., schedules are or-
ganized 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 re-
lationship 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 be-
lieve 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?
The subcategory of sexual orientation includes sexual majority and sexual
minority populations. Heterosexism, the preference of heterosexual orienta-
tion 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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Chapter 3: The Calgary Family Assessment Model 59
or female and who define themselves outside of these definitions. The prem-
ise is that sexual identity is socially constructed. Although the term queer
previously was used in a negative manner, now it has a more positive con-
notation. Intersexed describes someone with ambiguous genitalia or chro-
mosomal 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 treat-
ment. Despite the fact that approximately 1% of all U.S. households are iden-
tified as consisting of same-sex couples (USA Today, 2003), the topic of
sexual orientation is one that nurses approach with varying levels of accept-
ance, 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 compli-
cated 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 out-
comes. In addition, immigrants may have also been exposed to varying be-
liefs 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 com-
paring 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 orien-
tation path he or she takes and that the patient’s sense of integrity and inter-
personal 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 per-
son, 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 assump-
tions 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 per-
son “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?
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 assess-
ment, because sibling relationships can be significant across the family de-
velopmental 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 care-
Toman (1993) has been a major contributor to research about sibling con-
figuration. 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 re-
garding 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 multi-
level 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 configu-
rations. Newman (2011) notes that in the last 20 years, the number of families
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Chapter 3: The Calgary Family Assessment Model 61
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 kinder-
garten, 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 per-
sistent 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
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 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
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 be-
haves 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 single-
parent 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 neces-
sary 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
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 fam-
ily 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
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?
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 ex-
plicit 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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Chapter 3: The Calgary Family Assessment Model 63
Boundaries can be diffuse, rigid, or permeable. As boundaries become dif-
fuse, 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 in-
dividual 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 dis-
engaged. 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 bound-
aries, on the other hand, allow appropriate flexibility. Under these condi-
tions, 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
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 cou-
ples 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 am-
biguous boundaries was quite evident in the days shortly following 9/11 or
Hurricane Katrina, when people were missing. Boss (2002) named the situ-
ation “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 ex-
ample, 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 as-
pects of contact time (time together), personal space (physical nearness,
touching), emotional space (sharing of affects), information space (informa-
tion 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 includes two subcategories:
1. Extended family
2. Larger systems
The subcategory of extended family includes the family of origin and the
family of procreation as well as the present generation and stepfamily mem-
bers. 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 ex-
tended family to provide information about the quality and quantity of sup-
port. For example, the importance of social media connections cannot be
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Chapter 3: The Calgary Family Assessment Model 65
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
In our clinical work, we consider whether there are many references to
the extended family. How significant is the extended family to the function-
ing 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?
The subcategory “larger systems” refers to the larger social agencies and per-
sonnel with whom the family has meaningful contact. Larger systems gener-
ally 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 pro-
vide 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 pre-
ferred 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
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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 multiprob-
lem, 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 com-
puter 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. Inter-
net romance may begin outside any real-life context, but it quickly can esca-
late to a context all its own.
But the Internet can offer families valuable assistance in terms of infor-
mation, validation, empathy, advice, and encouragement. Some have used
e-mail, blogs, and online resources to augment, extend, deepen, inform, en-
rich, 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 stim-
Vigorous attention should be given to ways that professional expertise
and electronic connectivity can be combined. Telenursing is one such exam-
ple. Questions for consideration in providing family-centered telehealth care
include how do health professionals ensure that the voices of all family mem-
bers are part of the discussion between the nurse and the family? Using video-
conferencing 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 be-
lieve that increasingly health care will be provided in people’s homes. Equip-
ment 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 infrastruc-
ture 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 fam-
ily and the larger system? How regularly do they interact? Is their relationship
symmetrical or complementary? Are the larger systems overconcerned? Over-
involved? Underconcerned? Underinvolved? Does the larger system blame the
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Chapter 3: The Calgary Family Assessment Model 67
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 fam-
ily 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 is explained as the whole situation or background relevant to some
event or personality. Each family system is itself nested within broader sys-
tems, 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 cir-
cumscribes both the individual and the family, its consequences are pervasive.
