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Developed by Eggenberger (2007); Revised by

Eggenberger, Meiers, Krumwiede, Bliesmer, &

Earle (2009); Revised by Eggenberger,

Krumwiede, Christian, & Van Gelderen

(2012); Revised by Eggenberger, Meiers, &

Krumwiede (2014)

Family Constructs and Family Focused Nursing Actions

Background Information:

The Oxford dictionary definition of construct re-

lates to the action of fitting parts together

(Abate, 2002). A construct suggests a broader

and more encompassing approach when com-

pared to concept, variable, or nursing action.

These family nursing constructs address the

science of family focused nursing knowledge

and the praxis of family focused nursing ac-

tions.

Family constructs are not identified to align with

one family nursing theory or model; rather they

can be viewed from the perspective of multiple

family nursing theories, frameworks and

models.

This compilation is not intended to be an exhaustive

and inclusive list of either the family constructs

or family nursing action that can be useful in

family nursing practice.

References cited are not intended to be exhaustive,

rather selected literature provides a beginning

foundation for the construct and nursing ac-

tions. Additional valuable references are avail-

able.

Multiple family focused nursing actions are not

fully tested or examined, but supported by re-

search.

Family nursing actions identified in a particular

construct can be useful and effective in other

constructs.

Nursing actions related to nurse presence and part-

nerships address communicating, relating, con-

necting, and interacting with a family which

can be useful in multiple constructs.

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Nursing 5:426–442.

Family Anxiety 4

Family Balancing 5

Family Beliefs 6

Family Burden 7

Family Caregiving 8

Family Caring Strategies 9

Family Change 10

Family Communication 11

Family Connection 12

Family Coordination 13

Family Coping 14

Family Crisis 15

Family Cultural Influences 16

Family Engagement 17

Family Experience 18

Family Fear 19

Family Financial Concerns 20

Family Growth 21

Family Illness Experience 22

Family Inquiry 23

Family Integrity 24

Family Loss 25,26

Family Management Styles 27

Family Pondering 28

Family Reintegration 29

Family Relating 30

Family Resilience 31

Family Sharing/Storytelling 32

Family Stress 33

Family Structure 34

Family Struggling 35

Family Suffering 36

Family Support 37

Family Transitions 38

Family Uncertainty 39

Family Vigilance 40

Family Violence and Abuse 41

Family Vulnerability 42

References 43-52

TABLE OF CONTENTS

Family Anxiety

(Bay, & Algase, 1999; McAdam, Fontaine, White,

Dracup,& Puntillo, 2012; Mitchell, Courtney, & Coy-

er, 2003; Mohr & Schneider, 2013; Thome, & Arnar-

dottir, 2013)

“A heightened state of uneasiness to a potential nonspe-

cific threat that is inconsistent wih the expected

event…” (Bay and Algase, 1999). Impending change

resulting in feelings such as uneasiness, fear, or worry

resulting from a danger or threat being sensed. Anxiety

can manifest as a wide range of symptoms with unique

nature in family members and impacting family unit

processes, depending on the person, stressors and fami-

ly involved. Ask family members their perceptions of

threats.

Discuss actual and perceived threat with caution about

minimizing threats

Provide open, honest, clear and direct information

Invite family questions and repeat information as of-

ten as needed

Arrange and guide family communication

Plan and guide family meetings

Encourage family discussions about conflicts, differ-

ences, and issues

Use family commendations (Wright & Leahey, 2013)

Be diligent in sharing consistent information

Help family identify networks and resources that

could provide support

Nurse Presence-Stay close to patient and family while

listening and sharing information and providing care

(Gardner, 1985)

Reassure family members(s) about the quality of nurs-

ing care and nursing concern for family and individual

with an illness

Provide honest and realistic information

Teach family the necessary information to understand

Teach family management strategies

Explain how family can assume advocacy role

Encourage family dialogue about concerns and needs

Use “one question question” technique to elicit family

concerns (Wright & Leahey, 2013)

Initiate family interaction and relationship

Develop therapeutic conversation with family mem-

bers and family unit (Svavarsdottir,Tryggvadottir, &

Sigurdardottir, 2012; Sveinbjarnardottir, Svavarsdot-

tir, & Wright, 2013; Svavarsdottir, Sigurdardottir, &

Tryggvadottir, 2014; Wright & Bell, 2009; Wright &

Leahey, 2013)

Mosher, C. E., Bakas, T., & Champion, V. L. (2013).

