In their recent text on Family Theory Development in

Nursing, Whall and Fawcett (1991) presented an historical overview of nursing literature related to family.

They concluded that “interest in the family as a unit of

nursing care originated with Nightingale’s concern for

family members. Continued interest in the family is documented in books and journal articles since Nightingale’s

time as well as in the American Nurses’s Association

standards of practice” (pp.24-25). For example, as early

as 1917 Beard wrote about the implications for public

health nursing of considering the family as the primary

unit of intervention, and in 1937 Bean and Brockett reported the results of an investigation aimed at documenting the extent to which public health nurses had expanded

their practice to include the entire family. Since 1950,

Whall and Fawcett (1991) noted a dramatic increase in

the quantity and scope of nursing literature related to

families. Not only do clinical texts continue to include

sections on family systems, theories, and roles, but textbooks dealing entirely with family content began to appear in the mid 1970’s. Increasingly, such texts have

reflected a combined focus on family theory, practice,

and research (Gilliss, Highley, Roberts, & Martinson,

1989; Sherwen, 1987).

The amount of research of families has been

sufficient to generate major reviews both in nursing and

other disciplines which have categorized the substantive content of this research and identified areas which

have received considerable attention as well as notable

gaps in the literature (Feetham, 1984; Gilliss, 1989;

Litman, 1974; Schwenk & Hughes, 1983). A large body

of research exists which addresses how families and their

individual members respond to a variety of illness and

health care situations. Depending on the investigator’s

theoretical and methodological convictions, the research

may be framed as a study of family impact, coping, adjustment, adaptation or management. Nurse researchers

have focussed considerable attention on family roles and

the transition to parenthood. Gilliss (1989), in a recent

review of family research in nursing, found that over

half of the studies reviewed dealt with perinatal events.

According to Murphy (1986) other areas of substantive

focus include family interface with societal institutions

including the health care system, public policy and the

family, and cross cultural family research. Complementing these substantive investigations has been a growing

body of theoretical and methodological work which addresses issues pertinent to conceptualizing the family as

a unit of study and intervention (Feetham, 1991; Gilliss,

1983; Leahey & Wright, 1987).

In spite of the tremendous body of family research, relatively few studies have been undertaken on

the interface between the family and the health care system. Gilliss (1989) identified only 5 out of 76 articles

which focussed on the family - practitioner interface.

Whall and Fawcett (1991) concluded that there was inFamily Outcomes: Family-Practitioner Interface

Kathleen A. Knafl
sufficient research in this area to include it in their recent anthology of nursing perspectives on the family.

Similarly, a major review of the literature on help seeking and receiving behavior noted a relative scarcity of

literature on the practitioner-patient relationship

(Whitcher-Alagna, 1983).

Although, the family - practitioner interface has

not been a primary focus for family researchers in nursing or other disciplines, there is modest body of research

directed toward describing the relationships that develop

between health care providers, families, and family members and identifying variables and themes associated with

these relationships. In addition, there are several theoretical models which depict the level and nature of family -

practitioner relationships. The intent of this discussion

is to provide an overview of this literature as a basis for

conceptualizing and designing nursing-focussed patient

outcomes research.

PATIENT-PRACTITIONER RELATIONSHIPS

Varying conceptualizations of patient-practitioner relationships set the stage for subsequent investigations of

the family-practitioner interactions and nursing practice

and family outcomes. In an early theoretical work, Szasz

and Hollender (1952) described three models of the doctor-patient relationship: activity-passivity, guidance-cooperation, and mutual participation. They maintained that

these models have implications for how illness, treatment, and therapeutic outcome are defined and how decisions are made in each of the three arenas. For example, in the activity-passivity model, the physician

alone defines the quality of the therapeutic outcome;

while in the guidance-cooperation and mutual participation models both the physician and the patient contribute to the evaluation of outcome.

Over 30 years later, Whitcher-Alagna (1983)

continued to identify the nature and quality of the patient-provider relationship as a key determinant of the

patient’s medical outcome. Based on an extensive literature review, Whitcher-Alagna developed what she

termed an “integrative model of reactions to medical

aid”. As shown here, specific aspects of the relationship

which either directly or indirectly influence outcome

include: patient’s desired role, patient’s preferences for

information, empathy, and control over decision making, practitioner’s characteristics, extent to which the

desired patient role is fulfilled, and the magnitude of

preferences for the desired patient role.

As reflected in Whitcher-Alagna’s review, numerous empirically based studies have addressed the

types, dimensions, and importance of the patient-provider relationship. For example, Lorber (1975) distinguished between good, average, and problem patients.

Good patients were characterized as passive, cooperative, and undemanding; problem patients resented being cast in a passive role and were viewed as complaining and disruptive. Similarly, Rosenthal, Marshall,

MacPherson, and French (1980) described problem patients as unpleasant, controlling, non compliant, complaining, violent, manipulative, and demanding.