Context includes but is not limited to these five subcategories:
3. Social class
4. Spirituality and/or religion
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 an-
cestors 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 orig-
inating 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
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. Spe-
cific 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 perspec-
tive.” What matters is the family’s cultural narrative, how it is deconstructed
Ethnic differences in family structure and their implications for interven-
tion 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 bound-
aries, 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 op-
portunities 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 ap-
preciating 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 injus-
tice. 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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Chapter 3: The Calgary Family Assessment Model 69
about a family’s ethnicity. Also, if we engage a translator to assist us with fam-
ily work, we should not assume that the translator is an expert on this partic-
ular 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 ex-
change cannot be underestimated whether in working with aboriginal com-
munities 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 ques-
tions 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
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 sep-
aration 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 conver-
sation be different? Are the assessment and testing instruments we use in
our clinic relevant for this ethnic group? Do they match the values and be-
liefs 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?
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 atti-
tudes, stereotyping, and discrimination are powerful influences on family in-
teraction 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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70 Nurses and Families: A Guide to Family Assessment and Intervention
especially with increased use of the Internet and other social media. Many
college-age and younger Americans are rejecting the color lines that once de-
fined racial identity in favor of a much more fluid identity. The crop of stu-
dents 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 per-
centage 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 de-
velopment of African Americans, Asians, Hispanics, whites, and others are
potential strengths in helping these families to function under various eco-
nomic and social conditions. There is a dearth of literature on potential re-
lationship strengths in intercultural and interracial relationships. We
encourage nurses to elicit strengths rather than challenges in working with
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 com-
posed 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 ag-
gression based on these differences are problems. With the number of inter-
racial 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 as-
sumptions that have guided America’s politics, customs, and habits for many
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 var-
ious racial groups. For example, we ask ourselves how a Jamaican American
family might differ from an African American family in their beliefs about hos-
pitalization 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 compe-
tent. 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 shapes educational attainment, income, and occupation. It is fre-
quently confused with socioeconomic status (SES). Kliman (2011) points out
that SES is typically a decontextualized and hierarchical formula of educa-
tion, occupation levels, and income dividing people into upper-upper, lower-
upper, 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 work-
ing 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 them-
selves and are defined; what they cherish; how they organize their day-to-
day 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 sub-
group to represent the lower-income class and the white statistical subgroup
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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 be-
come 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 employ-
ment, 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 terror-
ism, and the aftereffects of 9/11 have created increased difficulties for the
working poor. We have found in our clinical work that particularly in low-
income 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, di-
minish 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.
72 Nurses and Families: A Guide to Family Assessment and Intervention
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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 mean-
ing 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 cen-
tered 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 as-
certain 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 spiritu-
ality. 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 intergen-
erational 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 influ-
ence 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 typi-
cally 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 be-
comes 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 encour-
age 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,
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 rel-
evant 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 disturb-
ing issue about the environment: “In America’s rundown urban neighbor-
hoods, 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 neigh-
borhoods have the highest mortality rates in the country owing to the preva-
lence 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 fastest-
growing 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 trans-
portation 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 be-
tween 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 en-
courage nurses to develop a fit between these tools to depict specific family
These tools have been developed as family assessment, planning, and inter-
vention 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
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 ap-
propriate 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 friend-
ship; 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
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 spe-
cific family patterns, resiliencies, and symptom constellations. Gathering,
mapping, and tracking family history is much easier using a computer data-
base. 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 re-
search, 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 his-
tory. 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
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 por-
tray the facts thus represented, it becomes clear how simple and useful
these tools are. Genograms, when placed on patients’ charts, act as con-
stant 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 implemen-
tation 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 evalu-
ation 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. Chil-
dren 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.
Aunts & uncles
FIGURE 3-2: Blank genogram.
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78 Nurses and Families: A Guide to Family Assessment and Intervention
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
Circle members of current household
Miscarriage or abortion
or common law (CL):
(husband on left;
wife on right)
oldest on left)
FIGURE 3-3: Symbols used in genograms.
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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 ma-
chinist, 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
FIGURE 3-4: Sample genogram: The Lamensa family.
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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 insemi-
nation. 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 hus-
band and became a widow when he died in 1993. Mitzi is considering trans-
gender 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
Adopted by Amanda
M 1987D 1986CL
FIGURE 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
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
Elena: No. I lived with my parents till I met Matias.
Nurse: Do either of you have children from prior relation-
ships? (Turns to both Matias and Elena.)
Matias: Yes, I have two sons.
