Name: Gretchen Badayos G.

Section: BSN-2D

Abstract:

Research shows that living with illness can be a distressing experience for the family and may
result in suffering and reduced health. To meet families’ needs, family systems intervention
models are developed and employed in clinical contexts. For successful refinement and
implementation it is important to understand how these models work. The aim of this study was
therefore to describe the dialogue process and possible working mechanisms of one systems
nursing intervention model, the Family Health Conversation model. A descriptive evaluation
design was applied and 15 transcribed conversations with five families were analyzed within a
hermeneutic tradition. Two types of interrelated dialogue events were identified: narrating and
exploring. There was a flow between these events, a movement that was generated by the
interaction between the participants. Our theoretically grounded interpretation showed that
narrating, listening, and reconsidering in interaction may be understood as supporting family
health by offering the families the opportunity to constitute self-identity and identity within the
family, increasing the families’ understanding of multiple ways of being and acting, to see new
possibilities and to develop meaning and hope. Results from this study may hopefully contribute
to the successful implementation of family systems interventions in education and clinical praxis.

A. Family Health Conversations: How Do They Support Health?

A substantial body of research reports of illness related distress and its impact on
quality of life for the person living with illness as well as for their significant others (i.e.,
spouses and family caregivers) is available. Most of these studies focus on the individual.
There are, however, few studies that focus on the family system and describe illness
experiences from the perspective of the family as a unit. These studies show that living
with illness is experienced as family vulnerability, helplessness, strain, and suffering [1],
as a struggle to make sense and maintain normality in family living [2] and as bringing
about difficulties in family relationships [3]. The results from the above reported system
focused studies point to a need to expand the focus for care in order to support families
living with illness and also to broaden the concept of health to embrace the family as a
unit, that is, family health. Family health has been described as an interactional, holistic,
and dynamic phenomenon positing circular causality [4] and comprising biological,
psychological, spiritual, sociological, and cultural aspects of well-being both on an
individual and family level [5]. The theoretical ground for this understanding is system
theory which focuses on interactions among the various parts of a system and the system
as a whole [6]. One example of this systemic view is Newman’s theory of health as
expanding consciousness in which individuals are seen as open systems that constantly
interact with their environment. One family member’s illness is reflected in the pattern of
family interaction and when these patterns are made conscious, health will be gained [7].

Although research findings and system theories suggest that chronic illness has an
impact on the family as a unit, the health care system is typically patient focused and
family systems needs are notably unmet. Recently published reviews of family
interventions [8–14] show that interventions provided by health care often are
characterized as psychoeducational versus relationship focused. Additionally,
interventions are mostly directed towards the individual family member or towards the
partner dyad. Outcomes targeting individual outcomes are domineering. Responding to
families’ experiences of distress and the lack of systems oriented support from health care,
family systems interventions have developed within the nursing profession.

The majority of family systems nursing interventions are grounded in the so-called
Calgary models, Calgary Family Assessment Model and Calgary Family Intervention
Model [15], and in the Illness Belief Model [16]. The aim of these interventions is to
support family health by creating a context for change [16]. This context is facilitated in
the interactions between the participants by assessing the families’ situations and
intervening by posing reflective questions targeting the problems experienced by the
families [15]. Changes that are hoped for concern the families’ ways of thinking and
responding in relation to the illness situation and to those problems experienced, having
impact on their well-being. This may embrace change or modification of constraining
beliefs and strengthening of facilitating beliefs, of finding alternative ways of talking about
the family situation and the discovery of new meanings [15, 16]. A small but growing body
of qualitatively designed outcome studies focusing on families’ experiences points at these
interventions to be a healing experience [17], improving family relationships [18, 19],
alleviating experiences of suffering [20, 21], and psychologically empowering [22, 23].

For the development of family systems support with the purpose to improve and
promote family health when living with illness, knowledge about the nature of the
intervention processes and understanding of the potent working mechanisms are central.
Most of the interventions are theoretically grounded but have not been evaluated from
how they are practiced. Evaluations that focus on the processes that actually take place
can contribute with knowledge of the working mechanisms in the intervention [24]. This
type of knowledge is a prerequisite for successful refinement and implementation in health
care. Therefore, the aim of this study was to describe the dialogue process and possible
working mechanisms of the Family Health Conversation (FamHC) [18]. The research
questions were as follows. What dialogue events may be identified and how are they
 interrelated? What characterizes the interactions between the participants? How may the
events and interactions be understood as supporting family health?

C. Research Methodology

Research Design:

An evaluative approach aiming at a description of the intervention process and the working
mechanisms of this process [24] was chosen. Data consisting of transcripts from the interventions
were analyzed within a hermeneutic tradition that emphasize the necessity to use ones pre-
understanding in the interpretation process but still remain open to the phenomenon at hand.
Openness is supported by not using theories in this phase of the analysis and also by getting into
a “dialogue” with the text in order to reach a first understanding. This understanding should be
critically examined in relation to the text throughout the analysis [25–27]. By going into the
hermeneutical spiral, where the parts are considered in relation to the whole and vice versa, the
interpretations can be validated so that the best possible interpretation is reached [26, 27], an
understanding that is grounded in a fusion of horizons [25]. To gain a deeper understanding of
the phenomenon, the findings could be further reflected on in relation to theories or philosophical
reasoning [26, 27].

