Expanding knowledge in family health care

Maintaining family health is one of the most important demands in the survival of a society and a special challenge to all disciplines which are committed to health care. There is growing evidence of the reciprocal relationships between illness, stress, and family function. Similarly, there are reciprocal influences between family behaviour patterns and health or well-being of family members. The obvious conclusion from this evidence is that the caring sciences must expand their perspective to include the family in the unit of care – not an entirely new concept. In fact, there has been a long-standing recognition that the relationship between families and health care is important. However, this relationship has been more implicit than explicit. In recent years as the family has moved increasingly into greater focus we have come to understand the need to expand the science of family health care through explicit knowledge development of the relationship between families as both a care taking and care recipient unit. Aside from the general need to increase knowledge of the complex reciprocal relationships between families and health, there are several current trends in health care that add to the urgency for research in this area; shorter hospital stays, greater dependence on families as caregivers, more chronic health problems as a result of our increasing technology, and increasing longevity. All of these trends expand family care taking demands and the consequent need for new models of family care. There have generally been two perspectives of the family in health care: the first is the family as the context of care; a perspective that acknowledges the impact of health and/or health care on one or more family members. The traditions in maternal–child health care studies are representative of this point of view and have continued to provide extremely important information regarding the complexities of this important dyadic relationship in families, which guides health care. A second point of view has emerged in the past decade and is more holistic and systemic. This perspective considers the family as a unit of analysis in which the health event has a systemic effect and can only be studied by examining the whole family dynamic to understand health phenomena. Some investigators include an even wider perspective and may include some variables that give a window on the effect of some factors in the family ecology on family experience. Methodologically, this second perspective tries to examine multiple perceptions of family members in order to apprehend a true family point of view or a collective perception in order that interventions can be tailored to fit the family need. A third area of study in family health is the direct exploration of relationship between the family and the professional care provider. This growing area of study which combines an analysis of some aspect of the family experience in health care with a focus on the potential for an effective therapeutic relationship shows great promise for the development of sensitive family care and the next important step of testing the efficacy of true family models of caring. The papers in this special issue of Scandinavian Journal of Caring Sciences illustrate all of the above perspectives, demonstrating the scope of research in family health being undertaken by investigators from both Europe and the United States. This theme issue takes a particular point of view in its definition of ‘family health’, a term which has suffered from a lack of consensus among family health theorists. We use the definition first promoted by sociologist Pratt (1). Pratt described family health as the ‘general level of health in a family so inextricably intertwined in the pattern of family relations that health itself becomes a vital aspect of the fabric of family life’ and that a family through its individual structure can encourage and support their member's development and functioning, thereby contributing to family health (1 : 59). Anderson and Tomlinson (2) and Tomlinson (3) later applied this understanding to what they called the ‘family health system’, based on an integrative holistic definition of family health and a model for special application in health care for research. According to them family health fits into a holistic family view, incorporates wellness and illness in interaction with the environment, and focuses on four family realms or processes that direct clinical family practice; family development/transitions, family coping, family integrity, and family interactions. This definition incorporates individual health with family health and explicitly links family function with potential health related phenomena and healthcare interventions. Family health and health care is experienced in all of these realms – sometimes more significantly in one than another – sometimes simultaneously in all. A perspective of health infuses all realms. Family health beliefs, health status, health practices and relationships with health care providers are central, adding to the potential of the model to help direct practice and provide an organizational framework for knowledge development (3). We present these definitions here as one example of many that can be used to promote health care and research in family health. We also used this framework to help guide the organization of this issue. In our judgement, these papers contribute prominently to knowledge development in several of the family health realms identified above; developmental/ transitions, family integrity/dynamics, and family interactions – particularly relationship with health care professionals. Transitions, especially those related to developmental change, are times that put an extra demand on family functioning and health and are frequently times when families interact with family healthcare providers. One of the most universal is childbearing. Most new mothers adapt well to the transition to motherhood as shown in Kiehl and White's study of Norwegian, Swedish and US mothers’ perception of their ability to cope and adjust to maternal responsibilities and tasks. This is an important comparative study of maternal transition in three countries with marked differences in maternal health values and policies and widely different maternal leave laws (6 weeks in the USA to over 51 weeks in Sweden) which one would think could affect the maternal experience. It is encouraging to note that maternal adaptability may override these differences. However, this adaptability is predicated on adaptation in pregnancy, thus underlining the importance of good prenatal care that enhances the experience of pregnancy and prepares couples for parenting. The transition does not go so smoothly for some mothers according to Thome who found 5% of Icelandic mothers were distressed post birth and were generally not seeking care. Situational transitions also commonly bring families into health care, as, for example, when a family member is hospitalized and/or is being discharged from hospital. In either case, there is an alteration in family functioning because of the change in the family system and a potential threat to family health. The Proot et al. study confirms that family caregivers of terminally ill family members in the context of palliative care are especially vulnerable since they may be struggling with the burden of caregiving. These families have special needs for instrumental, emotional and informational support, which calls for a complex model of caring during end of life, one of the most intense and important family transitions. The second of the family health processes well represented in these papers is the family dynamic of maintaining integrity in the face of health problems. The Billhult and Segesten paper is an excellent example that describes how mothers maintain family integrity during a life-threatening illness through mutuality and sensitive communication with children. This is an important concept. In the late 1970s, Barnhill (4), an American