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.
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 signifi-
cant, 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
■Elena lived with her family of origin before the marriage. They live next
■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 ex-
ample, 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.
FIGURE 3-6: Genogram of the Manuyag family.
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Chapter 3: The Calgary Family Assessment Model 83
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 con-
cerns (sports injury). The nurse can always expand to the third generation if
•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
•Ask family members how an absent significant family member might answer a
•Avoid discussion that is hurtful or blameful, especially of absent family members.
•Take an interest in each family member, and be sensitive to developmental
•Tailor questions to children’s developmental stages so that they become active
•Notice children’s nonverbal and verbal comments.
•If some members are shy or seem uninterested in participating directly (such as ado-
lescents), ask other family members about them.
•Begin by asking “easy” questions of individuals followed by exploration of
•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
•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 stepfami-
lies, 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 un-
necessary 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 stepfam-
ily, 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 mar-
ried 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 me-
chanic who is presently living in a common-law marriage with Camille and
CL 2011 CL 2008
George Robert Laura
FIGURE 3-7: Sample genogram of a stepfamily.
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Chapter 3: The Calgary Family Assessment Model 85
her three sons. Camille and her first husband, Rob, divorced in 2004, rec-
onciled in 2006, and then divorced in 2007.
There are no specific guidelines for drawing genograms illustrating com-
plex 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 chrono-
logical order from left to right. We have sometimes found it helpful to indi-
cate the number of the relationship or marriage in the lower corner when
there have been several relationships. See Figure 3–5, where Adrienne’s hus-
bands 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. Ad-
ditional pertinent information, such as children moving between two house-
holds, 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 con-
stellations 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 mul-
tiple 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
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 alter-
nate 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 be-
came pregnant with Sophia when she was 16. Sophia’s father, Michael
Gr. 1 Gr. 1 Gr. 8
FIGURE 3-8: Sample genogram: Faris stepfamily.
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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 con-
cern for this family is Sophia’s nightmares, especially after returning from vis-
its to Joan and Ben’s trailer. Figure 3–9 shows the Fitzgerald-Kucewicz family
Most families are extremely receptive to and interested in collaborating
with the nurse to complete a genogram. For some, it is the first time that
they have ever seen their family life pictured in this manner. Therefore, the
nurse needs to be aware that the family may have a reaction to significant
events. One family, for example, may express some sensitive material in a
M 14 yrs.
S 1 yr.
FIGURE 3-9: Genogram of the Fitzgerald-Kucewicz family.
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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 see-
ing the nurse write the word divorce.
As with the genogram, the primary value of the ecomap is in its visual im-
pact. 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 re-
sources, 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 cur-
rent 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 spir-
itual 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 repre-
sent 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 con-
nections 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
(CHN) once a week. Silvana’s mother, Nunziata, visits Silvana every day from
. 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 fre-
quently 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.
Sees M.D. weekly
Grade = D
once a week
FIGURE 3-10: Lamensa family ecomap.
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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 sys-
tems and their extended family. Box 3–2 gives helpful hints for drawing
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 genera-
tion. But what of family development? It is more than the concurrent devel-
opment 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 his-
tory and by their implied future together.
There is no single family developmental life cycle or model. This is espe-
cially evident as our population ages. The natural sequential phases of gener-
ational 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 mar-
riages, 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 de-
scribing family development in precise, absolute, universal ways. Postmod-
ernists differ from modernists in that exceptions interest them more than rules;
specific, contextualized details more than grand generalizations; difference
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
•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.
2739_Ch03_051-150 29/08/12 1:49 PM Page 90
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 distin-
guish between “family development” and “family life cycle.” Family devel-
opment emphasizes the unique path constructed by a family. It is shaped by
predictable and unpredictable events, such as illness, catastrophes (e.g., ter-
rorist 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 en-
trance 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 his-
tory. 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, ac-
cording 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 fam-
ily 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. Al-
though their approaches differed, these therapists similarly sought to un-
derstand the relationship between psychopathology and the family’s
developmental life cycle stage.
