Discuss applicability of research findings in clinical practice. Incorporate course readings when appropriate, with citations.
Critique a research article
Order Description
Research article PDF must contain a family theory in the research, with implications for nursing. Please follow the instructions for the assignment.
FAMILY RESEARCH CRITIQUE: grade worth maximum of 20 points
1. Select a nursing research article utilizing a family theory, preapproved by faculty.
2. Critique selected research, including from a family a family perspective .
3. Discuss applicability of research findings in clinical practice. Incorporate course readings when appropriate, with citations.
4. Content to include – how is family defined, are assumptions identified from the theory, how are theory concepts incorporated into the research?
5. All papers must conform to the standard academic format, APA style 6th ed, and be free of spelling, grammatical, and typographical errors. In addition, the paper should be cleanly type written, and submitted to SAKAI forum by due date and time. Please include an intro and a conclusion.
6. Length of paper – 5 – 7 pages, not including title page and references.
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/265856412 Nurses’ fidelity to theory-based core components when implementing Family Health Conversations – a qualitative inquiry
Article in Scandinavian Journal of Caring Sciences · September 2014 Impact Factor: 0.89 · DOI: 10.1111/scs.12178
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Ulrika Östlund Uppsala University/Region Gävleborg 27 PUBLICATIONS 268 CITATIONS
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Viveca Lindh Umeå University 23 PUBLICATIONS 371 CITATIONS
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Karin Sundin Umeå University 32 PUBLICATIONS 505 CITATIONS
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Britt-Inger Saveman Umeå University 100 PUBLICATIONS 1,794 CITATIONS
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All in-text references underlined in blue are linked to publications on ResearchGate, letting you access and read them immediately.
Available from: Karin Sundin Retrieved on: 26 June 2016
METHODS AND METHODOLOGIES Nurses’ ?delity to theory-based core components when implementing Family Health Conversations – a qualitative inquiry
Nurses’ ?delity to theory-based core components when implementing Family Health Conversations – a qualitative inquiry
Background and aim: A family systems nursing interven- tion, Family Health Conversation, has been developed in Sweden by adapting the Calgary Family Assessment and Intervention Models and the Illness Beliefs Model. The intervention has several theoretical assumptions, and one way translate the theory into practice is to identify core components. This may produce higher levels of ?delity to the intervention. Besides information about how to imple- ment an intervention in accordance to how it was devel- oped, evaluating whether it was actually implemented as intended is important. Accordingly, we describe the nurses’ ?delity to the identi?ed core components of Family Health Conversation. Intervention and research methods: Six nurses, working in alternating pairs, conducted Family Health Conversations with seven families in which a family member younger than 65 had suffered a stroke. The intervention
contained a series of three-1-hour conversations held at 2–3 week intervals. The nurses followed a conversation structure based on 12 core components identi?ed from theoretical assumptions. The transcripts of the 21 conver- sations were analysed using manifest qualitative content analysis with a deductive approach. Results and conclusion: The ‘core components’ seemed to be useful even if nurses’ ?delity varied among the core com- ponents. Some components were followed relatively well, but others were not. This indicates that the process for achiev- ing ?delity to the intervention can be improved, and that it is necessary for nurses to continually learn theory and to prac- tise family systems nursing. We suggest this can be accom- plished through re?ections, role play and training on the core components. Furthermore, as in this study, joint re?ections on how the core components have been implemented can lead to deeper understanding and knowledge of how Family Health Conversation can be delivered as intended.
Keywords: family, family systems nursing, Family Health Conversation, ?delity, intervention, stroke.
