565174 research-article2014

CNRXXX10.1177/1054773814565174Clinical Nursing ResearchDorell et al.


Experiences With Family Health Conversations at Residential Homes for Older People

Clinical Nursing Research 1­–23 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773814565174 cnr.sagepub.com

Åsa Dorell, RN, DN, MSc1, Britt Bäckström, RNT, MSc, PhD2, Marie Ericsson, RN, MSc2, Maria Johansson, RN, MSc2, Ulrika Östlund, RN, OCN, MSc, PhD3, and Karin Sundin, RNT, MSc, PhD1

Abstract The aim of this study was to highlight family members’ experiences of participating in Family Health Conversation (FamHC), based on families in which a family member was living in a residential home for older people. A total of 10 families and 22 family members participated in evaluating family interviews 1 month after participating in FamHC. The interviews were analyzed by qualitative content analysis. The main finding was being a part of FamHC increased family members’ insights, understanding, and communication within the family. Getting confirmation from nurses was essential to cope with the new life situation, which also meant that they felt comfortable to partly hand over the responsibility for the older person who moved to the residential home. By being open and expressing their feelings,


University, Örnsköldsvik, Sweden Sweden University, Sundsvall, Sweden 3Karolinska Institutet, Stockholm, Sweden 2Mid

Corresponding Author: Åsa Dorell, Department of Nursing, Umeå University, Box 843, S-891 18 Örnsköldsvik, Sweden. Email: [email protected]

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Clinical Nursing Research 

a bad conscience could be relieved. These findings showed that FamHC could be helpful for family members in adapting to this novel situation. Keywords family health conversations, family nursing intervention, family support, family systems nursing, residential home for older people

Introduction Getting older and in need of care may require a move to some form of assisted living, which generally triggers significant and potentially traumatic life changes. Indeed, studies show that when older people move to assisted living, older people’s emotions range from relief at obtaining help, to sorrow over the loss of identity and the life they previously lived (Anderberg & Berglund, 2010). Generally, a family member (e.g., spouse, child) is responsible to seek a form of assisted living for the loved one’s situation such as a residential home for older adults (Dellasega & Nolan, 1997), and there is often little opportunity to discuss the impending emotional impact (Davies & Nolan, 2003). Caron and Bowers (2003) explain that when the burden of caring increases, families struggle with the decision of whether to place an older family member in a residential home. The transition to a residential home might be hard to accept, both for the older person and for family members (Davies & Nolan, 2003). Some family members felt that the move to the residential homes alleviated some of the pressure on them to provide daily care (Davies & Nolan, 2004). Family members reported improvement in quality of life when an older family member moved into a residential home; however, studies have also shown that decisions regarding relocation to a residential home may be associated with feelings of failure, guilt, depression (Liken, 2001; Lundh, Sandberg, & Nolan, 2000; Sury, Burns, & Brodaty, 2013), frustration, feelings of betrayal, and powerlessness (Lundh et al., 2000). When moving, the relationship between family members and health care professionals has sometimes been shown to be superficial and strained. Hertzberg and Ekman (2000) find that family members were reluctant to point out problems to health care professionals; they worried about retaliation against the resident if they were to share their concerns with the nurses in the residential homes. In their study, Häggström, Kihlgren, Kihlgren, and Sörlie (2007) describe similar findings that family members did not dare disturb nurses with questions. Family members may have even had a sense of

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powerlessness when they felt they did not have control over their loved one’s situation, when they were uncertain about their ability to participate in and influence health and social care (Davies & Nolan, 2004; Kellett, 2007). In addition, according to Hertzberg, Ekman, and Axelsson (2001), family members do not usually give up their involvement in the life of their older significant other when that person moves to a residential home. Functioning communication between family members and nurses may be the key to a good relationship and involvement of family members in residents’ situations. Wright and Leahey (2009) emphasize that changes in one family member, such as disease and illness, may affect all members of a family in terms of family functioning, beliefs, and meaning. Therefore, it may be important to pay attention to the situation of the family as a unit, rather than focusing solely on the patient and the disease (Åstedt-Kurki, Paavilainen, Tammentie, & Paunonen-Ilmonen, 2001). When residential care nurses used a family-system nursing approach and realized the importance of involving the family in care, the relationship between families and nurses was shown to be improved (O’Shea, Weather, & McCarthy, 2014). Family-system nursing is an approach focusing simultaneously on both the individual family member and the family, where the family is seen as a unit, making the interactions important (Wright & Leahey, 2009). In Sweden, a family-system nursing intervention with nurseled family health conversations (FamHC) has been developed to strengthen the health of the family, to help families create new meanings and opportunities, and to alleviate suffering in relation to a health problem (Benzein, Hagberg, & Saveman, 2008). The FamHC is grounded in the Calgary Family Assessment Model (CFAM), the Calgary Family Intervention Model (CFIM; Wright & Leahey, 2009), and the Illness Beliefs Model (IBM; Wright & Bell, 2009), and it has been further developed for Swedish conditions. The FamHC is based on several theoretical assumptions, adopting a systemic, cybernetic approach in which each family member’s view is acknowledged as equally valid. Other theoretical assumptions involve the interplay and relationship between family members’ beliefs and experiences. A further standpoint is that narratives are closely intertwined with reflection and have a great impact on the family’s healing process. FamHC is based on core components as a framework for conducting the intervention. These core components are based on the theoretical assumptions of the FamHC (see Table 1; Östlund, Bäckström, Lindh, Sundin, & Saveman, 2014). FamHC has previously shown to improve family health (Benzein, Olin, & Persson, 2014; Östlund, Bäckström, Saveman, Lindh, & Sundin, 2014; Persson & Benzein, 2014; Sundin et al., 2015), but how FamHC may influence this health process and support families within a residential home is an unexplored area.