Carter and McGoldrick (1988, 1999b) included the impact of transgen-
erational stress intersecting with family developmental transitions. They be-
lieved 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 be-
cause 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 in-
creased consciousness of differences in male and female development and a
rethinking of the trajectory of various ethnic groups in North American soci-
ety. 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 “objec-
tive” 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 re-
quired 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 gen-
der relativity rather than universality, transitions rather than stages, dimen-
sions 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 em-
phasis 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
We believe that there is much evidence to support the position that nurses
will find heuristic value in the family development category of CFAM. How-
ever, 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 deter-
mined,” 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 de-
velopment category and overemphasizing smooth progression. Contradic-
tions and difficulties inherent in progressing through the life cycle are normal.
Families are complex systems that need to deal with many different progres-
sions 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. Fam-
ily 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
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 think-
ing 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 dur-
ing 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 situa-
tions 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 de-
scribe different relationships, we have chosen in this book and in our clinical
work to make no distinction between these terms. We recognize the com-
plexity 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 attach-
ments. 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 attach-
We are partial to the idea of the network paradigm as a useful base to in-
tegrate 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.
Very slightly attached
FIGURE 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 sys-
tem 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 at-
tachment processes (i.e., affect regulation, interpersonal understanding, in-
formation processing, and the provision of comfort within intimate
relationships) are as applicable to family systems as they are to individual
In the CFAM developmental category, we discuss family life cycle stages,
the emotional process of transition (namely, key principles), and second-
order changes—the issues dealt with and tasks often accomplished during
each stage. In an effort to emphasize the variability of family development,
we discuss six sample types of family life cycles:
1. Middle-class North American
2. Divorce and post-divorce
4. Professional and low-income
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 expan-
sion, contraction, and realignment of relationships as entries, exits, and de-
velopment 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 cou-
ples (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 di-
vorce, 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 influ-
ence 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
The Stages of the Family Life Cycle
Emotional Process Second-Order Changes in Family
Family Life Cycle of Transition: Status Required to Proceed
Stage Key Principles Developmentally
Joining of families
and moving on
tional and finan-
members into the
flexibility of family
Accepting a multi-
tude of exits from
and entries into
a. Differentiation of self in relation to
family of origin
b. Development of intimate peer
c. Establishment of self in respect to
work and financial independence
d. Establishment of self in community
and larger society
a. Formation of partner systems
b. Realignment of relationships with
extended family, friends, and larger
community and social system to
include new partners
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
a. Shift of parent-child relationships to
permit adolescent to move into and
out of system
b. Refocus on midlife couple and career
c. Begin shift toward caring for older
d. Realignment with community and
larger social system to include shifting
family of emerging adolescent and
parents in new formation pattern of
a. Renegotiation of couple system as a
b. Development of adult-to-adult rela-
tionships between parents and grown
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Chapter 3: The Calgary Family Assessment Model 97
The Stages of the Family Life Cycle—cont’d
Emotional Process Second-Order Changes in Family
Family Life Cycle of Transition: Status Required to Proceed
Stage Key Principles Developmentally
the end of life
realities of limita-
tions and death
and the comple-
tion of one cycle
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 constel-
lation of family relationships
e. Exploration of new interests/career
given the freedom from childcare
f. Dealing with care needs, disabilities,
and death of parents (grandparents)
a. Maintenance of own and/or couple
functioning and interests in face of
psychological decline: exploration
of new familial and social role
b. Supporting more central role of
c. Realignment of the system in rela-
tion to community and larger social
system to acknowledge changed
pattern of family relationships of this
d. Making room in the system for the
wisdom and experience of the elders
e. Supporting older generation without
a. Dealing with loss of spouse, siblings,
and other peers
b. Making preparations for death and
c. Managing reversed roles in caretaking
between middle and older
d. Realignment of relationships with
larger community and social system
to acknowledge changing life cycle
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 suc-
ceeding 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 iden-
tity centered around work. Women may choose to define themselves in rela-
tion 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 expecta-
tions 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, eth-
nicity, and nationality.
1. Differentiation of self in relation to family of origin. The young adult’s
shift toward adult status involves the development of a mutually re-
spectful 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 expec-
tations regarding acceptable ways to be attached and connected to fam-
ily 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 interdepen -
dent 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 oth-
ers 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 ori-
gin must sort through issues of competitiveness, expectations, and dif-
ferences regarding work and financial goals.
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 attach-
ments. 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 Father
FIGURE 3-12: Sample attachments in stage 1.
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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 particu-
larly 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).