Background
Family systems nursing can be conceptualised as focusing on the whole family as the unit of care, on both the indi- vidual and the family simultaneously, and on interaction and reciprocity within the family (1). The goal of family systems nursing is to sustain health and promote healing while directing practice towards both health promotion and relief from suffering due to illness (2). A family
systems nursing intervention, Family Health Conversa- tion (FamHC) has been developed in Sweden (3) by adapting the Calgary Family Assessment Model (CFAM), the Calgary Family Intervention Model (CFIM) (4) and the Illness Beliefs Model (IBM) (5) to Scandinavian con- ditions (6). The purpose of FamHC is to create a context for change and to support the creation of new beliefs, new meaning and opportunities in relation to ‘problems’ described by the family, that is things hampering the family’s health. The family is conceptualised as a self- de?ned group of two or more individuals who consider themselves to be a family (3). FamHC has several theoretical underpinnings, which are described below, to guide nurses’ interactions with the families (3, 6): in?uences from the CFAM, the CFIM
Correspondence to: Ulrika €Ostlund, Department of Neurobiology, Care Sciences, and Society, Nursing Division, Karolinska Institutet, SE-141 83 Stockholm, Sweden. E-mail: ulrika.ostlund@ki.se
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(4), the IBM (5) and their related theories. Adopting a systemic, cybernetic approach (7) is central to FamHC’s focus on the interplay and the relationships among fam- ily members’ beliefs and experiences rather than on indi- vidual family members. It is assumed that ‘the problem’ resides in the dialogue between individuals rather than within the individuals. Accordingly, the communication of a problem identi?es its focus and boundaries as well as the people related to it. This gives the family the prefer- ential right to decide what to talk about (3). Acknowl- edging each family member’s view as equally valid calls for recognising that a single event, situation or activity can be perceived in different ways (8). Our beliefs are understood as the truth of a subjective reality that in?u- ences our thoughts, feelings and behaviour in different ways (5, 9). Beliefs can be constraining or facilitative; often they have not been re?ected on (5). A further assumption is that narratives have great impact on the healing process (10) and are closely inter- twined with re?ection. A re?ected-on story is not intended to describe an event exactly but to try to under- stand what has happened; this can assist in ?nding new alternatives or meanings (3). Accordingly, re?ective thinking and re?ection are emphasised (11). A salutoge- netic approach, which focuses on the families’ internal strengths and external resources, is also adopted (12). All families have resources, but the experience of illness may hinder their ability to recognise them. Using nonhierar- chical participation built on mutuality and respect (13) is another important practice, as is asking questions that illuminate relationships and search for information about, for example, differences between people, family relations, events and beliefs (14). The theoretical assumptions for an intervention have to be put into practice. Implementing interventions is a complex process that consists of multiple steps (15). This process can be illustrated by the Knowledge to Action (KTA) framework (16), assuming a systemic perspective with both a knowledge creation and knowledge applica- tion phase. Identifying core components, which are the essential and indispensable components of an interven- tion model, as a way to translate theory into practice can be seen as part of the knowledge creation cycle. FamHC can be considered a complex intervention, that is it con- sists of a number of components and is ?exible in its delivery (17, 18). Achieving ?delity, the degree to which an intervention is delivered as intended, is more dif?cult in complex interventions then in relatively ‘simple’ ones (17), and the more clearly core intervention components are de?ned and described, the higher the likelihood of successful implementation of the intervention and achievement of desired outcomes (19). Interventions, where core components are identi?ed in advance, have been found to produce higher levels of adherence than less well-structured interventions (17).
Therefore, in this study, we have brie?y described the theoretical assumptions of FamHC and the 12 core com- ponents identi?ed from the theory. In addition to infor- mation about how to implement an intervention in accordance with how it was developed, evaluating whether it was actually implemented as intended is important. Researchers performing interventions are sug- gested to involve an evaluation of implementation ?del- ity to help other researchers and practitioners to understand how and why an intervention works or not (17). To understand ?rst the ?delity under the research conditions is crucial for a practice to advance (20). Accordingly, this study aims to describe nurses’ ?delity to the identi?ed core components of FamHC when imple- menting the intervention within a research study.
Methods
A qualitative descriptive design (21) with a deductive approach (22) was adopted. We used qualitative content analysis (22) for describing the nurses’ ?delity to the identi?ed core components of FamHC based on tran- scripts of audio recordings from the FamHCs conducted.
