Family Systems Nursing

Transcription

1 Editorial Family Systems Nursing Re-examined Journal of Family Nursing Volume 15 Number 2 May SAGE Publications / hosted at Conversation: (1): oral exchange of sentiments, observations, opinions, or ideas (2): an instance of such exchange: talk <a quiet conversation> b: an informal discussion of an issue by representatives of governments, institutions, or groups c: an exchange similar to conversation Merriam-Webster s Online Dictionary Accounting for How the Family Systems Conversation Began Nurses are altering and modifying their usual patterns of clinical practice as they shift from caring for only the individual patient to seeing the family as the patient and increasingly including families in health care (Schober & Affara, 2001). The term Family Systems Nursing was first coined in the 1980s by Lorraine Wright and Maureen Leahey, two master clinicians and educators, to distinguish nursing interventions directed to the family unit. Their distinctions between family nursing and Family Systems Nursing were first presented as a coauthored plenary address at the First International Family Nursing Conference in Calgary in May 1988 and subsequently published in the Journal of Advanced Nursing in 1990: Family systems nursing can be conceptualized as focusing on the whole family as the unit of care. Concentration is on both the individual and the family simultaneously. The focus is always on the interaction and the reciprocity. It is not either/or but rather both/and. Family systems nursing is the integration of nursing, systems, cybernetics and family therapy theories. (Wright & Leahey, 1990, p. 149) Wright and Leahey s ideas were firmly grounded in clinical practice with families and informed by an exciting conversation and conceptual shift in the health care and family intervention literature that cut across disciplinary boundaries. In the late 1970s, George Engel (1980) began calling for an expansion of the biomedical model of care to include biological, psychological, and social domains of functioning and invited the health care providers 123

2 124 Journal of Family Nursing to expand their focus from just the cell and body systems of the individual to the larger relationship and cultural systems within which the individual was nested. Systems theory (von Bertalanffy, 1968) and later application of systems theory to families (Whitchurch & Constantine, 1993) offered further ideas about how to conceptualize families as relational systems and subsystems in a new way. Health disciplines caught this vision, arguing that a systemic lens is critical for assessment and intervention (Doherty & Baird, 1986; Kazak, Simms, & Rourke, 2002; McDaniel, Belar, Schroeder, Hargrove, & Freeman, 2002). Practice applications in family therapy also expanded the conversation about how to think about multiple systems simultaneously and linked these ideas to interventions. The specialty of medical family therapy enriched the conversation about how to assist families experiencing illness (McDaniel, Hepworth, & Doherty, 1992). My colleagues and I added our voices to this conversation in 1992 with a reminder that nurses also valued a Family Systems perspective in their practice with families experiencing health concerns (Bell, Wright, & Watson, 1992). Involving families in a systemic, relational way in health care is called many different kinds of names within the literature, depending on the context of the practice and the health care provider: family-focused practice, familycentered practice, family health and healing, family nursing, Family Systems Nursing, systemic health care, family medicine, medical family therapy, medical social work, and so on. A number of peer-reviewed journals have particularly contributed to this ongoing Family Systems conversation: Family Systems Medicine (now called Family, Systems, and Health), Family Process, Journal of Marital and Family Therapy, Family Relations, Journal of Family Psychology, and, most recently, Journal of Family Nursing. One of the more exciting developments within the Family Systems movement has been the creation of several practice units that were developed for education, research, and service and have provided significant learning opportunities for learners across many disciplines and rich dissemination opportunities for practice knowledge and research. Although not exhaustive, offered below is a list of several practice units in the world where a Family Systems orientation is or has been used to deliver care to individuals and families experiencing illness: Family Nursing Unit, University of Calgary, Alberta, Canada ( ) Family Therapy Program, Calgary, Alberta, Canada ( ) Calgary Family Therapy Centre, Alberta, Canada (1973-present). Web site: Denise Latourelle Family Nursing Unit, University of Montreal, Quebec, Canada (1993-present)