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 rou-
tine 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 re-
searched over many years, but more nuanced views of the so-called
marriage advantage are coming to light (Parker-Pope, 2010). Those in-
dividuals 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.
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 out-
side interests (such as work and friends) than to his wife. We have found that
negative attachment–related events occurring early in the marriage are espe-
cially 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 Husband Wife
FIGURE 3-13: Sample attachments in stage 2.
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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 genera-
tion. 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
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 responsibil-
ities 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 sup-
port significantly more often than do men.
We believe the work-family issue of juggling childcare and other house-
hold 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.
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 be-
coming parents include shifts in the sense of self, shifts in relation-
ships 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 child-
care responsibilities must be addressed. The influence of illness, such
as autoimmune disease, on maternal fatigue and its impact on the care-
giving 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 achieve-
ment and productivity, whereas some working-class families may re-
spond to this pressure by feelings of alienation. Recent immigration
experiences and whether the children are documented or undocu-
mented can also influence peer and school interaction.
3. Realignment of relationships with extended family to include parent-
ing 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
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 op-
portunities to develop positive sibling relationships. We believe teaching in-
terdependence 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 com-
petitive, 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 tran-
sition, in which biological, emotional, and sociocultural changes occur with
great and ever-increasing rapidity. Peers, texting, social networks such as Twit-
ter 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 respon-
sibility, 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 fi-
nancially dependent on the parents and continuing to live in the family home.
FIGURE 3-14: Sample attachments in stage 3.
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Chapter 3: The Calgary Family Assessment Model 105
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 ques-
tion 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 de-
pendent 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 ex-
ample, Fulkerson and colleagues (2007) found that general family con-
nectedness, 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 associ-
ated with poor psychological health in the 7th to 12th graders they
studied. For parents to find a balance between encouraging healthy eat-
ing 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’ per-
ception of more secure adolescent attachment was associated with bet-
ter 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 ask-
ing 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 rec-
iprocity are key tasks.
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 in-
volved 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
FIGURE 3-15: Sample attachments in stage 4.
Teen Teen Child
Teen 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.
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
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 commit-
ments. The key emotional process during this stage is for family mem-
bers to deal with a multitude of exits from and entries into the family
3. Realignment of relationships to include in-laws and grown children.
The parents adjust family ties and expectations to include their child’s
spouse or partner. This can sometimes be particularly challenging if the
parents’ expectation is for a heterosexual son-in-law or daughter-in-
law of the family’s race, religion, and ethnicity and the child chooses
someone different. The once-prevalent idea that the time after a grown
child marries is a lonely, sad time, especially for women, has been re-
placed. Increases in marital satisfaction have frequently been noted.
4. Dealing with disabilities and death of grandparents. Many families re-
gard 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 be-
havior in ineffective and counterproductive ways. Thus, they inadver-
tently intensify their own stress. We have found that many times female
caregivers seek support for depression that often stems from the mul-
tiple 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.
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
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 flex-
ibly 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 rec-
ognize 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.
FIGURE 3-16: Sample attachments in stage 5.
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Chapter 3: The Calgary Family Assessment Model 109
1. Maintaining own or couple functioning and interest in the face of
physiological decline: exploration of new familial and social role op-
tions. Marital relationships continue to be important, and marital sat-
isfaction 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 associ-
ated with family functioning and, to a lesser extent, with health and
As the couple in later life finds themselves in new roles as grand-
parents and mother-in-law and father-in-law, they must adjust to their
children’s spouses and open space for the new grandchildren. Diffi-
culty 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 succes-
sion in a family business. The shift in status between the senior family
members and the middle-aged family members is a reciprocal one. Dif-
ficulties 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 incom-
petent. Another adjustment might be if the older seniors start dating
and/or marrying with the middle-aged family members feeling chal-
lenged 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 over-
functioning 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 health-
care 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 histo-
rians by writing and/or recording their individual or family biographies
and collecting and identifying family pictures.
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 house-
hold. 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,
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?
FIGURE 3-17: Sample attachments in stage 6.