Physical Health, Mental Health, and Life Changes

Among Family Caregivers of Patients With Lung Can-

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Moules, N., & Streitberger, S. (1997). Stories of suffer-

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Meleis, A. I. (Ed.). (2010). Transitions theory: Middle

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Family Balancing

(Meiers, Eggenberger, Krumwiede, Bliesmer, & Earle,

2009; Eggenberger, Krumwiede, Meiers, Bliesmer, &

Earle, 2004 )

Assist family to alter routines and activities of daily life

and family life as needed

Prepare family for possible future fluctuations and

variations in health, family life, and family routines

Address modifications in family roles

Help family make decisions regarding sharing family

roles

Anticipate individual and family times of transitions

Acknowledge the families’ experience of uncertainty,

turmoil, stress and suffering during waiting periods

Family Beliefs

(Wright & Bell, 2009; Marshall, Bell, & Moules, 2010)

Help families discuss constraining and facilitating be-

liefs regarding health and illness experiences

Explore differences in individual and family beliefs

regarding treatment regimens and end of life decision

making that may emerge with illness

Identify key family processes and celebrations that

should be recognized and honored (Denham, 2003)

Use nurse presence to develop connecting nurse-

family relationship

Provide open, honest, clear, direct, information that

faculty seeks

Provide assurance to family (e.g. care, ill family mem-

ber condition, family care)

Use introductions and manners and communication

skills to develop therapeutic relationships (Wright &

Leahey, 2013)

Initiate family interaction with nurse and health care

team

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Family Burden

(Goodew, Isaacson, & Miller, 2013)

Family burden in the context of chronic illness occurs

when there is an imbalance in the perceived demands of

managing the chronic illness and resources to meet those

demands. Family burden can cause a family sense of

bearing the load, stress, or worry (Goodew, Isaacson, &

Miller, 2013)

Assess family members for perceptions of stress

Accompany the family as they explore their sources of

family stress

Explore the family’s perceived demands and missing

resources; discuss the family’s ideas for which missing

resources would be most helpful and seek ways to ac-

cess support from community and extended family

support

Explore with family the meanings of illness, events,

and experiences to members

Provide consistent information with a credible ap-

proach

Give updates at regular intervals and explain time

frame to expect next update on next update of infor-

mation

Help family members explore their individual under-

standings and interpretations

Family Caregiving

(Hunt, 2003; Kitrungrote, & Cohen, 2006; Mosher, Ba-

kas, & Champion, 2013; Popejoy, 2011; Williams, Wil-

liams, & Williams, 2014)

Concern for other family members generated by rela-

tionships that result in actions aimed to support family

member development, health, and illness needs

(Denham, 2003). Informal and formal networks engage

in caregiving that requires care such as functional (e.g.

tasks and daily living) and affective (e.g emotional)

assistance. A variety of factors influence caregiving

experiences in a family (Popejoy, 2011) Commend

family strengths and praise efforts to meet needs

Identify members current roles in providing care for

individual family members with an illness and family

unit

Identify ways family can access needed family and

community resources

Assist family in negotiating responsibilities

Identify priority concerns in family caregiving

Explore the self-defined membership of family and

assist to identify extended family network

Assess, recognize and acknowledge caregiver role

strain

Strengthen facilitating beliefs that positive impact

family health promoting behaviors (Wright & Bell,

2009)

Challenge constraining beliefs that negatively impact

family health promoting behaviors (Wright & Bell,

2009)

Support empowerment of family to develop and attain

their goals

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chronic illness. Unpublished master’s thesis, Winona

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family response to childhood chronic conditions. Jour-

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Family Caring Strategies

(Eggenberger, Krumwiede, Meiers, Bliesmer, & Earle,

2004)

Intentional strategies (protecting, planning, creating

order, seeking respite, balancing acts, seeking support)

used by the family to keep the illness in its place and

care for the family member with CI (Cavanaugh, East-

wick, & Kronebusch, 2014; Eggenberger et al., 2011).

Explore family caring strategies currently being useful

to health of family

Reinforce family actions that support family health

Explore additional family caring strategies that support

family health Guide family in developing processes that support

family health

Family Change

(Wright & Bell, 2009)

“Alterations from the previous family situation that oc- cur due to the experience of managing illness (Goetzke,

Parks, & Peterson, 2014). Family changes occur in roles

(Hogan et al., 2003; Roberto et al., 2004), rituals, rou-

tines (Öhman & Söderberg, 2004; Roberto, Gold, &

Yorgason, 2004), schedules, activities, responsiblities

(Ek, Ternestedt, Andershed, & Sahlberg-Blom, 2011),

interpersonal relationships (Jumisko, Lexell, & Söder-

berg, 2007), personality, geographic location, deferment

of other personal needs, personal health, social in-

volvment, and employment status (Sherwood et al.,

2011).

Affirm family strengths and competence

Distinguish illness and health beliefs

Create a context for change by developing collabora-

tive relationships, identifying obstacles to change, and

therapeutic conversations (Wright & Bell, 2009)

Explore constraining and facilitating beliefs

Use motivational interviewing techniques to develop

discrepancy between current and potential of family

approaches to managing the family experience of ill-

ness (Rollnick, Miller, & Butler, 2008)

Coach ways to move toward healthy changes in indi-

vidual and family health (Pender, Murdaugh, & Par-

sons, 2006; Rollnick, Miller, & Butler, 2008)

Compare and contrast meanings of change (Denham,

2003)

Acknowledge the possibility of changes in roles, ritu-

als, routines, schedules, activities, responsibilities,

interpersonal relationships, personalities, geographic

location, attention to personal caregiver needs, social

involvement, and employment factors within the fami-

ly health experience (Goetzke, Parks, Peterson, 2014)

Abate, F. R. (2002). Oxford American Dictionary of

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Alpert, E. J., Cohen, S., & Sege, R. D. (1997). Family

violence :An overview. Academic Medicine, 72, (No. 1

Supplement) S3-6.