Research Intervention:

The Family Health Conversation Model was developed by the last author and her colleagues at
the Linnaeus University in Sweden during the late 1990s [18]. The model is inspired by the
Calgary Family Assessment and Intervention Models [15] and particularly the Illness Beliefs
Model [16]. The conversation model builds on system oriented theories and models [6, 15, 28],
change theory [29], and narration and reflection theory [26, 30, 31]. The model is used by the
research team in clinical practice and in research [17, 18]. The structure of the model is three
conversations, a closing letter, and an evaluative follow-up interview. The three conversations
have somewhat different intentions [18]. The first conversation with each family started with a
discussion of the aims and of the family members’ expectations of how the conversations possibly
could support them. Then, each family member was invited to tell their story about how they
experienced the family’s situation. Based on these stories, the family and the two conversational
leaders together agreed what to talk about and what changes might be desirable and possible for
the families. The intention in the second conversation was to progress further towards minimizing
the family’s suffering by illuminating family members’ beliefs and by strengthening facilitating
beliefs and modifying constraining beliefs. The intention of the third conversation was much the
same as the second but also included a termination of the series of meetings and a reflection of
the process of change that had occurred.

Research Data:

Data for this study consisted of 15 transcribed FamHCs with five families that had participated in
a series of three conversations. Each series was held within a period of 6–10 weeks. The time for
each conversation varied between 60 and 80 minutes.

Research Participants:

A purposive sampling strategy was used to get a sample of families that varied according
to chronic illness, time since onset, sex, and age of patients and family members. The five
families that were included had all participated in FamHC either at our campus-based
Center for research on families’ health (n=3) or in their own homes (n=2). They were either
self-referred or recruited from a rehabilitation clinic at the local hospital (Table 1). Four
nurses from the research team, of whom one is the second author of this paper, participated
in three different pair constellations of conversational leaders. All nurses had education at
advanced level and several years of experience with this type of conversations.

Table 1: Characteristics of the families ().

Type of illness (n)  

Stroke 2

Parkinson’s disease 2

Dementia 1

Members participating in the conversations (n)  

Husband and wife 3

Husband, wife, and children 2

Time since onset of illness (months) 2–60

Family member with illness  

Female (n) 3

Male (n) 2

Age (range) 40–65

Employed (n) 5

Sick-leave (n) 1

Retired (n) 0

Other participating family members  

Female (n) 4

Male (n) 5

Age (range) 7–65

Referral to FamHC (n)  

Self-referred 3
 Participants in one research study 2

Ethical Consideration:

This study was approved by the Research Ethics Committee at Linköping University, Sweden
(reference number 2010/51-31) and was conducted in accordance with the Declaration of Helsinki
(1964). Participants gave their written consent for the tape-recorded conversations to be used for
research purposes. Efforts to preserve confidentiality were guaranteed.

Data Analysis:

The analysis comprised two phases in relation to the use of theories: one inductive phase and one
deductive phase. In the inductive phase, dialogue events were described and explored by the first
author (Carina Persson) who was not yet familiar with the intervention model or its central
assumptions and theories and thereby data could speak “for itself.” The transcribed conversations
were read, one conversation at a time, and text segments focusing on dialogue events were
identified. The identified text segments were reread focusing on the question: what are the
characteristics of these dialogue events? One further reading was done to identify sequence
patterns within and between the dialogue events guided by the question: what is preceding and
what follows? The author strived to become involved in a hermeneutical “dialogue” [25, 26], that
is, asking new questions to the text, gaining new understanding, and asking new questions, “is it
really so? Could it be in any other way?” (see Table 2 for one example of the analysis’ process). In
the deductive phase, we wanted to further understand how the events and sequence patterns may
support family health from a theoretical perspective. The results of the inductive analysis were
reflected on using literature embracing health theory, systems intervention models, and
philosophic literature highlighting phenomenon/concepts with meaning for health.

D. Summary of Finding

The findings in our analyses indicate that the FamHCs have a theoretically grounded potential to
facilitate a movement towards family health. This theoretically driven argument is supported in
qualitative studies of family systems nursing interventions when evaluated by families living with
chronic illness in various phases [17, 20, 23]. In an integrative review of family responses from
participating in systems nursing interventions only a few studies were found indicating that
families did not benefit compared to standard care [35]. In another study, six families living with
different cancer illnesses in palliative phase described moments during the conversations as being
emotionally demanding, although the overall experience was that of a healing and comforting
experience [17]. The invitation and facilitation of families’ narrating were found to be a starting
point for the conversations analyzed in this study. Narrating was also interpreted as an essential
part of a movement towards family health. The invitation to tell the family illness story has
previously been related to unburdening oneself and as a way for making sense of suffering and
finding hope from a family perspective when living with cancer illness in palliative phase [17]. In
an interpretative research synthesis study with the aim to develop an understanding of how
narratives may be a path to health, the analyses resulted in a model where narrative
understanding in a caring conversation was seen as consisting of three phases. The first phase
involved the patient telling their story, the second was about narration of the suffering experience,
and, in the third phase, the narrative was reconnected to the patient’s life story. Going through
this process meant going from understanding to interpretation and finally to creation of meaning
in and of suffering in connection with illness [36].

E. Follow-up questions:
1. How is this research relevant to public health nursing?

2. How can families benefit from this research?