Abstract

With the complexity of the health-care system and the

increasing attention to cost effectiveness and efficacy

of care, it is imperative that we can define nursing care

and outcomes for one of our major constituencies—families. However, in order to accomplish this, we must

build on limited empirical knowledge and research expertise in outcomes research, research on families, and

research on practitioner/family interventions. An even

more critical problem is that while there is very little

work in each of these areas individually, there is virtually no research that combines practitioner/family interventions and family outcomes.

This paper describes what is known, identifies the conceptual and methodological gaps, and describes what

can be done to use the limited knowledge we have concerning research of families, family outcomes, and practitioner/family interventions. Operational definitions for

family outcomes and family interventions are proposed,

and the conceptual and methodological challenges of

the definitions reviewed. To frame the issues, some premises of research of families such as the family realm

perspective and the criteria for research of families are

presented.

Interventions with family members and families are complex and multifactorial. This complexity, coupled with

the complexity of health-care delivery, makes it imperative that the interventions to be studied are very focused

and linked conceptually and in time to the outcomes

measures. The work of Feetham (1984; 1991), Gilliss

(1991) and Doherty (1986) can be used to develop models that address the complexity of the family realm perspective and to study practitioner/family interventions.

When examining outcomes in research of families, the

investigator must be able to show the relationship between the nursing action or intervention and the outcome. Longitudinal research that observes the process

of the intervention and the family outcome should increase our knowledge and research expertise in this complex arena.

To continue to develop this important area of research,

it is critical that we continue to build from the existing

research in outcomes, families, and the practitioner/family intervention. At the same time it is important to recognize that much of the previous research of families

did not derive from the family realm perspective and

may have used deficit rather than resource models. In

spite of these limitations, the clinical and research literature provides usable findings and directions. Important conceptual and methodological considerations in

research of the practitioner/family interventions and family outcomes are: To expand the context of the interventions tested to schools, health-care systems, and social

systems; to examine the relationships between the biological and behavioral responses of family members and

families to health and illness; and to address the effects

Family Outcomes: Conceptual And Methodological Issues

Suzanne Bellinger Feetham, PhD, RN, FAAN
of the advances in biomedical technology on family functions and structure (Edward, 1991). These recommendations for future research reinforce the need for interdisciplinary teams that include clinicians, family scientists, and biological scientists.

Some of the major conceptual and methodological approaches to developing practitioner interventions for

research of family outcomes are the need to:

• Build on the clinical and research literature of

family responses to health and illness

• Determine indicators of family outcomes

• Identify interventions from clinical practice using qualitative and triangulation research

• Begin with the more developed area of family

related research to define nursing interventions

and outcomes

• Use meta analysis to contribute to operational

definitions of family outcomes and family interventions

• Use practice models such as those of Doherty

and Gilliss in defining measurable interventions

• Determine measures of the efficacy and effectiveness of the intervention

• Determine measures of short-term and longterm outcomes

• Conduct the research within the family realm

perspectives

• Use comparative samples and longitudinal

methodologies

There is ground work across the three research areas of

family, practitioner interface and outcomes. It is expected that future research will identify the predictors

of family outcomes and interventions to guide nursing

practice and improve family outcomes in health and illness. If practitioners could reliably identify high- and

low-risk families, resources could be directed to reinforcing the strengths of the low-risk families and providing additional resources for the high-risk families.

Statement of the Problem

With the complexity of the health-care system and the

increasing attention to cost effectiveness and efficacy

of care it is imperative that we can define our nursing

practice and outcomes for one of our major constituencies—families. However, in order to accomplish this,

we must build on limited empirical knowledge and research expertise in outcomes research, research of families, and research on practitioner/family interventions.

An even more critical problem is that while there is very

little work in each of these areas individually, there is

virtually no research that combines practitioner/family

interventions and family outcomes. The purpose of this

paper is to describe what is known, identify the conceptual and methodological issues and describe what can

be done to use the limited knowledge we have concerning research of families, family outcomes, and practitioner/family interventions. To frame these issues some

premises of research of families are presented and directions for future research are proposed.