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health system as an emerging paradigmatic view for

nursing. Image: The Journal of Nursing Scholarship,

24, 57–63.

Anderson, G., & Horvath, J. (2004). The growing bur-

den of chronic disease in America.

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Bay, E., & Algase, D. (1999). Fear and anxiety: a sim-

ultaneous concept analysis. Nursing Diagnosis, 10(3),

103-112.

Bell, J. M. (2011). Relationships: The Heart of the Mat-

ter in Family Nursing. Journal Of Family Nursing, 17

(1), 3-10.

Benzies, K. & Mychasiuk, R. (2009). Fostering family

resiliency: A review of the key protective

factors. Child and Family Social Work, 14, 103-114.

Black, K. & Lobo. M. J (2008). A conceptual review of

family resilience factors. Journal of Family Nursing, 14

(10), 33-55.

Boss, P.G., Doherty, W.J., LaRossa, W.R, Schumm,

W.R, & Steinmetz , S.K. (Eds.), (1993). Sourcebook of

Family Theories and Methods: A Contextual Approach

(pp. 651-672). New York: Plenum Press.

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tual approach. Thousand Oaks, CA: Sage.

Boykin, A., & Schoenhofer, S. (1991). Story as link

between nursing practice, ontology, epistemology. Im-

age, 23(4), 245–248.

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competence in the delivery of healthcare services: A

model of care. Journal of Transcultural Nursing, 13(3),

181-184.

Caplan, G. (1964). Principles of Preventive Psychia-

try. New York: Basic Books.

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Goals of Medicine. New York: Oxford University

Press.

Carr, J., & Clarke, P. (1997). Development of the con-

cept of family vigilance. Western Journal Of Nursing

Research, 19(6), 726-739.

Carr, J. M. (2014). A Middle Range Theory of Family

Vigilance. MEDSURG Nursing, 23(4), 251-255.

Family Vulnerability

(Eggenberger, Krumwiede, Meiers, Bliesmer, & Earle,

2004; Leffers, Martins, McGrath, Brown, Mercer, Sul-

livan, & Viau, 2004)

“The chance of being exposed, at risk, susceptible, un-

protected, unguarded, defenseless, open to attack, or

easily physiologically or psychologically wounded as a

family in the context of illness (Goetzke, Parks, & Pe-

terson, 2014; Purdy, 2004).

Explain environments and elements of the experience

Assist family to plan for transitions

Explore what information would be the most helpful

at this time

Assume the role of family advocate when necessary

(Eggenberger & Nelms, 2007)

Help family advocate for their ill family member

(Meiers & Brauer, 2008)

Acknowledge the family’s sense of feeling wounded

(Goetzke, Parks, & Person, 2014)

Family Communication

(Denham, 2003; Vangelisti, 2004)

Verbal, nonverbal messages exchanges in family mem-

ber interactions (Vangelisti, 2004) . How messages

interpreted over time in a family includes elements

such as themes, attitudes, values, and beliefs. Interac-

tions such as intergenerational, child-parent, family

member-family member are often repeated and evolve

over time to create communication patterns. Shared

and individual communication exists in a family

(Vangelisti, 2004). A family process that expresses

emotion and ideas, knowledge and skills related to

health (Denham, 2003). A family process that socializ-

es family members to health (Denham, 2003). Com-

munication impacts both individual family member

and family health (Vangelisti, 2004). Explore family’

usual patterns of communication and then initiate and

facilitate healthy family communication and discus-

sions

Encourage and guide family discussions about con-

flicts and differences

Explore individual concerns and compare to thinking

of other family members

Arrange family meetings about decisions, health and

illness, beliefs, concerns, illness experience

Family Connection

(Denham, 2003; Eggenberger & Nelms, 2007)

The bonds, attachments, commitments, linkages and

relationships that develop between individual and per-

sons interacting as a family. Being a family emerges

through these interactions with a sense of their family

togetherness, family communication and relationships

(Eggenberger & Nelms, 2004). Connections exist within

and between the family system to individual family

members and systems outside the family (Denham,

2003; Wright and Leahey, 2014) influence health of

individual family members and family unit. Support

family sharing of emotional bonds (cathexis) in healthy

actions (Denham, 2003)

Acknowledge the importance of family connections

Explore stresses on the family bonds with illness expe-

riences

Develop nurse-family relationship with nursing pres-

ence (acknowledge family, empathy, eye contact, in-

troduction, commendations) (Wright & Leahey, 2013)

Family Violence and Abuse

“the intentional intimidation, physical and/or sexual

abuse, or battering of children, adults or elders by a

family member, intimate partner, or caretaker” (Alpert,

Cohen, & Sege, 1997, p. 53) Family violence can en-

compass child abuse and neglect, violence among part-

ners and elder abuse (McDaniel, Campbell, Hepworth,

& Lorentz, 2005; Segrin & Flora, 2011). Abusive fam-

ilies often lack the internal controls to create a safe

environment and a significant power differential may

exist that increases the risk of violence. An abuse of

power contributes to an emotional or physical environ-

ment that is not nurturing for family members.