Sample
Six Registered Nurses, all women and aged 48–62 years old, conducted the FamHC and constituted the study sample. They were all part of the research group, had participated in university training on the FamHC inter- vention and were also teaching family nursing. The uni- versity training comprised advanced-level nursing courses wherein the learning outcomes focused on family systems nursing theory and the development of conver- sation skills for planning and conducting FamHC (23). As the nurses had differing amounts of experience using FamHC, they conducted the conversations in differ- ent combinations of pairs, grouping them ?rst from most to least experienced and then shifting one from each team to the next FamHC. By the end of the conversation sessions, all of the nurses had conducted FamHCs with at least two families.
Procedure
FamHCs were performed in parallel with any ‘standard care’ received with seven families in which one family member younger than 65 had suffered a stroke. The fam- ily members who had suffered the stroke were approached for invitation during their stay in a rehabili- tation centre. They were then asked to identify family members who they also wanted participating in the Fam- HC. The decision to intervene with this group was based on the premise that having a stroke often results in dependence and experiences of a changed identity and
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social life for both the person with the stroke and his or her family (24) and that a family systems approach in stroke rehabilitation is warranted (25). Ethical approval for approaching the families, imple- menting FamHC, and recording the sessions was obtained from the Regional Ethical Review Board in Umea, Sweden (No 210-101-31M). After the families had given their con- sent to participate in the study, the nurses approached them to plan the intervention appointments. Informed consent was obtained from each family member sepa- rately. The nurses in the study sample were aware, as part of the research team, of the transcripts to be analysed. The nurses followed a conversation structure based on the core components described in Table 1. All seven fam- ilies participated in a series of three-1-hour conversations held at 2–3 week intervals in the families’ homes. One nurse took the primary responsibility for the conversation while the other acted as a co-participator. During the ?rst conversation, all family members were invited to tell their stories, to listen to each other’s stories and to begin identifying problems. The second conversation was intended to focus on and explore the problems identi?ed in the ?rst conversation. The third conversation focused more on coping strategies and on the future. Two or three weeks after the last conversation, a ‘closing letter’ was sent to the family (3, 26) as an additional way of concluding the conversation series. The closing letters are not analysed in this study.
Core components of the FamHC intervention
A description of the 12 core components of FamHC iden- ti?ed as a frame for conducting the intervention follows. These intervention components are based on the theoret- ical assumptions of the FamHC (3–14), which in?uences several components. For a description, see Table 1.
Data collection and analysis
The data consisted of audio recordings from seven Fam- HCs for a total of 21 conversations that were conducted between April 2011 and April 2012. The recordings were transcribed verbatim and analysed using manifest (27) qualitative content analysis with a deductive approach (22). The entire text of the conversations was chosen as the unit of analysis (27). The core components of FamHC described in Table 1 were used as a prede?ned frame- work. A category scheme (28) in which the codes corre- sponded to this framework was developed. First, the conversations were read through to get a sense of the text as a whole, and sections with the nurses’ verbal activities were marked. The marked text was then coded for correspondence to the category scheme by two researchers. Second, three tables were created: one for the ?rst, one for the second and one for
the third conversation. To enable comparisons, the col- umns of each table were used to separate the seven Fam- HCs and the rows to separate the codes. The coded text units were extracted from the transcripts and assembled in the tables. All of the authors re?ected on and dis- cussed the coded content as well as the entire analysis. Finally, the abstracted content was described according to the core components. Trustworthiness issues (28) were considered through- out the process of planning and conducting the study. As the researchers are the same nurses who conducted the interventions, the coding was performed so that no nurse coded a conversation that she had conducted. Further- more, two researchers worked together with the coding, initially performing the coding individually and then comparing their results and coming to an agreement. All researchers were involved in a dialogue regarding how to describe the data under the prede?ned categories.
Results
The results are described in relation to the prede?ned framework based on the core components.
Jointly re?ecting with the family on expectations for the conversation series
Nurses opened the ?rst conversation in the series by explaining their planned structure for the sessions and expressed their own expectations and beliefs. Joint re?ec- tions on family expectations related to the conversation series were initiated by the nurses in only one of the conversations. There was no explicit co-creation and joint re?ection between nurses and family members on the expectations for the conversations.