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Table 1.  Core Components of the FamHC. Core component Jointly reflecting with the family on expectations of the conversation series

Exploring the family structure

Ensuring all family members are given space within the conversations and have the opportunity to narrate their experiences Jointly prioritizing which problem(s) most need to be discussed

Exploring significant parts of the family narratives

Using reflective questions

Content and purpose The nurses invite the families to jointly reflect 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. In the first 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 To give the family members opportunity to share and listen to each other’s stories, all family members are invited, one at a time, to narrate their stories and to focus on their problem(s). Through narratives, family member can find new alternatives or meanings and detect new associations. 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 family about what is most in need of being discussed. The nurse 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 member’s narratives and also support a more reflective story. During the conversations, reflective thinking is emphasized. Circular questions, to define relations between and searching for information about differences between, for example, people, family relations, events and beliefs, initiate reflections and are intended to allow the nurses to help family members put into words their internal conversations and become aware of their own beliefs. (continued)

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Dorell et al. Table 1.  (continued) Core component Using appropriately unusual questions and challenging family beliefs

Giving commendations and acknowledging suffering

Inviting family members to reflect on each other’s narratives Offering nurses’ reflections

Asking what has happened since the last conversation

Closing the conversation series

Content and purpose Appropriate unusual questions, intended to depart just enough, but not too much, from 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. When nurses practice 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 be acknowledge. Nurses invite family members to reflect 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. The nurses also offer their reflections to the families. At the end of each conversation, the nurses invite the family to listen to a more comprehensive reflection, giving the family members a respite from conversation and time to listen. Within the reflections, nurses may acknowledge suffering, give commendation, and challenge constraining beliefs. After the nurses’ reflection, the families are invited to reflect on the nurses’ thoughts. During the second and third conversations, the nurses ask what has happened in the family since last conversation. This is not only to learn more about the family’s situation but also to help the family identify changes that have taken place or been reflected on. At the end of the third conversation, the nurses summarize 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 reflections on topics and issues that have emerged in the conversations and their thoughts about the future—that is, a “closing letter”—are sent to the family.

Source. Table 1 Core components of the family health conversation, Östlund et al. (2014).

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Clinical Nursing Research 

Purpose The aim of this study was to highlight family members’ experiences of participating in FamHC, based on families in which a family member was living in a residential home for older people.

Method Design A qualitative design (Patton, 2002) was chosen to highlight family members’ experiences 1 month post-intervention of participants in FamHC, using qualitative content analysis, where both the manifest and latent message of the text were sought (Elo & Kyngäs, 2008).

Setting and Participants Families of residents staying in three residential homes for older persons in a municipality in the north of Sweden were approached to participate in FamHC. The heads of the residential homes for older persons, together with the participating registered nurses (RNs), selected 4 families at each unit (12 families in total) deemed to have a need for FamHC to participate in the intervention. None of the residents were included in the FamHC because of the residents’ conditions or illnesses. In this evaluative study, 2 families who participated in the FamHC declined to participate in the follow-up interviews due to illness and lack of time, respectively. Thus, a total of 10 families comprising 22 family members were included in this study. The participating family members were between 39 and 84 years old, and the related residents were between 74 and 89 years old (see Table 2). Exclusion criteria were families that did not speak and read Swedish.

Intervention Before the intervention was initiated, three RNs from three residential homes for older persons in Northern Sweden underwent special education and training in FamHC. The members of the research group designed, carried out the education on FamHC, and administered the training program to the RNs. The proposed learning outcomes were skill development and knowledge of how to conduct and plan the FamHC series. The education was similar to regular university education in FamHC (cf. Lindh et al., 2013). The course comprised 1 week of theory learning—RNs were introduced to theories forming

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Dorell et al. Table 2.  Demographics of the Participating Families. Sex, age, and diagnosis of the older family member

Year moved to the residential home for older persons

Male, 87, dementia, Chronic obstructive pulmonary disease Male, 81, dementia




Male, 76, dementia, heart disease Male, 84, dementia


2011 2012


Female, 81, stroke Male, 84, Transient ischemic attack, heart disease Male, 76, stroke

Daughter Daughter Wife Daughter Wife Daughter Son Daughter Wife Daughter


Male, 80, stroke



Male, 89, stroke



Male, 82, dementia


Family A B C D




Family members’ relation

Wife Son Wife Daughter Daughter Wife Daughter Daughter Daughter Daughter Daughter

the basis of family-system nursing with content, systems theory, communication theory, and reflection theory. The RNs then had 3 more weeks to study the literature. Subsequently, they were assigned 3-day follow-up with practice and role-playing for skill development. Narratives, reflections, and a salutogenic approach were in focus (Benzein et al., 2008; Östlund, Bäckström, Lind et al., 2014). The resident and the remaining family members were seen as one unit with the purpose of identifying and realizing the family’s internal and external resources and striving to identify and strengthen the healthy instead of focusing on what was sick and did not function (Antonovsky, 1987). Reflection was seen as a prerequisite in