Screen for safe family environment

Recognize signs of abuse and assess family to rule

out abuse

Ask about specific behaviors

Mobilize a safety network for the family

Acknowledge a range of conflict and difficulties in

relationships

Initiate the work of change and healing

Launch referral system to obtain help

Interview family members individually

Ask questions in nonjudgmental, nonthreatening

manner

Ruther assess use of substances

Develop safety plans as needed

(McDaniel, Campbell, Hepworth, & Lorentz, 2005;

Rizo, Macy, Ermentrout, & Johns, 2011).

Family Vigilance

(Carr, 2014; Carr & Clarke, 1997)

Family member’s experience of staying with and nearby

a family member hospitalized with an illness or manag-

ing an illness experience. Categories of the meaning of

vigilance include: a commitment to care, resilience,

emotional upheaval, dynamic nexus and transition

(Carr, 2014). Family’s belief and desire to protect their

family member and safeguard outcomes contributes to

family vigilance. Caregiver’s continual oversight of the

care recipient ‘s activities with a sense of watchfulness,

guarding, being there, and protective intervening

(Mahoney, 2003)

Demonstrate an empathic understanding of family’s need for and purpose of vigilance

Support and encourage a family’s presence

Offer ways to support vigilance (e.g make sleeping

arrangements with family)

Reassure family a caring presence of a nurse is avail-

able and helping the family protect the family mem-

ber; but, do not expect family to disregard their re-

sponsibilities.

Engage the family in a partnership in caring for the

family member with an illness.

Develop trusting relationship with the family to de-

crease their stress.

Strengthen family member’s resilience in illness ex-

perience.

Family Coordination

(Denham, 2003; Wright & Leahey, 2013)

Assess family function in meeting needs/concerns of

members and family unit

Commend family strengths and praise efforts to meet

needs

Explore beliefs of family about concerns, needs, and

resources

Arrange and guide family discussion to explore net-

works, resources, and decisions

Work with family to identify ways family can access

resources in the family and community

Assist family to plan ways to meet family needs and

tasks

Sharing of resources, skills, information, knowledge,

abilities within the family and the family environment

(Denham, 2003). Tasks to meet health needs and family

goals are linked to the ability to coordinate among the

family members.

Family Coping

(Boss, 2002; Lazarus & Folkman, 1984; McCubbin &

McCubbin, 1993)

Explore family processes, such as communication, con-

nection, coordination that may influence coping

(Denham, 2003)

Examine factors that increase protection of family

Identify factors that pose rise for family

Discuss meaning of events to individual and family

Dialogue about family past experiences that may in-

fluence current experience

Identify individual and family unit perception of re-

sources

Explore individual and family unit perception of sup-

port

Suggest coping techniques that are acceptable to the

family, such as support groups, activities, gathering

information and helping family members

Guide family in communication about processes that

will support coping

Consistently share information with family in timely

ways

Prepare family members for upcoming events

Teach family about what can be expected.

Develop therapeutic relationship where family per-

ceives nurses as support

Implement interventions that directly focus on uncer-

tainty in illness events.

Explore with the family any mixed messages related

to the illness or the treatment regime

Discuss seriousness and prognosis of an illness with

all family members and family unit.

Address the symptoms of an illness with family mem-

bers and family unit; discuss patterns and trajectory

changes in illness; examine expected and actual

events.

Reassure family of presence of nurse.

Provide factual information

Help family members structure and attach meaning to

events

Be specific in describing contextual cues such as what

patients and families will see, hear and feel during

procedures, as well as signs, symptoms, and trajecto-

ries.

Help families anticipate changes and predict and man-

age changes with education and support.