Exploring the family structure
In all the initial conversations, the nurses explored the families’ structures. This was done by using open ques- tions (e.g. ‘Can you start by telling us about how your family is constituted’?) and follow-up questions (e.g. ‘Is there anyone else that you think belongs to your fam- ily’?). The questions posed were mostly of a linear char- acter, and asked about both what traditionally could be seen as the nuclear family and the extended family; how- ever, some conversation leaders also included questions about, for example, friends.
Ensuring all family members are given space within the conversations and have the opportunity to narrate their experiences
Nurses saw to it that all family members were given space in the ?rst conversation, one at a time, to narrate their
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Table 1 Core components of the Family Health Conversation
Core component Content and purpose
Jointly re?ecting with the family on expectations of the conversation series
The nurses invite the families to jointly re?ect on their own and each other’s expectations of the conversations. This is important as a way to acknowledge all participants within the conversation as equals and because a mutual expectation of what can be achieved contributes to the success of the conversations Exploring the family structure In the ?rst conversation, the family structure is explored. Through the nurses’ curiosity about who is part of the family, the family members’ beliefs about their own family might be made evident and then challenged, thus identifying and acknowledging resources within and outside the family. Ensuring all family members are given space within the conversations and have the opportunity to narrate their experiences In order to give the family members the opportunity to share and listen to each other’s stories, all family members are invited, one at a time, to narrate their own stories and to focus on their problem(s). Through narratives, family members can ?nd new alternatives or meanings and detect new associations Jointly prioritising which problem(s) most need to be discussed The nurses give the family the preferential right to decide what to talk about. What is shared by the family in the narratives can be seen as an invitation allowing the nurses, after listening carefully, to begin a dialogue with the family about what is most in need of being discussed. Exploring signi?cant parts of the family narratives The nurses use different methods of questioning, see below, to understand what has happened and what beliefs and problems are central for the family. The questioning can generate meaning from the family members’ narratives and also support a more re?ective story Using re?ective questions During the conversations, re?ective thinking is emphasised. Circular questions, to de?ne relations between and searching for information about differences between, for example, people, family relations, events and beliefs, initiate re?ections and are intended to allow the nurses to help family members put into words their internal conversations and become aware of their own beliefs Using appropriately unusual questions and challenging family beliefs Appropriately unusual questions, intended to depart just enough, but not too much, from the family’s own beliefs, allow new directions for thinking. This might lead to beliefs becoming conscious and is therefore one way to challenge constraining beliefs and support facilitating beliefs Giving commendations and acknowledging suffering When nurses practise commendations in which family strengths, competencies and resources are drawn forth, they make visible the family’s own internal strengths and external resources. However, the suffering families have gone through, and still may experience, should also be acknowledged. Inviting family members to re?ect on each other’s narratives Nurses invite family members to re?ect on each other’s narratives. This helps in focusing the conversations on the interplay and the relationship between family members’ beliefs and experiences rather than on individual family members Offering nurses’ re?ections The nurses also offer their re?ections to the families. At the end of each conversation, the nurses invite the family to listen to a more comprehensive re?ection, giving the family members a respite from the conversation and time to listen. Within the re?ections, nurses may acknowledge suffering, give commendation and challenge constraining beliefs. After the nurses’ re?ection, the families are invited to re?ect on the nurses’ thoughts Asking what has happened since the last conversation During the second and third conversations, the nurses ask what has happened in the family since the last conversation. This is to learn more about the family’s situation but also to help the family identify changes that have taken place or been re?ected upon Closing the conversation series At the end of the third conversation, the nurses summarise what they have experienced during the entire conversation series and recount the central issues that have been raised and pursued. In addition, the nurses’ written re?ections on topics and issues that have emerged in the conversations and their thoughts about the future – that is, a ‘closing letter’ – is sent to the family
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stories. They usually started with the family member who had suffered the stroke (e.g. ‘If we start with you, X, will you tell us your story about what happened’?). The most common way to invite family members to talk was to turn towards them with a question. This was done in a similar way throughout the conversation series.