3 Bell / Editorial 125 Chicago Center for Family Health, an affiliate of the University of Chicago, Illinois (1991-present). Web site: Institute for the Family, Family Therapy Services, Department of Psychiatry, University of Rochester, New York (1970-present). Web site: Family Nursing Center, University of Wisconsin-Eau Claire ( ) Family Focused Nursing Unit, Kalmar University, Sweden (2004-present) Family Stress and Illness Program, Behavioral Health Center, The Children s Hospital of Philadelphia, Pennsylvania (2001-present) The Family Systems Conversation Within Nursing Wright and Leahey s (1988, 1990) plenary and subsequent publication, referred to above, marked the beginning of the Family Systems conversation within family nursing, and they have continued to make similar distinctions within their textbook, Nurses and Families, now in the 5th edition (Wright & Leahey, 2009). Kathryn Anderson and Patricia Tomlinson (Anderson, 2000; Anderson & Tomlinson, 1992) wrote about the family health system and emphasized the connection between family systems and health. Carole Robinson (1995a, 1995b) offered even more distinctions between individuals, family members, and family units in the practice and research domains. There appears to be few other conceptual articles related to Family Systems Nursing published since that time. I hypothesize that these conceptual articles are written out of love, and the current academic structures that reward research grants and publications leave little time or space for publishing more than data-based publications. Despite Segaric and Hall s (2005) critique that the conceptual distinctions between family unit and family systems are still messy, a recent Google Scholar search of the term Family Systems Nursing uncovered 1,950 citations focused on applications of Family Systems Nursing to practice, research, and education. Many of these publications have been written by faculty or graduates associated with the Family Nursing Unit, University of Calgary, where opportunities to observe Family Systems Nursing practice and receive live supervision of clinical practice were available for the past 25 years ( ; Bell, 2003; Bell & Wright, 2007; Flowers, St. John, & Bell, 2008; Gottlieb, 2007; Wright, Watson, & Bell, 1990; Wright, Watson, & Duhamel, 1985). The University of Calgary continues to offer Family Systems Nursing as a specialization and is one of several graduate programs in the world where Family Systems Nursing is taught. Although the list is not exhaustive, Family Systems Nursing is taught at the University of Montreal, Canada; Florida

4 126 Journal of Family Nursing International University, United States of America; Burapha University, Thailand; University of Iceland; Webster University, USA; and Kalmar University, Sweden. Family Systems Nursing requires nurses to make a conceptual shift, even a paradigm shift, to account for interaction and reciprocity between health/ illness suffering and family functioning, the interaction between themselves and the families in their care, and also consider the larger systems within which families and health care providers exist. A vogue term for this increasing ability of the health care provider to think systemically, recursively, and interactionally is relational practice (Doane & Varcoe, 2005; Robinson, 1996; Silverstein, Bass, Tuttle, Knudson-Martin, & Huenergardt, 2006; Tapp, 2000). Within the discipline of nursing, Family Systems Nursing is, I believe, an advanced practice with individuals and families. I have been musing about the key characteristics of Family Systems Nursing in a recent blog ( Here is a summary of my beliefs about Family Systems Nursing: The focus of Family Systems Nursing is on sustaining health and promoting healing while directing practice toward both health promotion and illness suffering. For example, addressing a mother s illness suffering within a family meeting can be health promoting for generations to come. The practice of Family Systems Nursing recognizes that relationships between people (especially significant relationships with people who give a damn about you) reciprocally influence health/illness. A useful summary of protective and risk factors in families experiencing adult chronic illness has recently been offered by Weihs, Fisher, and Baird (2002). The word family in Family Systems Nursing is a misnomer. The term family is used to symbolize a conceptual systemic lens that accounts for the interaction, reciprocity, and relationships between multiple systems levels that range from the smallest level of the cell to the largest level of society. These include the illness, the ill individual, the family, the nurse, and the larger systems within which they are nested. The nurse, using Family Systems Nursing, is adept at assessing multiple systems levels and choosing interventions that target the systems level that offers the greatest possibility for health and healing, that is, the intervention might target the individual, the relationship between two or more family members, the relationship between the family and the nurse or other health care provider, the health care system, society and culture, or some combination of these. It does not matter how many people you have in the consultation room in front of you. Family Systems Nursing can be operationalized with one person or with an entire unit of people who are connected together in some way, that is, family unit, hospital unit, and so on. Family Systems