Premises: Research of Families

The work of Burr and colleagues(1988) suggest that a

reason for the lack of movement in family theory and

research is that the family has been viewed and studied

as other social institutions such as governments and educational and health-care systems. These theorists delineate several differences that distinguish families from

other institutions and propose that these differences serve

as a family realm perspective. The perspective presented
by these theorists clarifies the uniqueness of family and

highlights some of the conceptual and methodological

issues in the research of families.

• Families are different because they have:

• Generational relationships and familial memories

• Unique sets of rules, standards, ethics, priorities and processes

• Different nature of aspirations, feelings, temporal orientations, achievements, and interacting.

• Are affected by cultural patterns

These perspectives of research of families are also clarified by Feetham (1984; 1991) who proposed criteria for

research of families. These criteria have been revised

to clarify criteria common to all research of families and

to make a clear distinction between family research and

family-related research (Feetham, 1991). The criteria

common to family and family-related research are as

follows:

• There is a conceptual/theoretical framework for

the research consistent with family theory

• There is a conceptualization of the family

• The definition of family, and the design, instrumentation, analysis, and interpretation are consistent with the conceptualization

• The research adds to the knowledge of family

functioning and family structure

• In a practice discipline, the research is relevant

to practice.

The specific criterion for family research is that the

conceptualization, measurement, analysis, and interpretation is of the family as a unit/or system resulting in

knowledge of the family system. In family-related research the research examines the responses of individual

family members and/or examines constructs related to

families or family members. While family or familyrelated research are of equal importance, the interpretation of this differentiation is affected by the investigators conceptualization of the family as the context of

care or of the family as the client. Research building

from the conceptualization of the family as the context

can meet the criteria for either family or family related

research.

The terms “family member(s)” and “families” will both

be used throughout this paper to continue to reinforce

the distinction between family and family-related research,

It is important to note that while excellent research is

being conducted that adds to our knowledge of roles

and functions occurring in families, such as parenting

relationships and/or marital relationships, many of these

studies are not conducted using a family framework and

therefore, are not family or family-related research. The

critical criterion is that the research adds to our knowledge of family functioning and structure.

Practitioner/Family Interventions

Conceptualization of family interventions

A critical dimension in outcome research is the definition and measurement of the intervention affecting the

outcome. Interventions with family members and families are complex and multifactorial. This complexity

coupled with the complexity of health-care delivery

makes it imperative that the interventions to be studied

must be very focused and linked conceptually and in

time to the outcomes measured. The work of Feetham

(1984; 1991), Gilliss (1990), Doherty and colleagues

(Doherty and Baird,1986; Doherty & Campbell, 1988),

Leahy and Wright (1984), and Knafl (1991) can be used
to develop models that address the complexity of the

family realm perspective and to study practitioner/family interventions. When examining outcomes in research

of families, the investigator must be able to show the

relationship between the nursing action or intervention

and the outcomes. Both qualitative research and longitudinal research that documents the process of the intervention and the family outcome should increase our

knowledge and research expertise in this complex arena

(Deatrick & Knafl, 1988).

Definition: Practitioner/family intervention

The family/practitioner intervention can be defined as

the direct activities by the practitioner to affect family function and/or structure through work with individual family members and/or the family system.

The intervention can result in a short-term or a longterm effect.

Intervention research conducted with the expectation of

measuring family outcomes may be facilitated by the

use of frameworks that provide some direction for identifying measurable ranges/scopes of practice. Doherty

(1985; Doherty and Baird, 1986; Doherty & McCubbin,

1985) has described five levels of interventions with

families or family members. These levels of interventions are:

1. Having minimal emphasis on family

2. Providing ongoing health information and advice in a family context

3. Addressing feelings and providing support

within the family context

4. Conducting systematic family assessment and

planned family focused interventions and

5. Conducting family therapy

A related three level nursing model is proposed by Leahy

and Wright (1987) These models can provide direction

for operationalizing the intervention to assure a direct

link between the intervention and an outcome measure,

such as family interaction patterns. For example, an intervention may be directed to families of adolescents

newly diagnosed with diabetes. The intervention may

assist the adolescents to assume responsibility for their

injections while assisting other family members with

interaction patterns to adjust their roles to encouraging

rather than controlling the adolescent. Application of

the models can also address the critical issue of the timing of the practitioner/family intervention to ensure that

the family outcome measured is affected by the intervention.