A recent nursing study by Waterworth and

Luker (1990) described “toeing the line” as the role assumed and preferred by the 12 hospitalized medical patients in their study. “Toeing the line” included strict

adherence to rules and was grounded in the patients’

trust in the expertise and competence of the staff. The

authors concluded that the promotion of individualized

nursing care may not be synonomous with active patient involvement as much of the literature suggests.

Hayes-Bautista (1976) studied 200 urban, Hispanic patients’ perceptions of doctor-patient interactions

and identified convincing, countering, and bargaining

tactics used by patients who were attempting to alter a

prescribed treatment as well as counter-management tactics used by physicians to ensure compliance with the

regimen. The outcomes of patients’ attempts to influ-
ence decision making were classified in terms of both

the patient’s and practitioner’s satisfaction with the negotiated treatment regimen.

Using a simulated clinical situation involving

84 undergraduate nursing students as subjects, Krouse

and Roberts (1989) compared three different patientprovider interactive styles which varied with regard to

the patient’s role in decision making. They found that

“subjects who participate in an actively negotiated process of decision making with the nurse practitioner expressed significantly stronger feelings of control over

their treatment decisions” (p. 723).

Although focussing on individual patient-practitioner relationships, this literature highlights salient

components of those relationships which also are likely

to be relevant to understanding the family-practitioner

interface. In particular, the patient’s and the

practitioner’s preference for an active or passive role

influences both the nature of the relationship and the

participants’ satisfaction with it. Specific aspects of patient-practitioner relationships and interactions which

often vary on an activity-passivity dimension include

information seeking and exchange, decision making role,

the extent to which trust is an important aspect of the

relationship, and the subjective quality of the human

interaction. In general, authors of empirically based studies have discussed outcomes of varying types of relationships and roles in terms of either satisfaction with

the interaction or compliance with the medical regimen.

FAMILY MEMBERS AND HEALTH CARE PROVIDERS

Most research on the family-practitioner interface has

focussed on the roles that individual family members

assume in health care settings. Like patients, family

members’ roles have been described, categorized and

evaluated. For example, based a participant observation

study of a community hospital in Canada, Rosenthal, et

al (1980) described three such roles, visitor, worker, and

patient, into which nurses cast family members when a

relative is hospitalized. They noted that by casting family members into these roles, the nurse “transforms the

relative into someone who becomes part of the work

context and therefore more controllable by nurses” (p.

101). This is especially true for the worker role where

the family member becomes part of the health care team

and the patient role where the family member becomes

a legitimate focus of intervention.

The so called “worker” role has been the focus

of attention for several authors who investigated family

members’ preferred participation in the care of a relative during hospitalization (Algren, 1986; Deatrick, Stull,

Dixon, Puczynski, & Jackson, 1986; Knafl & Dixon,

1984; Knafl, Cavallari, & Dixon, 1988). These studies

revealed a wide range of preferences, with some relatives wanting extensive involvement in care activities

and others favoring a much more limited role.

Taking a somewhat different focus, Barbarin

and Chesler (1984) explored seven general dimensions

of parent-practitioner relationships: information transmission, communication, parental efficacy, conflict resolution, empathy with child, personal contact with staff,

and assessment of staff competence. Based on interviews with 74 parents of children with cancer they found

that “the quality of parents’ personal contact with doctors, that is, the sympathy, warmth, concern, and attention shown to parents as individuals, was most highly

related to their general satisfaction with the medical

staff” (p. 310). Conversely, anger with the staff was

most highly related to staff’s lack of empathy with the

patient.

In a community based study, Darling (1979;

1988) investigated the development of what she termed

an entrepreneurial role in parents of children with handicaps. Based on a sample of 25 families, she described

how parents became advocates “promoting their child’s
cause as a result of repeated negative interactions with

medical, educational, and social agencies” (1979, p.

225). Behaviors encompassed by the entrepreneurial

role included seeking information, seeking control, and

challenging authority in order to obtain necessary services.

Other authors described how family memberpractitioner relationships evolved over time. Combining data from two qualitative studies of family response

to chronic illness, Thorne and Robinson (1988a; 1988b;

1989), described three stages in the evolution of the relationship between chronically ill patients, family members and health care providers. They described these

stages, which they named naive trust, disenchantment,

and guarded alliance in the following way:

The stage theory proposes that the naive trust

with which the chronically ill and their families enter

health care relationships is inevitably shattered in the

face of unmet expectations and conflicting perspectives

between themselves and their professional health care

providers. This shattering of trust precipitates a stage

of extreme anxiety, frustration, confusion, and profound

distrust. Eventually, in the resolution stage, an alternative form of trust is reconstructed on a more guarded

basis. (1989, p. 154)

The authors suggested that sharing their proposed model

with clients may facilitate the development of satisfying relationships.