Explore past experiences with health care systems and

structure providers that may influence their uncertain-

Family Uncertainty

Uncertainty is defined as the inability to determine the

meaning of illness-related events (Mishel, 1984; 1988;

Mitchell, Courtney, & Coyer, 2003). A cognitive state

created when family members can’t accurately predict

outcomes (Mishel & Clayton, 2008), adequately struc-

ture or categorize an event because of the lack of suffi-

cient cues’ (Mishel, 1988; p. 225). Stimuli frame, cogni-

tive capacity and structure providers affect uncertainty

(Mishel, 1988). Stimuli frame is defined as the percep-

tion of stimuli such as patterns of symptoms, familiarity

with events or congruence between expected and expe-

rienced illness events (Mishel & Clayton, 2008). Cogni-

tive capacity is the information processing ability and

structure provides are the resources to assist the family

in interpreting the stimuli. Nurses play a key role as

structure providers that provide education, social sup-

port and credible authority. Those families with high

levels of uncertainty have a reduced ability to apply

adequate coping mechanisms during the illness situation

which has the capacity to negatively impact on patient

outcomes (Mishel & Braden, 1988; 1999) and family

health (Mishel, 1997; Mitchell, Courtney, & Coyer,

2003; Eggenberger, Meiers, Krumwiede, Bliesmer,

Earle, 2011).

Family Transitions

(Meleis, 2010)

The period in which a change is perceived by a family

member or others; denotes a change in needs, health

status, expectation or abilities that require new

knowledge or change in behaviors (Meleis, 1986; 1991).

Often characterized by changes in social support; loss of

reference points; new needs or changes in prior needs

(Meleis, 2010, p. 42). Explore individual and family

events and development creating family transitions

Discuss family patterns that are being disrupted

Assess change occurring within the family that may

influence the health and illness experience

Identify key family celebrations and routines that

should be recognized

Family Crisis

(Boss, 2002; Tomlinson, Peden-McAlpine, & Sherman, 2012)

Disturbance in the family equilibrium that is over-

whelming and severe. The change may also be acute so

family system has difficulty functioning or family is

immobilized (Boss, 2002). An extreme response in a

situation in which individual family member of family

coping resources are overwhelmed (Boss 2002; Caplan,

1964). Implement nursing actions that balance threats

and resources to prevent crisis.

Explore perceptions and meanings of events and then

provide support; such as information, emotional, guid-

ance and advocacy

Identify who helps the most with the family’s greatest

challenges

Nurse presence to balance perception of threats and

resources

Family Cultural Influences

(Campinha-Bacote, 2002; Giger & Davidhizar, 2002;

Leininger, 2002)

Racial and ethnic background, as well as the values,

beliefs, traditions, routines, as well as race and ethnicity.

Explore individual families cultural beliefs, routines and

patterns.

Assist the health care team to provide care that honors

the families culture and unique nature

Assess and recognize family cultural beliefs and influ-

ences on health

Family Support

(Cohen, 1992; Hupcey, 1998; Kahn, 1979)

Develop a trusting and connection relationship between

nurse and family (Eggenberger & Regan, 2010)

Use nursing presence actions

Identify family’s greatest concern or challenge and act

based upon data

Ask family to identify how nurses could be the most

helpful at this time

Explore extended family networks

Dialogue about what family perceives as supports

Family Suffering

(Lindholm, Eriksson, 1993; Marshall, Bell, Moules,

2010; Wacharasin, 2010; Wright, 2005, 2008; Wright &

Bell, 2010; Wright & Leahey, 2013)

“…physical, emotional, or spiritual anguish, pain or dis-

tress. Experiences of suffering can include illness that

alters one’s life and relationships as one knew them;

forced exclusion from everyday life; the strain of trying

to endure; longing to love or be loved; acute or chronic

pain; and conflict; anguish, or interference with love in

relationships.” (Wright, 2005, p. 3). Suffering has also

been defined as “the state of severe distress associated

with events that threaten the intactness of the person”

and the family unit (Cassell, 1991, p.33; Wright and

Leahey, 2013).

Use relational and communication skills to develop a

trusting relationship between nurse and family

Explore individual family member’s and family unit

thoughts, emotions, beliefs about suffering in the fami-

Dialogue about cultural and religious beliefs that could

provide peace and support

Family meetings and dialogue to increase family inter-

action and induce understandings and provide family

support

Find ways to empower family

Engage in dialogue that facilitates family finding

meaning in suffering

Search for new meanings in suffering

Create and invite therapeutic conversation with family

members

Invite family stories of suffering

Acknowledge suffering in the family

Seek means of support for each individual family

member and unique family

Use therapeutic questioning techniques, examples:”

How can we be most helpful?”, “Who do you believe

is suffering most and needs the most support?”, “What

is one question you would most like answered during

our time together?” (Wright & Leahey, 2013).

Family Engagement with the Illness: Connecting,

Pondering, Relating, Struggling

(Krumwiede, Meiers, Bliesmer, Eggenberger, Earle,

Murray, Harman, Andros, & Rydholm, 2004)

Invite family presence and engage in use of nurse

presence

Develop individual-nurse-family relationship/

connection/partnership

Assess family struggling and ways to support the fam-

ily

Acknowledge the work of family during illness expe-

rience

Explore the thinking and concerns of family

Discuss with family their connections with each other

and the illness

Family Experience with End of Life (EOL )

(Weigand, 2008; Wiegand, Grant, Jooyoung, & Gergis,

2013)

The complex and challenging family experience related

to multiple issue surrounding life and death; such as

legal, ethical, communication, family, decision-making

and life-sustaining therapy issues. The nature of the

patient’s illness, family context, and family and health

care provider interactions influence decision making and

family processes during this time of vulnerability

(Wiegand, 2008). This experience can be overwhelming,

devastating, and difficult for families (Wiegand, 2008;

Tilden, Tolle, Nelson, Thompson, & Eggman, 1999).