The level of professional development of the practitioner can be an intervening variable in the design and

implementation of family interventions. While the five

levels of Doherty and colleagues (1986) describe the

types of interventions they also indicate a level of skill

or expertise required for the practitioner to conduct the

intervention. This issue of developmental level or expertise must be addressed in the conceptualization, design and conduct of intervention studies. The Doherty

framework can be useful to define clearly the type of

intervention and may give direction to who (what level

of practitioner) should be trained to conduct the intervention for the research.

The measurement of the practitioner intervention with

the family is also influenced by the conceptualization of

the practitioner in relation to the family member(s) and/

or the family system. The practitioner can be conceptualized as a mediator between the family and the larger

environment such as the health-care system, a context

for the family (in this case an intervening variable), and/

or the etiology or factor affecting the family outcomes

(Feetham, 1984; 1991).
Another contribution to the delineation of nursing interventions related to families is the work by Craft and

Willadsen (In press). In their survey of 130 nurse experts nine categories or labels of interventions, their definitions, and their critical and supporting activities were

indentified. In this study the distinction is made between

interventions directed toward the family as a unit, interventions directed toward the family as context, and interventions directed toward both the family as a unit and

the family as the context. Both clinical and empirical

validation of this work is required.

Approaches to methodological considerations

As stated, determining measurable, well-defined interventions is extremely difficult (Feetham, Lunney, Weiss,

1991; Webster-Stratton, 1991). To reduce some of the

ambiguity of the intervention, investigators can build

from the clinical and research literature. Possible interventions for research of families have been implied or

specifically recommended in the clinical literature, review articles of research of health and illness, and reports of research of family member and family responses

to health and illness (Doherty & Campbell, 1988;

Feetham, 1984; Kazak & Nachman, 1991; Patterson,

1990; Skipper & Leonard, 1968; Woods, Yates, &

Primono, 1989).

For example, from the clinical literature, Leske (1991)

recommends several family interventions to be tested in

critical care ICUs. These include the effectiveness of

multidisciplinary team conferences for families; culturally sensitive family interventions of information exchange; the systematic study of selected mechanisms

used by nurses to “support” families while the family

member is in the ICU; and contracted or planned visitation for families with a family member in the ICU.

Another approach to bridging the knowledge gap across

family outcome and family intervention research is for

investigators to start with our strongest knowledge base

and most developed research expertise. The state of the

science, conceptually and methodologically, is more

advanced in family related-research. Therefore, a logical step may be to begin with family-related research

when examining interventions, family outcomes, and the

practitioner/family interface.

Family Outcomes

The critical questions for nursing practice are: What are

family outcomes? Can they be defined and can they be

measured? To answer these questions, some of the reasons why we have limited knowledge on family outcomes are reviewed and directions for research are discussed.

Conceptualization of family outcomes

The definition of family outcomes affects both the

conceptualization and measurement in research of families. Research in nursing and other disciplines has not

yet resulted in a clear or consistent definition of family

outcomes. Although a large body of literature reports

the responses of families and family members to health

and illness, these responses have not been examined

within the context of family or family member outcomes.

For conceptual consistency with theory development and

research of families, the definition of family outcomes

could be “the changes or stabilization in family functioning as an endpoint of nursing practice, or the

abilities/functions of the family (at the family system

or family member level) as an endpoint of nursing

practice.

The inclusion of stabilization within this definition could

be challenged by persons from a family systems perspective as the family system is perceived as being in
constant realignment and change. An understanding of

how families change has lagged behind our knowledge

of individual development and change. In family outcomes research, while the measure of change is important, we also have to determine conceptually when no

measurable change, “stabilization”, in family functioning may be a positive outcome. This is in contrast to

our usual interpretation of no apparent change as a negative outcome. Once conceptual definition(s) of family

outcomes are determined, there is the need to define

operationally the indicators or measures of family functions that are outcomes for research and practice.