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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 ter-
rorism, and increased faith-based initiatives may cause divorce rates to de-
cline. 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 like-
lihood 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. Single-
parent 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 ef-
fort 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 out-
comes, 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 be-
haviors 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 seem-
ingly 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, con-
structive, 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 parent-
child relationship” (p. 47). She recommends that children, depending on their
age and developmental capacity, should have input into the living arrange-
ments 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 re-
sponsibility 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 im-
prove 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 situa-
tion; 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 sib-
lings, 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 in-
formation exchange; constructive problem solving; and knowledgeable, ex-
perienced, 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 grandpar-
ents, 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 fos-
tering 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 in-
tractable disputes, we encourage them to develop a good-enough climate in
which parents maintain distance from each other, thus minimizing conflict
Divorce may occur at any stage of the family life cycle and with any fam-
ily, 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
Additional Stages of Family Life Cycle for Divorcing
and Remarrying Families
Emotional Process of
Phase Task Attitude Developmental Issues
Acceptance of inability to
resolve marital problems
sufficiently to continue
arrangements for all
parts of the system
a. Willingness to con-
and joint financial
support of children
b. Working on resolution
of attachment to
Acceptance of one’s own
part in the failure of the
a. Working cooperatively on
problems of custody,
visitation, and finances
b. Dealing with extended
family about the divorce
a. Mourning loss of intact
b. Restructuring marital and
and finances; adaptation
to living apart
c. Realignment of relation-
ships with extended fam-
ily; staying connected with
spouse’s extended family
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114 Nurses and Families: A Guide to Family Assessment and Intervention
Additional Stages of Family Life Cycle for Divorcing
and Remarrying Families—cont’d
Emotional Process of
Phase Task Attitude Developmental Issues
Working on emotional
hurt, anger, guilt, etc.
Willingness to maintain
contact with ex-spouse
and his or her family
Willingness to maintain
and parental contact
with ex-spouse and to
parent’s relationship with
Recovery from loss of
1st marriage (adequate
Accepting one’s own
fears and those of new
spouse and children
about forming new
Accepting need for time
and patience for adjust-
ment to complexity and
1. Multiple new roles
2. Boundaries: space,
3. Affective issues: guilt,
loyalty conflicts, desire
a. Mourning loss of intact
family; giving up fantasies
b. Retrieving hopes,
from the marriage
c. Staying connected with
a. Making flexible visitation
ex-spouse and family
b. Rebuilding own financial
c. Rebuilding own social
a. Finding ways to continue
b. Maintaining financial
ex-spouse and children
c. Rebuilding own social
Recommitment to marriage
and to forming a family with
readiness to deal with the
complexity and ambiguity
a. Working on openness in
the new relationships to
b. Planning for maintenance
of cooperative financial
and coparental relation-
ships with ex-spouses
c. Planning to help children
deal with fears, loyalty
conflicts, and member-
ship in two systems
d. Realignment of relation-
ships with extended
family to include new
spouse and children
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Chapter 3: The Calgary Family Assessment Model 115
Additional Stages of Family Life Cycle for Divorcing
and Remarrying Families—cont’d
Emotional Process of
Phase Task Attitude Developmental Issues
for mutuality, unre-
solvable past hurts
Resolution of attachment
to previous spouse and
ideal of “intact” family
Acceptance of different
model of family with
Accepting evolving rela-
tionships of transformed
e. Planning maintenance of
connections for children
with extended family of
a. Restructuring family
boundaries to allow for
inclusion of new spouse-
b. Realignment of relation-
ships and financial
arrangements to permit
interweaving of several
c. Making room for relation-
ships of all children with
all parents, grandparents,
and other extended family
d. Sharing memories and
histories to enhance
a. Changes as each child
graduates, marries, dies,
or becomes ill
b. Changes as each spouse
forms new couple relation-
ship, remarries, moves,
becomes ill, or dies
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
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.
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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 house-
holds at any one time.