Jointly prioritising which problem(s) most need to be discussed
In only a few conversations, the nurses explicitly initi- ated prioritising what to talk about in the conversations. However, in all conversations, the nurses were ?exible in following the topics brought up by the families.
Exploring signi?cant parts of the family narratives and using re?ective questions
The nurses posed mostly linear questions through all three conversations to explore the ‘heart’ of the families’ situa- tions and problems. In the ?rst conversation, open ques- tions were posed to invite the families’ narratives (e.g. ‘Will you please tell us about your experience of the stroke and what’s happening now’?). In the second conversation, nurses’ questions more explicitly targeted topics relating to family beliefs that could be challenged in the subsequent conversation (e.g. ‘Do you see any possibility of ?nding someone nearby to talk with’?). In the third sessions, some conversations were still dominated by linear questions exploring health potentials in the family and in some con- versations questions had turned to thoughts about the future and potential for change. The circular questions posed were often intended to explore the distinctions between cognition, feelings and actions. The nurses often combined circular questions with linear exploratory ques- tions, asking solitary circular questions less frequently.
Using appropriately unusual questions and challenging family beliefs
Within the ?rst conversation, the nurses did not chal- lenge the families’ beliefs to any great extent but did so more frequently as the FamHC went on. The nurses posed quite simple questions, to challenge a belief that, for instance, after the stroke the patient could not ?nd his or her way back home after being out: ‘Can you use the mobility service for such things, do you think’? The nurses also posed more complex questions: ‘If you have a bad conscience because of also thinking of yourself (as a relative), my question is, do you really need that? How would the situation be for you and the rest of the family if you didn’t’? Furthermore, the nurses offered short re?ections to challenge beliefs disclosed by family mem- bers, for example, ‘that after a stroke, one is not a whole human due to having disabilities’. The nurses re?ected:
‘Well, it is probably important to have a dream to work towards, don’t you think? And if you cannot run on the beach, perhaps you can walk’.
Giving commendations and acknowledging suffering
The nurses drew out family strengths and resources to various extents, but such practice became more common towards the end of most of the conversation series and within the longer re?ections at the end of the conversa- tions. Methods of commending family members included statements such as: ‘I can see that you have been a sup- port for the rest of the family. It is good to know that you are a strong person. I think you showed consider- ation and took responsibility by doing that’. In the second conversation, the nurses provided af?r- mation by giving examples of resources and strengths they had heard during the conversations, for instance, family members showing each other respect. The nurses also acknowledged family members for being wise, brave, caring and loving and took note of improvements seen in relation to the family members who had suffered a stroke. In the third conversation, the nurses expressed that they had heard trust, energy and perseverance and high- lighted what they heard had been accomplished. Further- more, they pointed out positive strategies, for instance, families working together. Suffering was not acknowledged very often, but when it was, it was more or less done speci?cally and some- times within a mixture of af?rmations. The nurses most commonly con?rmed that they understood that the fam- ily had been through a dif?cult time.
Inviting family members to re?ect on each other’s narratives
Inviting family members to re?ect on each other’s narra- tives was found to vary from no questions to a couple of questions being posed to invite re?ections on other fam- ily members’ narratives.
Offering nurses’ re?ections
Nurses’ re?ections were divided into three parts: (i) shorter re?ections during the conversation, (ii) longer re?ections at the end of the conversation and (iii) invita- tions to the family to re?ect on the re?ections.
During the conversations. The nurses included shorter re?ections quite often during all conversations and more commonly as the conversation series proceeded. Using shorter re?ections was less common in conversations in which the nurses gave expert advice. This practice, which was either systemic in character or addressed individual family members or events, was sometimes undertaken by
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one of the nurses exclusively and at other times by the two nurses in collaboration.