psychologist, proposed a circular framework for healthy family systems with eight interrelated bipolar dimensions. He saw mutuality as the central factor in healthy families with clear communication and role reciprocity important in promoting stability, which in turn leads to flexibility and individuation among family members. This framework is the basis for the Family Dynamics Measure (FDM), developed by a group of US family health scientists and widely used in the US–Nordic Family Dynamics Nursing Research Project initiated by Marjorie White, University of Florida. An extension of White's work is a very active family health research group in Finland studying family dynamics and well being at the University of Tampere. Both the Rask et al. study and the Paavilainen and Åstedt-Kurki study are products from this group. The FDM II was used in the Rask et al. study to measure the dynamics between adolescents and one of their parents. Results indicate not surprisingly, that adolescent perception of family dynamics was significantly less positive than their parents and that family mutuality and stability were the most important influence on adolescent well-being. The importance of this study is that it not only found significant differences between parents and adolescents, but also between males and females. These findings should serve to remind us of the importance of a systemic perspective both in research and in clinical practice because of differences in perception among family members. The Paavilainen and Åstedt-Kurki study takes quite a different approach to examine family integrity. Its importance lies in development of a cogent model to help understand the profile of families prone to violence, especially as it involves children. Caring and mutuality again show up as key factors in healthy family dynamics, in this case the absence of which puts the child at risk. The qualitative methodology of this study provided a wide lens to view the complicated phenomenon of child abuse and allowed us to understand not only the family as the environment of the child but also the influence of the family environment on its capacity to care. This is a serious family health issue, which concerns all professionals whose job it is to assess children's health and is a very difficult area to study because of the sensitivity of the issue. The final area of family health is family interaction, represented here primarily by studies of family perceptions of health care personnel and the relationship between families and health care providers. The first (Georgsson Öhman, Grunewald and Waldenström), a study of common concerns of women during pregnancy showed that even though outcomes of pregnancy were important, there were significant worries about safety and availability of midwives and doctors, suggesting that families’ concerns about their relationship to health personnel is always in the background. How health personnel manage to support and care for families is also present in the Olin and Faxelid study of first-time and multiple-time new parents which emphasized the importance of talking about what matters to a patient – in this case the birth with the midwife who delivered the baby. One of the most interesting areas parents wanted to discuss was feeling of failure – a very important concern that can interfere with the sense of parenting mastery and later family functioning if not resolved. Two studies of families and child health nurses, one by Fagerskiöld, Timpka and Ek– the other by Arborelius and Bremberg, presented clear evidence of the importance of the relationship with the child health nurse both as a positive and negative influence. The results of the Arborelius and Bremberg study were especially provocative, showing a strong association between a negative relationship with the child health nurses, maternal depression, and perceptions of competency. The nurse interaction was considered negative if there were conflicting ideas and the nurse attempted to exert control due to differing perspectives. A nurse who is open and willing to share emotions and experiences is considered most caring. The Shields, Kristensson-Hallström and O'Callaghan study reported similar results. Family nurse relationship has also been studied in more intense treatment centres where the survival of the patient is uncertain. Two studies in intensive care environments from two family research groups; one in Sweden and one in the US represent this emerging systemic approach to understanding the interaction between health care provider and family. Söderström, Benzein and Saveman belong to a research group in the Department of Health and Behavioral Sciences, Kalmar University, which utilizes a family systems context inspired by Lorraine Wright, University of Calgary. Their study focuses on nurses’ perception of self and family. Like the Arborelius and Bremberg study, interactions between nurse and family members are dependent on whether the nurse considers self as expert or the family as paramount. The Meiers and Tomlinson study comes out of the family health research group at the University of Minnesota attached to the Tomlinson and Anderson family health systems framework. This study takes the interaction between family and nurse one step further and examines experiential meaning construction as a mutual influence in this relationship during interactions in the setting of paediatric critical care. One of the important results is evidence that the caring relationship of the nurse with the child when observed by the family can change attitudes about family relationships and that trust was enhanced through both interaction and shared care of the child. The results are presented from an existential perspective of how meanings of space, time, body and relationships within the crisis of caring are co-constructed. The experiences of ‘living with another's fear’ and ‘journeying through troubled waters’ were shared between family and nurse. Most important was the perception for both that when the relationship was at its best families perceived the nurse as a member of the family. Finally, a word about measurement. It is a credit to the investigators that the aim of several of these studies was to test measures developed in another country, an important step in measurement standardization for international development of family health science. Georgsson Öhmanet al. made this contribution with their work on the Cambridge Worry Scale (CWS) while Rasket al. further tested the Family Dynamics Measure (FDM II). Translation and restandardization of a measure help discover cultural biases that may be intrinsic to the questionnaire. In this process, the internal consistency of the translated instrument is estimated and new standards for interpreting responses are developed for new target language groups. Subsequent researchers will benefit the work done here. It is very satisfying to present these excellent papers, which are representative of the current international development in this particular focus of study. It is also very encouraging to see the multiple research teams with significant research programs in family health care and evidence of collaboration, which is essential for the development of this science. These papers show compelling evidence that the area of family health care research is expanding. They represent different paradigms, values, contexts and practices. The studies included here also show a progression from family context studies to those with a more complex systemic perspective as well as a focus on families across the life span. In the future it is our hope that studies in family health care research will continue to expand to include families in later life transitions. There will continue to be a need to focus on family health in long-term chronic illness and increasingly in end of life care. It is our hope that in presenting these papers we were able to show how each paper contributed in its own unique way to the growing development of knowledge in Family Health Care.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.