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moving toward health and wellness. Reflections were facilitated through narrative and listening to other family members’ narratives. Through the narratives, family members were able to share each other’s perspectives. As a result of narrating, one tries to understand what has happened, and that can assist in finding new alternatives and meanings; it is not a story intended to describe an event precisely. Listening to each other’s stories can give an idea of how the other family members experience reality, and thus allow for a better understanding (Ricœur, 1994). Reflection thus becomes a tool for developing new insights and understanding of one’s own and others’ perspectives (Andersen, 1995). The relationships within the FamHC were non-hierarchical relationships, and the RNs and family members, together in partnership, aimed to create new solutions (Meiers & Tomlinson, 2003). A series of three FamHCs with each family was conducted at the residential homes. All the family members of each family unit attended all three FamHC sessions. The three trained RNs and three nurses from the research group conducted the conversations in pairs. One RN had primary responsibility for leading the conversation, whereas one other RN observed and reflected on the content in the conversations. Even if there was flexibility in their role assignments, it was always the same two RNs who conducted the conversations throughout the three FamHC sessions. Each conversation lasted about 60 min, and the delay between the three conversations with each family was about 2 weeks. The three conversations were intended to focus on what was important for the family to talk about. The three conversations had different focuses. All family members were invited to tell their story and encourage to listen to each other’s stories. During the first conversation, the purpose and expectations of the FamHC were clarified, and all family members were offered the chance to say how they felt about their personal and family situations. The second conversation focused on suffering, problems, and beliefs identified in the first conversation. The third conversation focused on the future, family strengths, and resources, and it summarized the process they had undergone during the series of conversations. The aim was to find the family’s strengths in problem solving and communication, where even the social networks and resources were identified. Conversations 2 and 3 also expanded on family members’ experiences and reflections from previous conversations and the time in between. About 2 weeks after the third conversation, a closing letter was sent to all participating family members. In the letter, the RNs provided written reflections over the three conversations, and the RNs acknowledged the family’s suffering, the family members’ strengths and resources, and further put the focus on the future (Bell, Moules, & Wright, 2009). Writing the closing letters was collaboration between the two RNs who conducted each conversation.

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Ethics Written and verbal information concerning the study aim, voluntary participation, and confidentiality were given to the participants. Permission to conduct the study was given by the head of administration, the heads of the units and the participating nurses. Consent to carry out and record the interview was sought from the families before they were included. The families and nurses were assured that all information would be kept confidential in accordance with research ethics. The University’s Research Ethical Review Board approved the study.

Data Collection Data were collected using semi-structured family group interviews (Eggenberger & Nelms, 2007; Polit & Beck, 2012), with each family 1 month post participating in FamHC. However, in two families only one family member participated, and consequently, individual face-to-face interviews were used. The interviewer was an RN who had not been involved in the current FamHC series. A semi-structured interview guide ensured that questions relevant to the aim were asked (Creswell, 2009). The family members were initially asked about their experiences with the three FamHC as well as the closing letter that followed. They were asked to describe whether the conversations had affected them and their family and if there was anything—and if so, what—in the conversations that surprised them. Clarifying questions were asked when necessary to illuminate their experiences, such as who, when, and what do you mean? (Polit & Beck, 2012). The interviews were conducted in a conversation room in each residential home for older persons. Each interview lasted about 45 to 60 min and was digitally taped and transcribed verbatim with pauses, silence, and expressed emotions noted in the transcription.

Data Analysis The audiotaped follow-up interviews with the families formed the unit of analysis, transcribed verbatim, and analyzed using qualitative content analysis (Elo & Kyngäs, 2008). The analysis was an interpretative process of coding and categorizing the data in which the whole context was taken into consideration (Patton, 2002). The analysis was performed in several steps. First, all interviews were read through several times to gain a sense of the content (Sandelowski, 1995). Then, the whole text was read again and sorted into two domains that were found in the data: “Experiences of the FamHC”

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and “Responses of the FamHC” (Patton, 2002). The next step was to reread and divide the text into meaning units, words that contained elements that were related to each other through their content (Graneheim & Lundman, 2004) in accordance with the aims of the study. The meaning units were then carefully condensed into everyday language, retaining the original essence, and they were then abstracted and labeled with a code. The codes, which were related to each other, were finally sorted step-wise into 14 subcategories and 4 main categories related by content, constituting an expression of the content of the text. In an attempt to identify underlying meanings, there was a continuous process of moving back and forth, constantly comparing parts of the data and the whole (Elo & Kyngäs, 2008). The analysis was an ongoing process in which all the authors reflected together on the domains, codes, subcategories, and categories until agreement was reached. For examples of the analysis process (see Table 3).

Results The results describe family members’ experiences after participating in the nurse-led FamHC under the two domains: “Experiences of the FamHC” and “Responses of the FamHC.” (see Table 4).