At the end of the conversation. At the end of each conversa- tion, the nurses offered a longer re?ection to the families. These re?ections were opened in different ways. In some of the conversations, the nurses simply began re?ecting. In others, the nurses clearly invited the family to listen to their re?ections and, after the family had consented to do so, the nurses turned to each other with the family as spec- tator. In some longer re?ections, one of the nurses led the re?ection and the other nurse made shorter contributions. In others, both offered re?ections, alternating without a visible order, with one of them starting but the re?ection continuing in interplay. In these re?ections, it was more common for the nurses to challenge the families’ beliefs and highlight strengths and resources. The re?ections could be initiated in a positive way by emphasising resources within the family. Nurses further- more re?ected on previous dif?cult life events that family members had gone through. Commendations were woven throughout the re?ections in only some conversa- tions. When such af?rmations or commendations were absent, the re?ections tended to summarise the conversa- tion rather than re?ect on it. Suffering was acknowl- edged in the re?ections but only rarely and in a way that was not expressed clearly – for instance, suffering was noted using short sentences that did not contain the word ‘suffering’.
Inviting the family to re?ect on the re?ection. The nurses rarely invited the family to re?ect on the re?ection in the ?rst conversations but did so more often in the subsequent ones. They did this both by turning to a speci?c family member and by addressing the family as a whole. When the re?ection given by the nurses was more of summary, questions like ‘Do you feel this is a realistic picture’? or questions about whether the re?ection offered was accu- rate or inaccurate were asked. In other re?ections, the nurses asked the family, ‘Is there anything you want to add or take away’?, or whether something in the re?ection had surprised them.
Asking what has happened since the last conversation
Questions asking what had happened in the family since the last conversation were commonly used at the begin- ning of the second and third conversations as a way to open up the discussion. Some questions were exclusively focused on whether the family members had been think- ing about something in particular and, if so, what. Some focused more generally on how the family had been and what had happened since the previous conversation or how the family members felt after the nurses left the pre- vious time.
Closing the conversation series
When returning to the topics discussed and summarising the three conversations, the nurses con?rmed what they had heard or drew attention to a particular issue by ver- balising their own re?ections.
Discussion
The description of core components seemed to be useful for the nurses conducting the FamHC. Other research has indicated that the more clearly an intervention’s core components are known, the more successfully it can be implemented (19). In our qualitative inquiry, the ?delity to the core components differed. Even if some of the components were followed relatively well by the nurses, the results also indicates failures. Accordingly, the process for achieving ?delity to FamHC may be improved. Fidel- ity does not encompass just the concept of adherence, that is, whether the core components have been fully implemented, but also that of competence in delivering the core components. This includes skills in responding to the participants receiving the intervention and in com- munication (29). Consequently, in addition to identifying the core components, developing a plan for how nurses can achieve the competence needed to deliver FamCH in harmony with participating families should be under- taken. In our study, all of the nurses had theoretical knowledge of FamHC but limited experience in practicing FamHCs, which might be a reason for the lack of ?delity found in regard to some core components. The nurses seemed to adhere relatively well to the core component ‘exploring the family structure’. The way ques- tions were posed seemed, however, to con?rm a tradi- tional view of a family rather than moving beyond such a view (5). Reviewing what had happened in the family since the last conversation was commonly done by asking an open question to begin the conversation. This could probably be more deliberately done by also focusing on identifying changes accomplished within the family as part of the commendatory practices within the intervention (30). The nurses did not explicitly adhere well to the core components emphasising joint re?ections with the family on expectations for the conversation series and prioritising the focus of the conversations. This might be improved so that all participants are viewed as equals (3). The nurses adhered well to the core components calling for giving room to all family members to narrate their stories. This is important, as it is central to FamHC to explore signi?cant parts of the family’s narratives. To a large extent, linear questions were used. Asking circular questions seems to pose some dif?culties, perhaps in part because it differs from a typical conversation style. However, the use of circular questions is one of the most important core components of FamHC and is thought to