Encouraging family to dialogue about various individual

perceptions of the illness experience and EOL decisions

Share and compare each individual family members

beliefs about end of life care and decisions

Invite family members to use techniques of storytelling

to share life experiences of the individual at end of life

Express understanding of families need for time to

build consensus & acceptance surrounding EOL care

Provide opportunities for repetition of accurate and

ongoing information to inform families

Give family members indicators to facilitate decision

making

Family Struggling

(Goodew, Isaacson, & Miller, 2013; Krumwiede, Mei-

ers, Bliesmer, Eggenberger, Earle, Murray, Harman,

Andros, & Rydholm, 2004)

Family struggling in the context of chronic illness is

characterized as an all-consuming battle that becomes

an ongoing part of the family’s daily life necessitating

constant reorganization (Persson & Sundin, 2008). Fam-

ily members struggle with accepting the diagnosis and

treatment plan, working with the provider, enacting

supporting and caring roles now and in the unknown

future, maintaining normalcy in family life while coping

with the reality of the illness, and the reactions of others

to the illness (Goodew, Isaacson, & Miller, 2013).

Discuss the diagnosis and treatment plan, working

with the provider, enacting supporting and caring roles

now and in the unknown future, maintaining normalcy

in family life while coping with the reality of the ill-

ness, and the reactions of others to the illness

(Goodew, Isaacson, & Miller, 2013)

Assess family struggling and ways to support the fami-

Family Structure

Family composition and context of the family (Wright

and Leahey, 2014). Internal structure includes family

composition, gender, rank order, sexual orientation, sub-

systems and boundaries (Wright and Leahey, 2014, p.

54). External structure includes extended family and

larger systems (Wright and Leahey, 2014, p. 64). Devel-

op and discuss genogram and ecomap with family

Conduct a brief 15 minute interview including thera-

peutic conversation (Svavarsdottir, Tryggvadottir, &

Sigurdardottir, 2012; Wright & Leahey, 2013; Wright

& Bell, 2009)

Family Fear

(Bay & Algase, 1999)

“a …motivated state where …threat guides behavior. ..A

defensive response to perceived threat or result of expo-

sure to an environmental reminiscent of the original fear

experience.” Critical attributes include a focus on the

threat and behavioral change with feelings of dread,

scared and frightened (Bay & Algase, 1999).

Acknowledge the illness experience may pose fear and

threats to the family unit and individual family member

Create opportunities for nurse to be viewed as re-

source

Use nurse presence techniques of eye contact, appro-

priate touch, and reassuring voice

Encourage discussion regarding fears of the individu-

al and family experience

Provide assurances and explanations

Provide thorough explanations of environment and

event

Reassure family that fear is understandable and ex-

pressing fears may be helpful

Empower family members to search for protective

factors

Take actions to minimize fear from family waiting,

uncertainty, and distresses

Family Financial Concerns Resentment, anger, anxiety (Grande, Barg, Johnson, &

Cannuscio, 2013), and distress (Yen, McRae, Jeon, Es-

sue, & Herath, 2011) because of the increased costs

(Anderson & Horvath, 2004) of managing illness and

the resulting social deprivation caused by the inability to

participate in previous activities due to limited finances

(Rijken & Groenewegen, 2006; Goetzke, Parks, & Pe-

terson, 2014).

Explore concerns regarding the ability to financially

manage throughout the illness (Goetzke, Parks, & Peter-

son, 2014).

Acknowledge the potential for social deprivation of

family members due to the costs of managing illness

(Goetzke, Parks, & Peterson, 2014).

Use active listening to determine family financial con-

cerns and propose potential solutions that fit the fami-

ly’s context and goals

Family Stress

(Boss, 2002; McCubbin, & McCubbin, 1993; McAdam,

Fontaine, White, Dracup & Puntillo, 2012; Werner &

Frost, 2000)

Pressure or tension in the family system. A change in

the family equilibrium with the degree of stress depend-

ing on family’s perception and appraisal of the situation

(Boss, 2002). A state in which family resources are

challenged by the environment and endanger family

integrity (Kazak, 1992). Explore the perception of

threat and the meaning of an event; then, intervene

based on findings

Identify individual and family unit perception of re-

sources

Explore individual and family unit perception of sup-

port

Create opportunities for nurse to be viewed as resource

Diligently provide consistent information

Use therapeutic questioning techniques, examples:

“How can we be most helpful?”, “What is one ques-

tion you would most like answered during our time

together?” (Wright & Leahey, 2013)

Family Sharing/Storytelling

(Boykin, & Schoenhofer, 1991; Moules, & Streitberger,

1997; Crogan, Evans, & Bendel, 2008)