Kazak and Nachman (1991) reminds us that, in contrast

to psychology where models for normal development

and behavior exist, there are few standards of family

normalcy and therefore few indicators of positive family outcomes. The definition or determination of family

outcomes has some similarity to the issues in the measurement of health. Hunt and his colleagues state that

health, like attitudes or motivation, cannot be measured

directly, and that there are several steps in the process

of measurement including the use of a number of health

indicators. In research of families, there is also the need

for indirect measures of family outcomes and for several indicators of effective family functioning (Hunt,

Lord, Thom, 1986).

Our study designs have contributed to this lack of knowledge of indicators of family development and change

(outcomes). First, the majority of studies have been

cross-sectional. Second, there have been few comparative studies. A third reason is that our research has tended

to use deficit models rather than to examine the strengths

and resources of the family and family members. This

focus has resulted in few indicators of positive family

outcomes. It is this author’s perception that with the

evolution of research by nurse investigators in family,

there have been more models measuring strengths and

resources of families and family members. For example,

McCubbin has proposed a health resources model as a

reframing of research using the double ABCX cumulative stress model of adjustment and adaptation

(McCubbin & Huang, 1989) With this paradigm shift

from deficit models, it is expected that indicators and

predictors for successful family outcomes will be identified.

The conceptualization and design of our research needs

to address the expected duration of the family outcomes.

For some acute-care situations, a short-term outcome

may be desired, such as the family’s ability to negotiate

visiting with the family member in the ICU. In other

clinical situations, the goal may be an ongoing or longterm change in family functioning or in the family structure.

Advances in health care and technology are changing

the course of health and illness and as a result are influencing research in family outcomes and family interventions. Illnesses and their treatments change, both

within the course of illness and over time. Diseases once

considered terminal are now designated as chronic. The

pattern of responses of both the practitioner and the family may change as a result both of the longevity of the

condition as well as of the changing prognosis of the

family member. For example, a longitudinal study of

children with cancer and their families revealed that,

during the first year, the family responds to the diagnosis and initial treatment; after two years the child is most

probably in remission; and by six years the child will

likely be a long-term survivor (Camaroff & Maquire,

1981). While this improvement in the course of the disease is positive, there are implications for both defining

family outcomes and determining the duration of the

outcomes for the conduct of intervention research of

families.
Methodological approaches to measuring family

outcomes

To advance the research of families related to family

interventions and family outcomes, it is important that

we build on the previous work of family and familyrelated research.

As the research issues related to family outcomes are

analyzed, two questions emerge from the large number

of studies of the responses of individual family members and the family to health and illness. The first question is: Can the reports of family responses to health

and illness in family members and families be interpreted

as family outcomes? The second is: How do these family responses apply to practitioner/family interventions?

While researchers can build from this work, it is important to recognize that three criteria for research of families are not met in most of this research. Therefore, there

are limitations in the application of the previous findings to research of family outcomes. First, most of this

work did not use a family conceptual/theoretical framework. Second, the outcomes measured, in most instances, were outcomes of individuals and were not family related. Third, there was little if any attempt to link

the outcomes to a specific nursing intervention. Gilliss

(1991) identifies the work by Thorne and Robinson

(Robinson & Thorne, 1984; Thorne & Robinson, 1988a;

1988b; 1989) as one of the best examples of family phenomena delineation and the examination of the processes

used by families in establishing relationships with health

professionals. This program of research contributes to

our understanding of family outcomes in response to the

professional interface. The data provide some directions

for determining possible interventions that could support families as they establish communication with health

professionals. While this previous research of family

responses has limitations, such as small, nonrepresentative samples, meta analysis of this previous work may

provide sufficient information to confirm the patterns

of responses. From this analysis, clear indicators of family outcomes can be determined.

