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Introduction
Modern-day nursing is developing in the direction of an integrated, evidence-based practice that approaches healthcare from the perspective of multifaceted systems and not from the point of view of only one individual. For that reason, the emergence and implementation of family theories and models in nursing are highly effective. The abundance of family theories implies differences in the benefits they provide, which necessitates the comparison of some of the most popular ones. The comparison and analysis allow for identifying strengths, weaknesses, application opportunities, and case fit.
Therefore, the purpose of this paper is to compare and contrast two family theories that may be adopted for use in clinical practice by the advanced practice nurse. In this paper, Calgary Family Assessment and Intervention Models (CFAM/CFIM), as well as the Family Health System Model (FHS), will be discussed. Within this paper, the strengths and weaknesses of each model, as well as the choice rationale, will be presented and validated. Additionally, a case study will be developed to apply one of the theories to determine what concepts are applicable and what do not fit the case particularities. Finally, the paper will address the challenges of integrating the theory into clinical practice and the likelihood of adopting one into clinical practice.
Identification and Description of Theories
Overall, the emergence of family theories was consistent with the requirement of nursing to address the needs of families as social units by which individuals’ physical and mental well-being is affected. Two models that will be at the center of this paper’s discussion include CFAM/CFIM, and FHS are well-developed, comprehensive, integrative, and highly applicable to different contexts. The choice of these two theories was validated by the scope of their application for a variety of family health cases, their extensive presence in the academic literature, and the relevance of these models’ concepts to clinical practice at multiple levels. While the Calgary models are often addressed and used separately (different concepts for assessment and intervention), they ultimately constitute a unified framework, which is why both CFAM and CFIM are integrated into one theory.
The first theory to be described is CFAM/CFIM, which has been introduced to the clinical field in recent decades. Indeed, CFAM/CFIM was created in 1984 by Lorraine Wright, RN, Ph.D., and Maureen Leahey, RN Ph.D. and are considered one of the four leading assessment models in the world (Leahey & Wright, 2016). The multifaceted set of concepts integrated into the models allows for a competent, structured, and well-informed assessment and intervention implementation procedure to be executed with an opportunity of adjusting practices according to case specifications. According to Zimansky et al. (2020), “the CFAM enables nurses to comprehensively assess current family strengths, resources, problems, and illness suffering through targeted questions that assess family structure, development, and function” (p. 346). The CFAM consists of three major areas, which include: structural, developmental, and functional.
At the structural level, family is addressed from the perspective of its formation and the networks between the members. Structural evaluation implies establishing how many family members there are, what their occupations are, and how they perform within a bigger context. Therefore, the structural category in the model is approached within such subcategories as internal and external structure and context (Leahey & Wright, 2016). At the developmental level, the model allows for evaluating the lifecycle of the family and the level of its development as a whole, and if each member is separately (Souza et al., 2017). Finally, at the level of functional evaluation, the model provides the basis for obtaining and compiling the information about family functioning and the interaction between family members (Leahey & Wright, 2016). The genogram and ecomap are commonly utilized when assessing families according to the three areas within CFAM (Zimansky et al., 2020). Thus, CFAM is an essential family theory that constitutes the basis of family nursing interventions since it helps to collect and arrange the most pivotal information and group the findings logically.
The second component of CFAM/CFIM also has a multifaceted and integrative nature and is commonly used after CFAM. Indeed, CFIM “provides an organizing framework for the nurse-family relationship and for a therapeutic conversation offered by nurses using specific family nursing interventions (e.g., interventive questions, commendations) that target the systems level that offers the greatest opportunities for family health and healing (Zimansky et al., 2020, p. 346). Essentially, this model includes the guidelines and system of different types of questions within three domains of family functioning that might be used for interviewing the family members at the stage of intervention suggestion and validation. In particular, the three domains of family functioning are cognitive, affective, and behavioral (Wright & Leahey, 1994). Using these dimensions in a combination or separately, a nurse might identify and address a problem in the family for its further solving with the help of appropriate interventions. Indeed, according to Wright and Leahey (1994), “interventions can be targeted to promote, improve, or sustain functioning in one or all three domains of family functioning, but a change in one domain will have an impact on another domain” (p. 382). Thus, the model assists in categorizing family issues according to functional domains.
In order to guide nurses through the process of interviewing and facilitate the retrieval of accurate and important information, the model provides several types of questions to be asked. Linear and circular questions help to either detect the perspective of one family member on a problem or retrieve different family members’ opinions about others’ concerns (Wright & Leahey, 1994). As for the specific types of questions, the choice of a question will yield a particular response, which is why it is essential to approach question type choice with regard to the context and family particularities. The types include difference questions, behavioral effect questions, hypothetical/future-oriented questions, and triadic questions (Wright & Leahey, 1994). Apart from the questions, the model involves such interventions helping address the cognitive domain of family functioning as commending family and individual strengths, offering information, and externalizing the problem. To address the affective domain of family functioning, such interventions as validating/normalizing emotional responses, storying the illness experience, and drawing forth family support are introduced (Wright & Leahey, 1994). Finally, the interventions to change the behavioral domain include encouraging respite and devising rituals.