Allow the family to share past life experiences that

affect the health experience

Encourage the family to express suffering throughout

the illness experience

Promote healing processes through family storytelling

Family Growth

Positive psychological change experienced as a result of

the struggle of a traumatic or challenging event

(Tedeschi & Calhoun, 2004) such as the diagnosis of

chronic illness and cognitive rebuilding of the family

schema (Cavanaugh, Eastwick, & Kronebusch, 2014)

Encourage the family to tell their illness, health, or

developmental transition story

Assist the family in setting and/or re-setting family

goals in the context of the current and projected future

health experience

Family Illness Experience

(ill child and adult/ acute and chronic illness)

(Eggenberger & Nelms, 2007; Davidson, 2009; Hyman

& Corbin, 2001; Corbin & Srauss, 1988; Meiers & Tom-

linson, 2003)

Assess the family response and experience occurring

with health and illness

Assess the change occurring within the family that

may influence the health and illness experience

Assist family members to communicate regarding their

individual experiences with the illness

Explore the family unit health and illness experience

Examine meanings of being a family during this illness

experience for each family (Eggenberger & Nelms,

2007)

Acknowledge family illness experience (Eggenberger

& Regan, 2010)

Help families construct meanings from life and illness

experience

Family Resilience

(Black, & Lobo, 2008; Walsh, 2003; Weihs, Fisher,&

Baird, 2002)

The “ability of a family to respond positively to an ad-

verse event and emerge strengthened, more resourceful

and more confident” (Benzies & Mychasiuk, 2009, p.

103; McCubbin & McCubbin 1993). Resiliency is fos-

tered by protective factors and inhibited by risk factors.

Protective factors transform responses to adverse events

so that families avoid possible negative outcomes

(Weihs, Fisher, & Baird, 2002). Affirm family

strengths and competence

Identify protective behaviors, as well as risk factors

within and outside the family unit that influence

health

Commend family strengths and praise efforts to

meet needs

Identify ways family can access resources

Identify who helps the most with family’s greatest

challenges

Explore families’ constraining beliefs that negative-

ly influence health and resilience

Explore families facilitating beliefs that positively

influence health and resilience

Implement actions that balance threats and resources

Identify spiritual or religious beliefs and sources that

are viewed as helpful to the family

Encourage family discussions about conflicts and

differences

Family Relating

Communicating, connecting, collaborating and cooper-

ating in routine domestic tasks and activities that consti-

tute individual and family identities (Cavanaugh, East-

wick, & Kronebusch, 2014)

Facilitate family communication, time for connec-

tions, and opportunities for collaboration and collabo-

ration to accomplish family and illness management

tasks (Cavanaugh, Eastwick, & Kronebusch, 2014)

Family Inquiry

(Krumwiede, Meiers, Bliesmer, Eggenberger, Earle,

Murray, Harman, Andros, & Rydholm, 2004)

Process of family seeking information and appraising

the meanings of occurrences and information about ill-

ness event to better understand the situation; a family

caring strategy that often includes questioning members

of their family and other families, as well as health care

providers in an effort to help understand the illness

event (Eggenberger, Meiers, Krumwiede, Bliesmer &

Earle, 2004). Use “one question question” technique to

elicit family concerns (Wright & Leahey, 2013)

Provide consistent and ongoing information to family

and guide family in the interpretation

Respond to questions with honest, direct, and clear

information

Explore current family understandings and interpreta-

tions of events, data, environment, and experiences

Provide mechanism for family to access information

(e.g., consistent nurse, telephone support, valid inter-

net resources, brochures)

Acknowledge uncertainty and threat of the situation

Acknowledge value of family group gathering infor-

mation (e.g., emphasize the importance of different

family member perspectives on the situation)

A wholeness of the family unit with processes and func-

tioning that supports family system (Krumwiede, Mei-

ers, Bliesmer, Eggenberger, Earle, Murray, Harman,

Andros, & Rydholm 2004; Anderson & Tomlinson,

1992).Explore family health (structure, functioning,

processes)

Examine family management of illness experience

and support for individual and family health

Identify family strengths and resources used in coping

Explore individual-family-nurse partnerships

Family Integrity

(Anderson & Tomlinson, 1992; Clarke-Steffen, 1997;

Krumwiede, Meiers, Bliesmer, Eggenberger, Earle,

Murray, Harman, Andros, & Rydholm, 2004; Tomlin- son, Peden-McAlpine, & Sherman, 2012)

Family Reintegration

(Eggenberger, Meiers, Krumwiede, Bliesmer, & Earle,

2011)

Explore family changes in processes and routines with

illness

Guide family in adjusting and developing new family

processes

Encourage family processes that support family health

Family Pondering

(Goodew, Isaacson, & Miller, 2013; Krumwiede, Meiers,

Bliesmer, Eggenberger, Earle, Murray, Harman, Andros,

& Rydholm, 2004)

Family pondering in the context of chronic illness refers

to reflecting upon the past and potential future meaning

of the illness in family life and analyzing the impact of

the illness on the family.