Experiences of the FamHC This domain includes two categories: “Positive sharing in the FamHC” and “Experiences related to the frame of the FamHC,” as well as eight subcategories. Positive sharing in the FamHC Being confirmed. The FamHC gave the family members validation of being good enough and commended them for their dedication and faithfulness to their relatives. Family members experienced confirmation that they also had to think about themselves to feel good. By obtaining confirmation within the families, it created an understanding for the whole family as a unit when they realized that everyone in the family is important. Through nurse-led conversations, family members experienced that it was valuable to be listened to, to be seen, and to get recognition for their commitment to the relative. Furthermore, by obtaining confirmation from the RNs, the family members also expressed that they felt alleviated from bad consciences. The family members additionally felt confirmed when the RNs showed interest in them and their situations, and that the conversations would be about them and not just the resident. They also expressed that it was positive to be seen and

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Dorell et al. Table 3.  Examples of the Analysis Process. Family

Meaning units




Domain: Experiences of the FamHC It was nice to Being It was  D And I thought it confirmed be listened experienced Daughter was positive . . . to and get positively You are not recognition that accustomed for their someone that someone commitment listened to listening to you the story and what you and got think and what credit for you have felt for what they sad things and had done. we’ve got credit for what we do. Usually everything You [are] not is taken for used to that. granted. You’re just used to everything being taken for granted. Domain: Responses of the FamHC Regarding Put a damper The bad  J Mm . . . to some own conscience on the bad Daughter extent to put a needs has reduced conscience, damper on your and they are which is a bad conscience more open training and that inevitably about what might be a comes back to they think little more you, even if it and feel. open to is a training, I what you think. Uh, and think and then I might be a feel. little more open to what I think and feel.

Category Positive sharing in the FamHC

Increased insight

acknowledged as an adult son or daughter. As the adult child is generally not invited to participate in support groups for families, it felt nice to converse and be listened to. Most of all that one has received validation from someone that you are good enough, for who you are. I think that has been the most important for me. (Daughter, Family E)

Putting feelings into words.  Family members described that they were able to express what they felt in the conversations and that they could put feelings into

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Table 4.  Domains, Categories, and Subcategories. Domains


Experiences of the family health conversations (FamHC)

Responses of the family health conversations (FamHC)

Positive sharing in the FamHC

Experiences related to the frame of FamHC Increased insight

Increased communication

Subcategories Being confirmed Putting feelings into words Receiving support and encouragement Opportunity for reflection Time frame and context Possibility to influence Favorable climate for conversation Confirmation via a closing letter Gaining new perspectives Regarding own needs Enhanced understanding within the family Enhanced communication within the family Enhanced communication with the staff

words, which was liberating. Experiences included being relieved and appreciating the opportunity to release their feelings and tears. Family members expressed that it was important to be able to verbalize how they felt without it being seen as complaining, or without someone making them feel bad about it. However, some family members said that it was positive, but it was also sad and exposing and a bit strenuous to put feelings into words. Family members expressed that they would have liked to have shared their emotions early on in the progression, prior to the move to the residential home for older persons. It was seen as not just useful for their sakes, but also for the sake of being able to take better care of the older relative. There were lots of feelings. Lots of old stuff came up. You feel that there is a lot left to work through, pertaining to this trip with mum and everything around it. So, I was quite exhausted after the first conversation, I was, but it was positive. (Daughter, Family E)

Receiving support and encouragement.  During the conversations, the family members expressed that the RNs were empathic, encouraging, and supportive. Family members felt that they were understood in reference to the problems the family was experiencing. Furthermore, it was a positive experience to have FamHC and receive guidance and support from someone outside the family. In addition, the family members explained that expressing their feelings was experienced as supportive because the RNs could see the distressing situation from a different view and help the family members to be aware of their beliefs.

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Dorell et al. I think you stand pretty alone when they get admitted, when your family member get[s] admitted to a residential home for older persons. You think that you are the only one, [who] has felt this way. That you need, you need support from the outside. (Son, Family G)

Opportunity for reflection. Family members experienced that space for reflection was created in the conversations. They expressed that to have conversations where all family members could participate was essential and valuable. It felt worthwhile to be given the opportunity for reflection together with the family. Family members experienced that, in the opportunity for reflection, the important aspects of the conversation could be brought to light and could be processed. By bandying ideas in a different way you can see things in a different light. (Daughter, Family F)

Experiences related to the frame of the FamHC Time frame and context.  The family members experienced that three conversations were sufficient, that the time frame of 45 to 60 min was adequate, and that the spacing of about 2 weeks between the conversations was satisfactory. However, some family members expressed the opinion that the conversations could have been shorter. The family members’ experiences were that the conversations were well-structured, which enabled them to keep to the subject and not digress from what was hard to talk about. They also expressed that it was positive that the RNs from the residential home had been involved in the conversations. When it comes to things that are hard to talk about, one can easily go off on a tangent, so it was good that someone brought you back to order, so to speak. (Daughter, Family J)

Possibility to influence.  Family members experienced that the FamHC were flexible and that they were free to talk about what was on their mind. They expressed that time was given to discuss what was important to the family. Family members highlighted that no one forced them to answer and that they could influence the content of the conversations, and they explained that the content was formed as the discussion progressed. We did it together; it came very naturally. (Daughter, Family F)

Favorable climate for conversation.  The families described it as being easy to talk, and they were allowed to talk without being interrupted. They did not