Over the last 10 years, reliable and valid measures of

family functioning have been developed and can be interpreted as indicators of family outcomes (Roberts &

Feetham, 1982: McCubbin, McCubbin, Patterson et.al,

1983; Thomas & Barnard, 1986; Forman & Hagen,

1983). However, what is still lacking is that investigators do not match the instrument to the conceptualization

of the study, source, level of data and level of analysis

(Feetham, 1991; Ranson, Fisher, Phillips, Kokes, &

Weiss, 1990; Moriority, 1990; Uphold & Strickland,

1989). It should also be noted that the norms for family

instruments tend to be based on ethnically and

sociodemographically limited samples. Kazak(1989)

reported that in a study of college students, families with

young children, grandmothers and therapists, perceptions

of family normalcy often did not correspond to norms

and varied developmentally and ethnically (Kazak,

McCannell, Adkins, Himmelberg & Grace, 1989).

Future directions

It is important that we continue to build from the existing research in outcomes, families, and the practitioner/

family intervention. At the same time it is important to

recognize that much of the previous research of families did not derive from the family realm perspective

and may have used deficit rather than resource models.

In spite of these limitations the clinical and research literature provides important findings and directions.

That family members scores differ by gender is a consistent finding in most quantitative measures of familyrelated variables collected from more than one family

member (Kazak, Snitzer & Jamas 1988). Traditionally

this difference has been labeled measurement error.
Family scientists are now indicating that this is a simplistic interpretation of differences (Brooks, 1991;

Schumm, Barner, Bollman, Jurich, Milliken 1985).

Methods have been developed to differentiate measurement error from the variance of individual family members and the shared variance of the family (Fisher, Terry

& Ransom, 1990; Larson & Olson, 1990; Ransom,

Fisher, Phillips, Kokes, & Weiss, 1990; Schumm,

Barnes, Bollman, Jurich, Milliken, 1985). In the future,

family scientists need to work collaboratively with scholars in gender theory to develop conceptual frameworks

and to design and conduct studies that account for rather

than negate the gender differences of family members

(Feetham, 1991).

The context of the intervention is another important conceptual and methodological consideration. Not only is

there little research on the family system, but also there

is even more limited examination of the family within

other systems. Prospective studies are needed to examine the family member(s) or family within the context

of the school system, health-care system, community

and/or social systems. These studies require both interdisciplinary and interinstitutional research.

Another future direction is the identification of predictors of family outcomes. This is particularly critical in

light of our diminishing personnel and economic resources for the care of families. If practitioners could

reliably identify high- and low-risk families, resources

could be directed to reinforcing the strengths of the lowrisk families and the provision of additional resources

for the high-risk families.

Another area where research by nurses can make specific contributions to research of families and practitioner/family interventions is in examining the

biobehavioral interface among the responses of family

members and families to health and illness. This area is

not well developed in the family sciences. For this and

other research of families there is a need for interdisciplinary teams that include clinicians, family scientists,

and biological scientists.

Advances in biomedical technology are having a significant effect on families as technology-dependent family members are cared for in the home, and the availability of new technologies challenge the structure and

functions of families (Edwards, 1991). In the case of

families with technology-dependent family members,

prospective, longitudinal research is needed from implementation of the technology through discharge and longterm care to determine the predictors of family outcomes

and appropriate interventions for family members and

families.

Summary

In summary, some of the major conceptual and methodological approaches to developing practitioner interventions for research of family outcomes are the need to:

• Develop and conduct the research within the

family realm perspective

• Build on the clinical and research literature of

family responses to health and illness

• Use existing practice models such as those of

Doherty and Gilliss in defining measurable interventions

• Begin with the more developed family-related

research to theoretically define nursing interventions

• Use meta analysis to contribute to the operational definitions of family outcomes and family interventions

• Identify interventions from clinical practice using qualitative and triangulation research
• Determine measures of the efficacy and effectiveness of the intervention

 Determine indicators of family outcomes

 Determine measures of short-term and longterm outcomes

 Use comparative samples and longitudinal

methodologies

 Conduct culturally sensitive, multisite studies

While there are conceptual and methodological issues

unique to research of families there are many issues common to outcomes research as evident throughout this

volume. It is expected that future research will identify

predictors of outcomes, and interventions to guide nursing practice and improve family outcomes in health and

illness.

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