Explore the thinking and concerns of family Invite the family to tell the diagnosis story and project

to the future

Family Loss

Loss in a family has numerous related definitions that

relate to grief, loss, bereavement, and complicated grief,

ambiguous loss, and chronic sorrow (Holtslander &

McMillan, 2011; Walsh, 2007; Boss, 2006; Boss,

Doherty,LaRossa, Schumm, & Steinmetz, 1993; Burke,

& Hainsworth, 1998; Isaakson & Ahlstrom, 2008 ).

Walsh (2006) suggests health care professionals mobi-

lize the capacity for healing and resilience in families

and communities experiencing a loss (Walsh, 2003,

2006).

Variables in the loss situation that require careful as-

sessment and attention (Walsh, 2007, p 209):

 Time of Death-Untimely losses such as parents’

loss of young children requires reorganization of

the family system.

 Sudden death-Sudden losses shatter a sense of

normalcy and predictability. Shock, intense emo-

tions, disorganization, and confusion are common

and family members may have regrets.

 Prolonged suffering with Loss-Prolonged physical

or emotional suffering before death increases fam-

ily agony.

 Ambiguous loss-Physical or psychological ab-

sence of a family member. Either a body or the

psychological presence of an family member.

Unclarity about the fate of a missing loved one

can immobilize families who may be torn apart,

hoping for the best yet fearing the worst (Boss,

1999). Mourning may be blocked until remains or

personal effects are recovered.

 Stigmatized losses-Mourning is complicated when

losses or their causes are disenfranchised (Doka,

2002), hidden because of social stigma and secre-

cy.

 Pile-up effects. Families can be overwhelmed by

the emotional, relational, and functional impact of

multiple deaths, prolonged or recurrent trauma,

and other losses (homes, jobs, communities) and

disruptive transitions (separations, migration).

 Past traumatic experience-Past trauma or losses,

reactivated in life-threatening or loss situations,

intensify the impact and complicate recovery.

Walsh (2007, p. 209) states a family experience can in-

clude the following losses:

 sense of physical or psychological wholeness (e.g.,

with serious bodily harm);

 significant persons, roles, and relationships;

 head of family or community leader;

 intact family unit, homes, or communities;

 way of life and economic livelihood;

 future potential (e.g., with the loss of children);

 hopes and dreams for all that might have been;

 shattered assumptions in core worldview (e.g. loss

of security, predictability, or trust).

Assist family as they attempt to find meaning in loss

(Boss, 2006).

Guide families in reconstructing meaning in way that

enables them to function (Neimeyer, 2001; Eggen-

berger, Meiers, Krumwiede, Bliesmer, & Earle 2011).

Help families find spiritual connections, memories,

deeds, and stories that are passed on across the genera-

tions (Walsh & McGoldrick, 2004)

Guide individual family members in exploring the

past, present and future functioning

Assist family members as they identify individual and

family past strengths and develop sources of support.

Help individual and family express understandings

about the meanings of loss and identify specific ways

to manage uncertainties over time.

Discuss with family a chronic sorrow experience of

Recurring and pervasive loss with no predictable end

(Eakes, Burke, & Hainsworth,1998)

Arrange and guide family discussions of perceptions,

experiences and beliefs related to the loss.

Encourage families to

 Share acknowledgment of reality of losses and

experiences of loss and living

 Clarify facts

 Plan tributes and rituals within their belief system

(Walsh , 2007)

Assist family to Construct new hopes, dreams and

realities and find new purposes (Walsh, 2007; Eggen-

berger, Meiers, Krumwiede, Bliesmer, & Earle 2011

Family Loss Continued

Family Management Styles

(Wiegand, Deatrick, & Knafl, 2008; Knafl & Deatrick,

2003; Knafl, Deatrick, & Havill, 2012)

Patterns or typologies of family response to health care

challenges (Knafl & Deatrick, 2003). Component of the

Family Management Style Framework include the situ-

ation, management behaviors, and sociocultural con-

text. The subjective meaning family members defines the situation while the management related to efforts

directed toward caring for the illness and family while

sociocultural context defines how the family manages

the situation (Knafl & Deatrick, p. 2003, p. ---“the

family’s role in actively responding to illness and

health care situations” (Deatrick & Knafl, 1990, p. 2).

Explore family strengths and praise efforts to meet

needs and identify family concerns

Explore family members: *Definition of the situation *Management behaviors *Perceptions of the consequences of the family mem-

ber’s health condition for family life

Explore sociocultural contexts of the family manage-

ment processes: *Extended family *Societal view of situation *Social network

Discuss perceptions of the individual family members

and family member with health concerns

Examine individual and family unit functioning

Identify management of family: *Progressing, accommodating, maintaining, strug-

gling, and floundering

Identify the underlying families structure and function

that influence the health and illness experience and can

be embraced to promote health