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Clinical Nursing Research 

feel pressured and could be themselves. Family members expressed that the RNs’ perceptiveness and understanding enabled a good and facilitating atmosphere during the conversations. It was experienced as a giving and taking. The family members expressed surprise over the RNs’ ability to read between the lines during the conversations; they could understand what the family members meant even though they had not said it out loud. You were allowed to open up if you wanted to. Yes, one never felt pressured, just that one could be oneself. (Daughter, Family F)

Confirmation via closing letter. Receiving the closing letter was a positive experience and a form of recognition, and it was consistent with reality for the family members. Experiences were of appreciation and affirmation, which gave strength. The picture of the family in the letter made them happy, touched, and proud. The closing letter offered a description of how others see the family. Furthermore, the closing letter works as a reminder for the family members if they perceive the old feeling—for example of not being sufficient; that is, their bad consciences. The family members used the closing letter as confirmation of what the RNs understood and reflected on during the conversations, which helped them think differently. Family members also experienced that the closing letter gave them a sense of sadness when they were reminded of what the family had been put through in connection with family members’ illness and transition to the residential home for older persons. The letter could be seen as a gift that family members want to preserve for future reflection. Amazingly well written, and I was quite touched, in the way when I read it. And I thought . . . have we been through that much? Yes, I will keep it and I will, I am sure, look at it from time to time. (Daughter, Family F)

Responses of the FamHC This domain included two categories “Increased insight” and “Increased communication” and six subcategories. Increased insight Gaining new perspectives. The FamHC opened up new thoughts as the situation could be seen from different perspectives. It also rendered strength and courage for equitable communication within the family. Both the closing letter and the reflection that ended each conversation could be perceived as both challenging and good by the family members, as new

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insights could be found. Family members had enlightening experiences when they were given the time to stop and reflect together with the RNs. The family members’ beliefs were challenged, which led to the formation of new beliefs in the families. Furthermore, family members expressed that the FamHC gave them the opportunity to find the tools to handle and to think about the future. You get new tools to work with pretty much, new thoughts and sort of to do this or that. (Daughter, Family E)

Regarding own needs.  The FamHC also gave insight into the importance of talking about individual feelings and remembering to think more of their own needs. The stress was reduced by letting go of the pressure and the demands on themselves and accepting that “what you do is enough.” Furthermore, the FamHC helped them differentiate between the demands they put on themselves, the demands from the relative, and the demands from the nurses in the residential home. When family members gained insight into the importance of thinking about their own needs, the FamHC gave them the opportunity to develop tools for how to handle and how to think about their feelings of insufficiency and guilt; that is, so they could release their bad consciences. The reflective parts of the FamHC created insight into individual well-being and needs. I have less of [a] bad conscience now . . . I learnt then to somehow make the time, I can`t go around with a bad conscience all the time because neither my dad nor I feel better for it so I just have to stop feeling bad. (Daughter, Family C)

Enhanced understanding within the family.  Family members described that they shared experiences with each other in a different way and saw each other’s problems from a different perspective than before the FamHC, which felt comforting and increased their understanding of each other. Talking about daily burdens and clarifying personal thoughts, where both laughter and tears were shared, enhanced understanding within the family. It gave them strength to discover that they were struggling with the same concerns and problems. This was experienced as liberating and creating a sense of solidarity. Furthermore, the FamHC created shared responsibilities within the family and decreased the demands on each other. The feeling changed from being just “me” to now having a feeling of “we,” and a feeling of enhanced acceptance of the new life situation was gained.

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Clinical Nursing Research 

You think much more “we,” before it was just me. Yes much more solidarity. That is good because then you have each other. (Daughter, Family D)

Increased communication Enhanced communication within the family.  Family members appreciated that the opportunity for conversation was given to the whole family, opening up the dialogue between all members of the family. They experienced that, after the FamHC, it is positive to be able to express their opinions and thoughts that they were unable to communicate to each other before. Now the conversations within the family were experienced as liberating, and family members feel comfortable expressing their wills and to verbalize the unspoken. It is sort of understood that if you need, if you need help you say so. I might not have said that in so many words, but it has been understood; now it sort of got said. (Daughter 2, Family I)

Enhanced communication with the staff. Family members experienced that the FamHC had given them courage, opened up the possibility for better cooperation, and encouraged more explicit communication with the RNs at the residential home. The enhanced communication led to experiences of trustfulness. After participating in FamHC, the conversations between family members and the RNs had more of a dialogue quality rather than, as previously, merely serving to solve practical problems concerning the older relatives and providing information to family members. We feel that there [is] more openness towards the staff and that gives us a sense of confidence. (Daughter 1, Family B)

Discussion The findings from our intervention study provide insight into the family members’ experiences of participating in FamHC. The main findings in our study are that family members render increased insight and communication within the family and with the RNs after participating in the FamHC, as the conversations made room for understanding each other better. After participating in the FamHC, the family members also experienced relief of their bad consciences and feelings of not being sufficient; they moved from feeling that they did not do enough for their relatives to seeing that they were doing the best they could. To be invited and have the chance to sit down together and to tell their stories about how they perceived having a relative at a residential home for older persons was highly valued by the families, and being