Wuest and Stern (1991) conducted unstructured

interviews with members of 10 families and described a

four stage process through which families learned to

manage a child’s persistent middle ear problems. Their

stages of acquiescing, helpless floundering, becoming

and expert, and managing effectively were related to the

child’s response to the disease process, the amount of

disruption to family life, and the family’s relationship

with health care professionals. These authors described

how families moved from trust to disillusionment to

knowlegeable empowerment in their interactions with

health care providers. Family members were particularly

frustrated by providers’ insensitivity to the disruptiveness of the illness on family life. In contrast to Thorne

and Robinson (1988a; 1988b; 1989), who focussed on

the eventual development of a satisfying working relationship between family members and providers, Wuerst

and Stern (1991) emphasized the desirability of empowering families vis a vis the health care system and the

role of nurses in promoting such empowerment.

All the research discussed in this section addressed the relationship between practitioners and individual family members. Similar to the previously discussed work on patient-practitioner interaction, these

studies focused on the importance of the activity-passivity aspect of the relationship and variations in trust,

decision making agency, and information exchange.

Although focussing on family roles, these studies did

not address the link between practitioners and the family as a unit of either interaction or intervention. To date,

work on the family-practitioner interface has entailed

primarily theoretical discussions of the range of possible

involvements.

CONCEPTUALIZING THE FAMILY-PRACTITIONER INTERFACE

Leahey and Wright (1987) have made important contributions to the development of family nursing, which they

conceptualized as occurring on three levels. First level

family nursing considers the patient in the context of

the family. At this level, the nurse’s interventions are

determined primarily by the patient’s needs; the family’s

needs are viewed as secondary. In contrast, the nurse

engaged in level two family nursing deliberately spends

time directly with one or more family members and plans

and implements nursing care with the family in mind.

This often is what we think of when we hear the terms

family centered or family focussed nursing care. The
third level of family nursing practice is family care in

which the nurse’s assessments and interventions are directed toward the family as a unit and include direct face

to face interaction with every family member.

 Another explicit attempt to conceptualize ways

in which providers interact with families is provided by

Doherty and Campbell (1988). They distinguished five

distinct levels of interaction with families: (a) minimal

emphasis on family, (b) ongoing medical information

and advice, (c) feelings and support, (d) systematic assessment and planned intervention, and (e) family

therapy. Doherty and Campbell (1988) discussed how

these levels differed in terms of the knowledge base,

degree of personal development, and skills needed for

effective interaction. For example, at level two, ongoing medical information and advice, the knowledge base

is primarily medical and personal development involves

an openess to engage patients and families in a collaborative way; at level four, systematic assessment and

planned intervention, the knowledge base is family systems and personal development involves awareness of

one’s own participation in a variety of systems.

Both Leahy and Wright’s and Doherty and

Campbell’s frameworks distinguished interventions directed to individual family members from those directed

to the family unit as a whole. Their developers pointed

out that each framework was meant to provide a range

of possibilities and was not a prescription for action.

These authors assumed that the appropriate level of interaction varied across situations and families.

Taking a somewhat different approach, Craft

and Willadsen (in press) surveyed nurses with expertise

in family to identify and validate interventions nurses

use with families. Using the Delphi method, they identified numerous intervention activities which they

grouped under the following headings: (a) family support, (b) family process maintenance, (c) family integrity promotion, (d) family involvement, (e) family mobilization, (f) caregiver support, (g) family therapy, (h)

sibling support, and (i) parent education. As indicated

by the preceding categories, the interventions they identified included those directed to the family unit as well

as those directed to individual family members. Their

work is ongoing and predicated on the assumption that

family interventions are an independent nursing function and “nursing cannot wait for the much needed family theory development . . . but must begin specifying

and testing interventions related to family” (p. 3).

CONCLUSION

Examining the effectiveness of nursing practice with

regard to family outcomes presents researchers in this

area with a plethora of substantive, methodological, and

conceptual challenges. Fundamental questions of who,

what, and how to research the family/practitioner interface have yet to be articulated let alone be translated

into “tight” experimental designs. Basic issues regarding what constitutes a family intervention or a family

outcome have yet to be resolved. To say the least, there

are no “classical” intervention studies to provide a model

for future research. It is a field for those with a pioneering spirit, a tenacious mindset, and a high tolerance for

ambiguity! As noted in this brief overview, the relevant

literature includes two parallel and largely unconnected

bodies of work, empirical studies of interactions between

family members and providers and theoretical models

of levels of practitioner involvement with the family unit.

Although not providing a definitive map for guiding

further research, this literature has been useful in identifying promising lines of inquiry. In order to stimulate

further development of research in this area, Dr. Feetham

and I have drawn on the existing literature to develop a

working model of the family-practitioner interface. As

shown here, the model includes characteristics of the

family, family members, the health/illness states of family members, the practitioners involved in providing care,
and the health care system. These multiple, interacting

characteristics shape health care interventions, which

vary in terms of their level and timing. For example,

family member’s and provider’s role preferences in terms

of decision making will influence the eventual intervention. Interventions result in both affective and behavioral reactions which are likely to be interdependent and

which give rise to different practitioner, family member, and family unit outcomes.

This model is meant as a heuristic device to foster our

identification and discussion of the conceptual and methodological issues associated with studying nursing interventions and family outcomes.

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