5 Bell / Editorial 127 Nursing is a conceptual lens that directs the nurse s conceptual, perceptual, and executive skills to focus on relationships, inquire about relationships, and offer assessment and interventions directed toward these relationships, regardless of who is involved in the therapeutic conversation in the immediate moment. Family Systems Nursing occurs in a relationship between an individual/ family and a nonjudgmental nurse who prefers collaborative, nonhierarchical relationships and who believes in the legitimacy of multiple realities. A strengths-based orientation of the nurse moves the therapeutic conversation toward family competencies and strengths rather than toward deficits and pathology. The proponents of family-centered care argue that respect, information, and partnership with families in decision making are hallmarks of good practice with families; however, what nurses can add to this practice description is a willingness and competence to address illness suffering and family healing as well. Extending the Conversation about Family Systems Nursing Steve de Shazer s clever miracle question in his practice model asks, I have a strange, perhaps unusual question, a question that takes some imagination. Suppose...while you are sleeping, a miracle happens and, the problems...are solved, just like that! But this happens while you are sleeping, so you cannot know that it has happened. Once you wake up in the morning, how will go about discovering that this miracle happened to you? (de Shazer, n.d.). Here s how I would answer the miracle question in relation to Family Systems Nursing. I dream that more graduate nursing programs in universities around the world will embrace the specialization of Family Systems Nursing. I dream that more practice units will be developed within these educational institutions or in collaboration with health care facilities so that graduate nursing students can catch the vision of this way of practicing with individuals and families and conduct clinical scholarship (Bell, 2003) and research about Family Systems Nursing practice. I dream that further development of Family Systems Nursing ideas for practice and research with various populations of families will be published. I dream that more models for Family Systems Nursing practice will be developed. At this moment, the Illness Beliefs Model (Wright & Bell, in press; Wright, Watson, & Bell, 1996) and the Trinity Model (Wright, 2005) are the only two models for advanced practice in Family Systems Nursing that I know. In 10 years, I hope that there will

6 128 Journal of Family Nursing be many more practice models to guide advanced practice in Family Systems Nursing that will address illness suffering and promote health. Janice M. Bell, RN, PhD Editor References Anderson, K. H. (2000). The Family Health System approach to family systems nursing. Journal of Family Nursing, 6(2), Anderson, K. H., & Tomlinson, P. S. (1992). The family health system as an emerging paradigmatic view for nursing. Image: Journal of Nursing Scholarship, 24, Bell, J. M. (2003). Clinical scholarship in family nursing [Editorial]. Journal of Family Nursing, 9(2), Bell, J. M., & Wright, L. M. (2007). La recherché sur la pratique des soins infirmiers a la famille [Research on family interventions]. In F. Duhamel (Ed.), La sante et la famille: Une approche systemique en soins infirmiers [Families and health: A systemic approach in nursing care] (2nd ed.). Montreal, Quebec, Canada: Gaetan Morin editeur, Cheneliere Education. (An English version of this book chapter is available from D Space at the University of Calgary Library: Bell, J. M., Wright, L. M., & Watson, W. L. (1992). The medical map is not the territory; or, medical family therapy? Watch your language! Family Systems Medicine, 10(1), deshazer, S. (n.d.) The miracle question. Brief Family Therapy Center. Retrieved March 27, 2009, from: Doane, G. H., & Varcoe, C. (2005). Family nursing as relational inquiry. Philadelphia: Lippincott, Williams, & Wilkins. Doherty, W.J., & Baird, M.A. (1986). Developmental levels in family-centered medical care. Family Medicine, 18(3): Engel, G. (1980). The clinical application of the biopsychosocial model. American Journal of Psychiatry, 137, Flowers, K., St. John, W., & Bell, J. M. (2008). The role of the clinical laboratory in teaching and learning family nursing skills. Journal of Family Nursing, 14(2), Gottlieb, L. (2007). A tribute to the Calgary Family Nursing Unit: Lessons that go beyond family nursing [Editorial]. Canadian Journal of Nursing Research, 39(3), Kazak, A. E., Simms, S., & Rourke, M. T. (2002). Family systems practice in pediatric psychology. Journal of Pediatric Psychology, 27(2), McDaniel, S. H., Belar, C. D., Schroeder, C., Hargrove, D. S., & Freeman, E. L. (2002). A training curriculum for professional psychologists in primary care. Professional Psychology, Research and Practice, 33(1), McDaniel, S. H., Hepworth, J., & Doherty, W. J. (1992). Medical family therapy: A biopsychosocial approach to families with health problems. New York: Basic Books. Robinson, C. (1995a). Unifying distinctions in nursing research with persons and families. Journal of Family Nursing, 1(1), Robinson, C. (1995b). Beyond dichotomies in the nursing of persons and families. Image: Journal of Nursing Scholarship, 27,