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able to listen to each other’s stories was much appreciated in our study. It was a surprise for the family members; they expressed it as positive that the FamHC was about them and the whole family as a unit and that the RNs were interested in their narratives. Family members expressed that it was the first time that several family members were invited to converse together with RNs about the changed life situation of having a family member moved in to a residential home. Adult children also described the experiences as positive because they had been focused on, whereas previous conversations with the RNs had mostly targeted only a spouse and not adult children. Family members were able to interact when meeting with the RNs during the conversation, and a relationship developed in partnership in which each family member felt affirmed. A strengthened relationship was created not only between the families and the RNs, but also within the family. This is in line with the findings of other studies (Leahey & Harper-Jaques, 1996) in which the relationship and collaboration between RNs and families are in focus as well as the relationships within the family. As the FamHC allowed every family member to listen to other family members’ stories and to narrate and share their own experiences, the family members expressed that they got a chance to put feelings into words and verbalize their thoughts. This created room for understanding each other and enhanced communication between family members. They could express their needs and expectations in a new way, which was experienced as valuable. This is in line with Ricœur’s (1994) thoughts about the importance of narratives; by narrating, you reflect, and by reflecting you become aware of your beliefs. They experienced that silence can be purposeful and may offer room for necessary internal dialogue for families and RNs, and it was useful because it provided room for new thoughts and ideas to grow (cf. Benzein et al., 2008). This mediates an understanding that having a relative living at a residential home is a common responsibility for the entire family. According to Wright and Bell (2009), it is through internal reflection that we may become aware of new beliefs, which can create an opportunity for change. Family members in our study explained that when they spoke about their feelings and, even further, had an internal dialogue, it made space for reflection and, thus, opportunity to challenge existing beliefs, which led to the creation of new beliefs and gave the family member a feeling of relief. Family members in our study described that it was also positive to receive a closing letter confirming the view of the families that the RN had perceived during the conversations. The closing letter was described as valuable for the families, because if the family members needed courage in some trying situation, taking out the letter and reading it gave strength to them. It has also been shown in other studies that a closing letter is a way to acknowledge and

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affirm suffering (Bell et al., 2009; Benzein et al., 2008; Benzein & Saveman, 2008; Moules, 2009). The closing letter, however, also aroused not only ambivalent feelings, as feelings of happiness and pride were aroused, but also a sense of sadness when they thought back on what they have been through. The family members experienced that the framework and content of FamHC functioned well for them. To get support from someone outside the family was experienced as positive and helped families manage their situation. Family members observed that the RNs added structure to the conversations and also made sure that all family members had time to narrate, so every family member was able to tell his or her story. Furthermore, family members apprehended the RNs as supportive, empathetic, and encouraging. Family members described amazement that the RNs were able to read between the lines during conversations. It was valuable that the RNs from the residential home for older persons were the ones who conducted the conversations; it made it possible to get to know each other better. The family members described that communication with the RNs was enhanced after the FamHC was completed. As Gavaghan and Carroll (2002) state, RNs can be a key resource for the family based on their holistic approach in nursing with the ability to protect all family members’ opinions and resources (Leahey & Harper-Jaques, 1996). That is in line with our study. In the present study, family members expressed that after participating in the FamHC, the feeling of a bad conscience had been relieved. The family members had previously found themselves failing in their duties when not visiting the family member living at the residential home for older persons as often as they should, according to themselves. They laid a heavy responsibility on themselves. They revealed themselves as not being “good enough,” without the ability to do what they felt they should. Their bad consciences had previously tormented them. Sørlie, Kihlgren, and Kihlgren (2005) say that our conscience is enabled when a decision needs to be made on how to deal with a particular situation. That is in line with our results that show family members had a lot of emotions prior to the move to the residential home for the older people, which made them feel guilty. The FamHC helped family members to differentiate between the demands they put on themselves and the demands from their relatives. Furthermore, they described it as liberating to drop individual demands and accept that they do enough; that is, they are doing the best they can. That is in line with Løgstrup (1997), who states when people meet, both spoken and unspoken demands arise. But he also says that it is the individual person placed under the unspoken demands who decides how to approach the demands. The family members explained their bad consciences originated in feelings of having abandoned their relatives when they were no longer able to take care of them. This can be understood through Løgstrup’s

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(1997) theory about us metaphorically “having something of the other’s life in our hands.” By that he means that in every encounter we experience the ethical demand not to betray but to protect others, and our consciences make us aware that if we do something in an improper way, we feel guilt, which results in a bad conscience. In our study, family members felt guilt when they could no longer protect and take care of their relatives, which made family members feel like they betrayed their relatives. The ethical demand that Løgstrup (1997) describes comes from within and only arises when one close human being is dependent on the other. The other’s life is to be dealt with in words and actions that are factual and sensible. According to this, family members experienced that by participating in FamHC and talking about the bad conscience, accepting the insight of being human, and doing the best they could, the feelings of guilt subsided. They felt like a burden was lifted off their shoulders.

Methodological Considerations The methods of data collection and analysis can be assumed to be relevant, as the aim was to illuminate experiences of the families participating in the FamHC. To strengthen trustworthiness of the study, the person performing the interviews with the families had not participated in conversations with the families, thus increasing the credibility of the data collection. The sample was 12 families with a total of 22 family members, which can be assumed as a sufficient number, and the interviews were rich in content. There was a predominance of women participating as family members in the FamHC, and most patients were male. All authors discussed every step in the analysis process of the interviews until consensus about the findings was achieved, and the trustworthiness was strengthened by all authors. The findings were also reflected in relation to the interview text to ensure nothing had been missed. None of the family members living at the residential home for older persons participated in our study because of their condition or illness. This may have influenced the results by providing the other family members to the opportunity speak without having to take the relatives into account. It is possible that the family members were able to be more honest in their responses. Krippendorff (2004) says that a text never contains only one single meaning. Our interpretation of these results is only one of many interpretations, but our intent is that the findings in the study can be transferred into similar contexts.