Ahrons’s longitudinal study (2007) of children 20 years after parental di-
vorce 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 re-
marriage 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 chil-
dren, 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 un-
productive 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 health-
care 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 step-
family 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 lan-
guage, and persist with pervasive chronic problems, then we encourage
nurses to consider whether attachment injuries are present and need inter-
vention (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) de-
velopmental 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 pe-
riod, 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, “cooper-
ative colleagues,” was a considerably larger and more typical group found
by Ahrons and Rodgers. Although not good friends, they worked well to-
gether 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 “dis-
solved 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 chil-
dren involved in divorce do seem to have longer-lasting adjustment diffi-
culties (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 differ-
ent 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 stepchil-
dren 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 stepfam-
ilies 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. Cur-
rently, 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 trans-
fer of ongoing parental responsibilities from the birth parents to the adop-
tive 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 au-
tomatically 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 ad-
justment 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 circum-
stances in forming adoptive families. For example, most agencies offer adop-
tion 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 em-
bracing 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 disconnec-
tion. 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 adopt-
ing 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 adop-
tion, can be a stressful and joyful experience for many couples. During the pre-
school developmental phase, the family must acknowledge the adoption as a
fact of family life. The question of the permanency of the relationship some-
times 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 facili-
tated the successful process included finding strengths in the children over-
looked 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 rec-
ognize adoptive families’ strengths and resources as they deal with challeng-
ing 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 chil-
dren 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 in-
crease 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 recontract-
As the adopted child proceeds to develop his or her own family of pro-
creation, the integration of the adoptee’s biological progeny can be a devel-
opmental 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 nav-
igate the complexities of the adoption process and life cycle. When complex-
ity is accepted, when the losses are acknowledged and resolved, when parents
and their children feel satisfied with adoption as a legitimate route to be-
coming a family, and when the community of family, friends, and profes-
sionals 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 ex-
presses a patriarchal, Anglo-Saxon, white, Christian, male, middle-class,
ableist, and heterosexual view of the world. More recently, with open dis-
cussion 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 same-
sex 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 de-
fined 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 so-
cially 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 influ-
enced 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
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 character-
istics 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
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.
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 mon-
itor, 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 rou-
tines 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 incor-
porate 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 rou-
tines and rituals were important positive coping mechanisms for them to
maintain a sense of normalcy. We recommend that health professionals un-
derstand 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 chal-
lenge in adaptation. Elderly spouses often rate the overall burden of caregiv-
ing 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 nurs-
ing care is thus highlighted.
As the nurse inquires into the ordinary routines that families living along-
side 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 sug-
gests 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.
The expressive aspect of functioning refers to nine categories:
1. Emotional communication
2. Verbal communication
3. Nonverbal communication
4. Circular communication
5. Problem solving
7. Influence and power
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 distin-
guished emotionally healthy families from those that were experiencing more
than the usual emotional distress. A more recent study by Aarons and col-
leagues (2007) noted that the Family Assessment Device is less applicable
for Hispanic Americans than for Caucasian Americans. They suggest, for ex-
ample, that Hispanic American families often operate according to more sta-
ble 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 is-
sues revolve around dressing changes and an exercise program while the ex-
pressive 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 ex-
pressive issues. Both need to be explored when the nurse and family have a
conversation about family functioning. Robinson (1998) points out the im-
portance of nurses attending to what she calls “illness work” and “illness
burden.” Making arrangements for managing chronic or life-threatening ill-
ness does not just happen. The ordinary context of women generally shoul-
dering 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 considera-
tion 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, de-
light, 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 func-
tional 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 fam-
ily 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 espe-
cially 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 im-
pact of the health problem on the family. If the nurse thinks “interactionally”
rather than “individually,” each family member’s behavior will not be con-
sidered in isolation but rather will be understood in context.
It is important for nurses to remember that, if they embrace a postmod-
ernist worldview, they will not be able to conduct an objective family evalu-
ation. 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. Par-
ticular 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 de-
fine 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 mem-
bers engage in conversations to make sense of their lives in the context of ill-
ness, loss, or disability rather than to explain their behavior.
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 fam-
ilies with difficulties commonly have quite rigid patterns within a narrow
range of emotional expression. For example, some families experiencing dif-
ficulties 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 per-
mitted to express it.
The feelings of subjective well-being are usually unrelated to socioeco-
nomic 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?
This subcategory focuses on the meaning of an oral (or written) message be-
tween 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 re-
cipient. 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 be-
tween 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?
This subcategory focuses on the various nonverbal and paraverbal messages
that family members communicate. Nonverbal messages include body pos-
ture (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 communi-
cation includes tonality, guttural sounds, crying, stammering, and so forth.
Nurses must remember that nonverbal communication is highly influ-
enced by culture. For example, in Taiwanese Chinese couples, indirect, non-
verbal means of communicating and relating serve a positive function but
can be viewed among Euro-Caucasian groups in the United States as an in-
dicator 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 tim-
ing. 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 communi-
cation 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 refers to reciprocal communicat