FHS, on the other hand, is a comprehensive and concise integrated framework that incorporates all necessary concepts and categories for effective work with families. According to Anderson (2000), the creator of the model, “the FHS offers an integrated way to examine family dynamics, family strengths, and family concerns in health and illness across the lifespan” (p. 104). Overall, this framework is designed to strengthen, maintain, or restore family functioning capacity to enhance healing opportunities. The model identifies five realms of family life within which family assessment is conducted. The realms are interactive processes, developmental processes, coping processes, integrative processes, and health processes (Anderson, 2000). Therefore, when assessing a family, strengths, and concerns within each of these realms are considered. The FHS assessment procedure “focuses on the dynamics of family interaction, including patterns of communication, conflict resolution, roles, instrumental and relationship functioning, nurturance, expressions of intimacy, and support” (Anderson, 2000, p. 108). After that, a family health plan is developed considering the anticipated outcomes and the interventions that might be helpful in achieving desired results.
Comparison of Strengths and Weaknesses
With the description of both theories at hand, the comparison of their strengths and weaknesses might be initiated. When concentrated on the strong features that are similar to both models, one might state that CFAM/CFIM and FHS are strong, evidence-based, and highly effective nursing practice frameworks. They both provide a detailed structure for conducting substantial work with patients and families. Moreover, they both are characterized by a vast scope of applicability, implying that different family health situations can be resolved using either of these models. On the other hand, FHS possesses one strength, the lack of which might be considered as a weakness of CFAM/CFIM, which is the concise integrative structure. Indeed, since FHS consists of easily recognizable and approachable domains that compile all important aspects in one structured theoretical tool. In this respect, the two-fold structure of CFAM/CFIM appears as a more complex and less approachable model in comparison to FHS. Alternatively, when discussing the weaknesses of FHS, this theory does not provide as detailed guidelines for interviewing with question types as CFAM/CFIM does, which implies a large degree of nurses’ professionalism and creativity in communication with patients. Such a feature might be considered as a limitation since it might yield vague outcomes if approached without diligence.
Application of Theory to Family Case Study
In order to validate the effectiveness of FHS as a comprehensive and integrative nursing practice framework for quality work with family systems, one might introduce a case study to which the model will be applied. The family, in this case, consists of two family members, a husband and wife, Mr. and Mrs. Jones, residing together in a rural area in their house. The husband has recently been diagnosed with prediabetes, and lifestyle changes have been advised for the elimination of the diabetes development risk. The couple is in their mid-50s; they have been married for 32 years; their only child has started her own family and lives separately. She seldom visits her parents and is not actively involved in their family affairs.
As the results of the first session show, Mr. Jones resists any efforts in lifestyle adjustment, although he complains about being overweight, having shortness of breath, blurred vision, frequent urination, and continuous thirst. Mrs. Jones acts as a health coordinator in regard to her husband’s health condition; she pursues Mr. Jones to follow the prescribed dieting and physical exercise routine but fails to reach an agreement. During the first session, the couple’s strengths and areas of concern have been identified within the five realms, namely interactive, development, coping, integrity, and health (see Table 1).
Table 1. FHS Family Assessment
During the second session, the following anticipated outcomes and interventions have been identified (see Table 2).
Table 2. FHS Family Plan
Thus, the majority of concepts within the framework apply to the case since FHS is a generalizable and detailed model. However, there were no areas of concern within integrity and development detected. Ultimately, the suggestions and interventions are compiled in a family plan for a scheduled and systematic execution of the procedures and check-ups.
Integration of Theory into Clinical Practice
As the application of FHS to the presented family case demonstrates, the framework allows for a structured and systematic identification of the problems, their causes, and solution methods. Such an effective model implementation allows for a more generalizable integration of the theory into clinical practice. However, there might be some challenges in the implementation of this model. In particular, since any nursing intervention involves close interaction with patients, rapport and trusting relationships are important, which might be difficult when approaching patients who are reluctant to cooperate. Additionally, nurses might face difficulties integrating FHS into clinical practice due to the necessity of allocating much time to identifying and resolving multiple communication issues. It might obstruct the quality and timeliness of some essential treatment procedures in cases of severe health impairment.
Conclusion
In summation, the analysis, comparison, and case application of family theories demonstrated that the implementation of a thoroughly developed nursing practice framework helps nurses to provide structured and balanced family care. CFAM/CFIM and FHS are both effective and integrative models which allow for a complete assessment of family problems and solution-finding. However, FHS is less complicated and more generalizable, which enhances its applicability to clinical practice. Thus, when using FHS in family nursing, professionals can benefit from a clear and concise framework that incorporates multiple domains of family functioning to identify family concerns, strengths, anticipated outcomes, and relevant interventions.
References
Anderson, K. H. (2000). The Family Health System approach to family systems nursing. Journal of Family Nursing, 6(2), 103–119. doi:10.1177/107484070000600202
Leahey, M., & Wright, L. M. (2016). Application of the Calgary Family Assessment and Intervention Models. Journal of Family Nursing, 22(4), 450–459. doi:10.1177/1074840716667972
Souza, T. C. F., Costa, C. M. L., & Carvalho, J. N. (2017). Calgary Family Assessment Model applied in riverside context. Journal of Nursing UFPE/Revista de Enfermagem UFPE, 11(12), 4798-4804.
Wright, L. M., & Leahey, M. (1994). Calgary Family Intervention Model: One way to think about change. Journal of Marital and Family Therapy, 20(4), 381–395. doi:10.1111/j.1752-0606.1994.tb00128.x
Zimansky, M., Stasielowicz, L., Franke, I., Remmers, H., Friedel, H., & Atzpodien, J. (2020). Effects of implementing a brief family nursing intervention with hospitalized oncology patients and their families in Germany: A quasi-experimental study. Journal of Family Nursing, 26(4), 346-357.
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