Application The results of this study show that FamHC could be relevant for families when a family member moves into or is staying in a residential home for older

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persons. The family conversations with the nurses gave confirmation and opened up opportunities to verbalize thoughts and feelings and to help family members see their own and others’ needs, which made room for an increased understanding within the family. The FamHC provided families with the realization that they were not alone and had the capability to share the burden. Being confirmed by the nurses was essential to coping with the new situation in life. Thus, being released from the bad conscience by participating in FamHC was something that was a big relief for family members. Cooperation between nurses and family members may be essential in the future, both in residential homes for older persons as well as in hospitals (Weman & Fagerberg, 2006) and in home health care. Therefore, it may be essential to encourage a change in approach from patient-related care to one in which the family is viewed as the unit of care and is treated as a collaborating partner. Acknowledgment The researchers are grateful to the families who participated in the study.

Author Contributions K.S., U.Ö., and Å.D. made the study design and the interviews; all authors have contributed to the data interpretation, and ÅD did the manuscript in preparation. The manuscript has been approved by all authors.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References Anderberg, P., & Berglund, A. (2010). Elderly persons’ experiences of striving to receive care on their own terms in nursing homes. International Journal of Nursing Practice, 16, 64-68. doi:10.1111/j.1440-172X.2009.01808.x Andersen, T. (1995). Reflecting processes: Acts of forming and informing, .pp. 11-37. In S. Friedman (Ed.), The reflecting team in action. New York, NY: Guilford. Antonovsky, A. (1987). Unraveling the mystery of health: How people manage stress and stay well (1st ed.). New York, NY: Jossey-Bass. Åstedt-Kurki, P., Paavilainen, E., Tammentie, T., & Paunonen-Ilmonen, M. (2001). Interaction between adult patients’ family members and nursing staff on a hospital ward. Scandinavian Journal of Caring Sciences, 15, 142-150.

Downloaded from cnr.sagepub.com at The University of Auckland Library on June 5, 2016


Dorell et al.

Bell, J. M., Moules, N. J., & Wright, L. M. (2009). Therapeutic letters and the family nursing unit: A legacy of advanced nursing practice. Journal of Family Nursing, 15, 6-30. doi:10.1177/1074840709331865 Benzein, E., Hagberg, M., & Saveman, B. I. (2008). “Being appropriately unusual”: A challenge for nurses in health-promoting conversations with families. Nursing Inquiry, 15, 106-115. Benzein, E., Olin, C., & Persson, C. (2014). “You put it all together”—Families’ evaluation of participating in Family Health Conversations. Scandinavian Journal of Caring Sciences. Advance online publication. doi:10.1111/scs.12141 Benzein, E., & Saveman, B. I. (2008). Health-promoting conversations about hope and suffering with couples in palliative care. International Journal of Palliative Nursing, 14, 439-445. Caron, C. D., & Bowers, B. J. (2003). Deciding whether to continue, share, or relinquish caregiving: Caregiver views. Qualitative Health Research, 13, 1252-1271. Creswell, J. (2009). Research design: Qualitative, quantitative, and mixed methods approaches. Thousand Oaks, CA: SAGE. Davies, S., & Nolan, M. (2003). Relatives’ experiences of decisions about care-home entry. Ageing & Society, 23, 429-450. Davies, S., & Nolan, M. (2004). “Making the move”: Relatives’ experiences of the transition to a care home. Health and Social Care in the Community, 12, 517-526. Dellasega, C., & Nolan, M. (1997). Admission to care: Facilitating role transition amongst family carers. Journal of Clinical Nursing, 6, 443-451. doi:10.1111/j.1365-2702.1997.tb00341.x Eggenberger, S. K., & Nelms, T. P. (2007). Family interviews as a method for family research. Journal of Advanced Nursing, 58, 282-292. Elo, S., & Kyngäs, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62, 107-115. doi:10.1111/j.1365-2648.2007.04569.x Gavaghan, S. R., & Carroll, D. L. (2002). Families of critically ill patients and the effect of nursing interventions. Dimensions of Critical Care Nursing, 21, 64-71. Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24, 105-112. Häggström, E., Kihlgren, A., Kihlgren, M., & Sörlie, V. (2007). Relatives’ struggle for an improved and more just care for older people in community care. Journal of Clinical Nursing, 16, 1749-1757. doi:10.1111/j.1365-2702.2007.01704.x Hertzberg, A., & Ekman, S. L. (2000). “We, not them and us?” Views on the relationships and interactions between staff and relatives of older people permanently living in nursing homes. Journal of Advanced Nursing, 31, 614-622. Hertzberg, A., Ekman, S. L., & Axelsson, K. (2001). Staff activities and behaviour are the source of many feelings: Relatives’ interactions and relationships with staff in nursing homes. Journal of Clinical Nursing, 10, 380-388. Kellett, U. (2007). Seizing possibilities for positive family caregiving in nursing homes. Journal of Clinical Nursing, 16, 1479-1487. doi:10.1111/j.13652702.2006.01844.x