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encourage re?ection about beliefs and behaviours and to help the family consider new options (31). Therefore, the ?delity to this core component needs to be improved. Trying to challenge families’ beliefs by using appropri- ately unusual questions and re?ections was not done very frequently. This has previously been described as a challenge (3). This practice was almost nonexistent in the ?rst conversations, indicating the need to build trust with the families before challenging their beliefs, whether facilitating or constraining (5). A deep knowledge about how a family understands its situation is probably crucial in order to pose questions or re?ections that are appro- priately different from the family’s views. Improved ?del- ity to this core component is important, as this is a measure for facilitating change within the families’ ways of thinking, feeling and acting, moving them towards improved family health (3). The language and culture may have had an impact on how this commendatory practice was carried out. In the northern part of Sweden, where this study was con- ducted, individuals are considered to be stoic in their manner of expressing themselves. However, through praise, families may become aware of their strengths and resources, thus creating a context for change (4). Conse- quently, when using this core component, cultural habits may be challenged. Acknowledging suffering was not common in the pres- ent study, and when done it was often wrapped in af?r- mations. In our study, neither the nurses nor the families used the word ‘suffer’ in the conversations. The concept of suffering has previously been shown to be confusing for families (32), so using other expressions might be advisable. To have the courage to admit, in a way that suits the family’s emotional style, that suffering exists (33), is an important practice that may move the fami- lies’ suffering from being unbearable to being bearable (34, 35). The nurses included shorter re?ections during the con- versations quite often, and these re?ections seemed to happen more frequently after a relationship had been built with the families. As described in an earlier study, a positive and equal relationship makes it easier for nurses and stroke patients to be open with each other (36). When the re?ection is a dialogue between the nurses, the family members can take a break in which their inner dialogue continues, after which they can ?nd their way back to the outer dialogue (37). If the nurses co-cre- ate the re?ections, the re?ection could take a new direc- tion and create new meaning. This can be contrasted to when only one of the nurses provided more of a sum- mary of the conversation, which not necessarily trigger the healing process. The way the families were invited to re?ect on the nurses’ re?ection differed; sometimes ques- tions were asked about how the re?ection was experi- enced, and other times family members were asked if the
way the nurses had understood the family was accurate. When using the latter practice, the nurses did not adhere to the assumption that the world is to be seen as a multi- verse (8). Furthermore, it is through invitations to re?ect that challenging constraining beliefs commences (5).
Methodological re?ection
Even though we, the researchers, also conducted the FamHCs, we have scrupulously attempted to describe both positive outcomes and failures in ?delity to the core components. In this qualitative study, in which FamHC was conducted under research conditions, six nurses intervened with seven families. The participating nurses not only had undergone university education on the FamHC but also were teaching family nursing, but they were not very experienced in conducting FamHC when the study started. These circumstances have to be consid- ered a transferability issue (29). Larger studies, building on frameworks such as KTA (16), on how to implement successfully an intervention may be a next step in expanding the knowledge of practising FamHC.
Implications for how to improve nurses’ ?delity to the FamHC
Our results indicate that the process for achieving ?delity when practising FamHC can be improved. Describing core components of an intervention is important, but it remains to be considered how nurses can reach the com- petence needed to adhere to these components and to deliver the intervention in harmony with participating families. Continual education in theory and practice in family systems nursing is needed. This can be accom- plished through re?ections, role play and training on the core components. We also learned that joint re?ections on the core components and how they have been imple- mented, as they were in this study, can lead to deeper understanding and knowledge of how FamHC can be delivered as intended.
Acknowledgements
The authors want to express their gratitude to the partici- pating families and to the staff at the Rehabilitation Departments assisting in connection with the recruitment of the families and to Catrine Jacobsson, RNT, PhD, at Umea University, who participated as a conversation leader.
Author contributions
All authors have been responsible for the conception of the idea for the study, collecting and analysing data and participated in the process of interpretation and the
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production of the manuscript. The manuscript has been critically approved by all the authors.
Ethical approval
Ethical approval was obtained from the Regional Ethical Review Board in Umea, Sweden (No 210-101-31M).
Funding
This research was supported by grants from the Strategic Research Program in Health Care – Bridging Research and Practice for Better Health (SFP-V) and the Swedish STROKE-Association.
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