7 Bell / Editorial 129 Robinson, C. A. (1996). Health care relationships revisited. Journal of Family Nursing, 2(2), Schober, M., & Affara, F. (2001). The family nurse: Frameworks for practice. Geneva, Switzerland: International Council of Nurses. Segaric, C. A., & Hall, W. A. (2005). The family-theory practice gap: A matter of clarity? Nursing Inquiry, 12(3), Silverstein, R., Bass, L. B., Tuttle, A., Knudson-Martin, C., & Huenergardt, D. (2006). What does it mean to be relational? A framework for assessment and practice. Family Process, 45(4), Tapp, D. M. (2000). The ethics of relational stance in family nursing: Resisting the view of nurse as expert. Journal of Family Nursing, 6(1), von Bertalanffy, L. (1968). General system theory: Foundations, development, applications. New York: George Braziller. Weihs, K., Fisher, L., & Baird, M. (2002). Families, health, and behavior: A section of the Commissioned Report by the Committee on Health and Behavior: Research, Practice, and Policy, Division of Neuroscience and Behavioral Health, and Division of Health Promotion and Disease Prevention, Institute of Medicine, National Academy of Sciences. Families, Systems, & Health, 20(1), Whitchurch, G. G., & Constantine, L. L. (1993). Systems theory. In P. G. Boss, W. J. Doherty, R. LaRossa, W. R. Schum, & S. K. Steimetz (Eds.), Sourcebook of family theories and methods: A contextual approach (pp ). New York: Plenum. Wright, L. M. (2005). Spirituality, suffering, and illness: Ideas for healing. Philadelphia: F. A. Davis. Wright, L. M., & Bell, J. M. (in press). Beliefs and illness: A model for healing. Calgary, Alberta, Canada: 4th Floor Press. Wright, L. M., & Leahey, M. (1988, May). Trends in family nursing. Plenary paper presented at the First International Family Nursing Conference, Calgary, Alberta, Canada. Wright, L. M., & Leahey, M. (1990). Trends in the nursing of families. Journal of Advanced Nursing, 15, Wright, L. M., & Leahey, M. (2009). Nurses and families. A guide to assessment and intervention (5th ed.). Philadelphia: F. A. Davis. Wright, L. M., Watson, W. L., & Bell, J. M. (1990). The family nursing unit: A unique integration of research, education and clinical practice. In J. M. Bell, W. L. Watson, & L. M. Wright (Eds.), The cutting edge of family nursing (pp ). Calgary, Alberta, Canada: Family Nursing Unit. Wright, L. M., Watson, W. L., & Bell, J. M. (1996). Beliefs: The heart of healing in families and illness. New York: Basic Books. Wright, L. M., Watson, W. L., & Duhamel, F. (1985). The family nursing unit: Clinical preparation at the masters level. The Canadian Nurse, 81,