Downloaded from cnr.sagepub.com at The University of Auckland Library on June 5, 2016


Clinical Nursing Research 

Krippendorff, K. (2004). Content analysis: An introduction to its methodology. Thousand Oaks, CA: SAGE. Leahey, M., & Harper-Jaques, S. (1996). Family-nurse relationships: Core assumptions and clinical implications. Journal of Family Nursing, 2, 133-151. Liken, M. A. (2001). Caregivers in crisis: Moving a relative with Alzheimer’s to assisted living. Clinical Nursing Research, 10, 52-68. Lindh, V., Persson, C., Saveman, B.-I., Englund, C., Idberger, C., & Östlund, U. (2013). An initiative to teach family systems nursing using online health-promoting conversations: A multi-methods evaluation. Journal of Nursing Education and Practice, 3(2), 54-66. Løgstrup, K. (1997). The ethical demand. Notre Dame, IN: University of Notre Dame Press. Lundh, U., Sandberg, J., & Nolan, M. (2000). “I don’t have any other choice”: Spouses’ experiences of placing a partner in a care home for older people in Sweden. Journal of Advanced Nursing, 32, 1178-1186. Meiers, S. J., & Tomlinson, P. S. (2003). Family-nurse co-construction of meaning: A central phenomenon of family caring. Scandinavian Journal of Caring Sciences, 17, 193-201. Moules, N. J. (2009). Therapeutic letters in nursing: Examining the character and influence of the written word in clinical work with families experiencing illness. Journal of Family Nursing, 15, 31-49. O’Shea, F., Weather, E., & McCarthy, G. (2014). Family care experiences in nursing home facilities. Nursing Older People, 26(2), 26-31. Östlund, U., Bäckström, B., Lindh, V., Sundin, K., & Saveman, B.-I. (2014). Nurses’ fidelity to theory-based core components when implementing Family Health Conversations—A qualitative inquiry. Scandinavian Journal of Caring Sciences. Advance online publication. doi:10.1111/scs.12178 Östlund, U., Bäckström, B., Saveman, B.-I., Lindh, V., & Sundin, K. (in press). Participating in a family systems nursing intervention: Family Health Conversation—Experiences from families suffering stroke. Journal of Family Nursing, 20. Accepted 140826. Patton, M. Q. (2002). Qualitative research & evaluation methods. London, England: SAGE. Persson, C., & Benzein, E. (2014). Family health conversations: How do they support health? Nursing Research and Practice. Advanced online publication. doi:10.1155/2014/547160. Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice (9th ed.). Philadelphia, PA: Wolters Kluwer Health. Ricœur, P. (1994). Oneself as another. Chicago, IL: University of Chicago Press. Sandelowski, M. (1995). Focus on qualitative methods. Qualitative analysis: What it is and how to begin. Research in Nursing & Health, 18, 371-375. Sørlie, V., Kihlgren, A., & Kihlgren, M. (2005). Meeting ethical challenges in acute nursing care as narrated by registered nurses. Nursing Ethics, 12, 133-142. doi:10.1191/0969733005ne770oa

Downloaded from cnr.sagepub.com at The University of Auckland Library on June 5, 2016


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Sundin, K., Pusa, S., Brännström, E., Wincent, N., Östlund, U., Bäckström, B., . . . Saveman, B. I. (in press). What couples chooses to focus during nurse-led family health conversations when suffering stroke. International Journal for Human Caring, 19 . Sury, L., Burns, K., & Brodaty, H. (2013). Moving in: Adjustment of people living with dementia going into a nursing home and their families. International Psychogeriatrics, 25, 867-876. doi:10.1017/S1041610213000057 Weman, K., & Fagerberg, I. (2006). Registered nurses working together with family members of older people. Journal of Clinical Nursing, 15, 281-289. doi:10.1111/ j.1365-2702.2006.01308.x Wright, L. M., & Bell, J. M. (2009). Beliefs and illness: A model for healing. Calgary, Alberta, Canada: 4th Floor Press. Wright, L. M., & Leahey, M. (2009). Nurses and families: A guide to family assessment and intervention (5th ed.). Philadelphia, PA: F.A. Davis.

Author Biographies Åsa Dorell, RN, DN, MSc, is a doctoral student at the Department of Nursing, Umeå University, Örnsköldsvik, Sweden. Britt Bäckström, RNT, MSc, PhD, is a senior lecturer at the Faculty of Human Sciences, Mid Sweden University, Sundsvall, Sweden. Marie Ericsson, RN, MSc, is a university lecturer at the Faculty of Human Sciences, Mid Sweden University, Sundsvall, Sweden. Maria Johansson, RN, MSc, is a university lecturer at the Faculty of Human Sciences, Mid Sweden University, Sundsvall, Sweden. Ulrika Östlund, RN, OCN, MSc, PhD, is a senior lecturer at the Department of Neurobiology, Care Sciences and Society, Stockholm, Sweden. Karin Sundin, RNT, MSc, PhD, is an Associate Professor at the Department of Nursing, Umeå University, Örnsköldsvik, Sweden.

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Experiences With Family Health Conversations at Residential Homes for Older People.

The aim of this study was to highlight family members' experiences of participating in Family Health Conversation (FamHC), based on families in which ...
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