Friedman Family Assessment Model: Evaluating Family Dynamics & Health

Family-Centered Care: Utilizing the Calgary Family Assessment Model for Comprehensive Interviews and Improved Health Outcomes

Introduction, The purpose of the family assessment interview is to gain information from clients about the psychosocial, developmental, and physical health histories of everyone in the family unit. During these interviews, healthcare providers and families collaborate to form a plan of care that focuses on both medical necessity and the health priorities of the family. The implementation of this decision-making partnership—which is often referred to as patient-centered or family-centered care—allows healthcare providers to tailor their interventions and education to the specific needs, strengths, and values of their clients.

This approach ultimately results in improved healthcare delivery, patient empowerment, improved self-management, and better health outcomes for patients (Kuo et al., 2012).

The Calgary Family Assessment Model (CFAM) has been recognized as one of the world’s leading family assessment models by such organizations as the International Council of Nurses and the Journal of Family Nursing (Wright & Leahey, 2012, p. 51). The CFAM has a comprehensive structure made up of three foci—structural, developmental, and functional assessments. The CFAM is easily customized for families of diverse structures. It was this model that was used as an outline for the following family assessment interview. The rationale for Referral L.H., who identified herself as a 34-year-old Caucasian female, was met at the office of her private psychiatrist. She reported making the office visit in regard to her chronic depression and acute anxiety exacerbation. She was concerned that these issues were beginning to affect her performance at work and her ability to care for her two sons—B.H., who is five years old, and T.H., who is three years old.

Friedman Family Assessment: Insights into L.H.'s Family Relationships and Developmental Concerns

She complained that she and her partner are currently under increased stress, which has impaired their communication and put a strain on the relationship. Pertinent History L.H. is in a heterosexual marriage with her husband of five years, S.H., who is one year her senior and also Caucasian. She met her husband at work in 2010, where they were both working as bachelor-prepared registered nurses on a medical-surgical step-down unit. They started dating shortly after meeting each other. They were married three years later but did not cohabitate until after the wedding. She stated that she and her husband were both surprised to find out that she was three months pregnant with her first son shortly after returning from their honeymoon. L.H. and S.H. were both born and raised in the greater St. Louis area. They now live with their two sons in a two-story home and own two mid-level cars via financing.

Their middle-class neighborhood is located in a highly-ranked school district. L.H. reported that the family feels safe in their home, and there is a very low crime rate in the area. Both parents in this family work full-time jobs, which brings in enough money to cover their bills and basic needs, with some money left over each month for small luxuries. L.H. also puts a small amount of money into college funds that she set up for both of the boys. B.H. and T.H. are on track with their peers in physical and intellectual development. B.H. loves going to school and participating in cub scouts. However, his kindergarten teacher reports that he is hyperactive and has difficulty staying on task at school. L.H. and S.H. agreed that they would continue to monitor the situation, and if his academic growth begins to suffer or his behavior becomes disruptive, they will have him evaluated by a doctor. T.H. is currently attending preschool part-time. He was previously being followed by the Parents as Teachers organization after the family noticed that his language development was delayed.

Friedman Family Assessment: Health Triumphs and Trials in L.H.'s Family

Around his second birthday, he was only saying a handful of words and making gestures, but his pediatrician couldn’t find any physical abnormalities, and testing did not show evidence of cognitive limitations. The representative from Parents as Teachers became a great comfort to L.H., especially as his verbal skills improved. T.H. is now scoring in the above-average range for children his age on standardized language tests and in vocabulary acquisition and comprehension. Family Strengths & Problems Healthcare Strengths. Despite his current high-stress level and having depression and alcoholism run in his family, S.H. is healthy and has never been diagnosed with a chronic health problem. B.H. is healthy, with some hyperactivity that is not currently causing him problems. T.H. is also healthy, except for suffering from mild seasonal allergies. Despite her current distress, L.H. has a psychiatrist that she trusts, and she is working with him to manage her symptoms and improve her overall mental health. Problems. L.H. has struggled off and on with her depression and anxiety, which were diagnosed in high school. In addition to an acute exacerbation of these issues, her increased stress has led to insomnia and difficulty concentrating at work. She was told at her last primary care check-up that she is pre-hypertensive, which her doctor attributed to her elevated anxiety and stress.

Friedman Family Assessment: Marital and Parental Dynamics in the Midst of Stress and Aspiration

She will continue to monitor her blood pressure, but her physician is not overly concerned and predicts that she will no longer be hypertensive once she has overcome her acute stressors and reduced her anxiety. Marital System Strengths. S.H. and L.H. have shared interests, including comedy, reading, and bowling. They are also in the same career field, so they “are able to vent to each other about work and ‘really get it,’” according to L.H. The couple has built a strong friendship over the years, and they have a deep understanding of each other. Problems. The couple has spent very little time alone together since S.H. started graduate school, which has made L.H. feel unwanted and insecure. Agitation from the increased stress they are both under has led to their decreased and worsening communication, more arguments, and a lack of physical and emotional intimacy. L.H. recognized that she had become resentful that S.H. was pursuing his MSN, and she wasn’t when they had made plans to fulfill this shared dream together. Parental System Strengths. B.H. and T.H. receive regularly scheduled preventative care, including well-child exams, dental cleanings/check-ups, and optometrist check-ups. The couple does their best to model positive self-care behavior. L.H. indicated that “As nurses, we both make it a point to teach our boys about personal hygiene and the importance of eating right and exercising to stay healthy. We try to do fun physical activities as a family every weekend, but it’s been difficult lately, with [S.H.] being so busy all of the time.”

Friedman Family Assessment: Unraveling Parenting Challenges and the Role of Extended Family Connections

Both parents have an authoritative parenting style and agree that they want to be emotionally supportive of their boys while maintaining consistent consequences for inappropriate behavior. Their goal is to raise men who are kind, happy, confident, and self-sufficient. Problems. L.H. is becoming overwhelmed and frustrated since taking on most of the household and parental responsibilities while S.H. is focusing on school. The boys are beginning to internalize L.H.’s frustration and noticing that their dad isn’t spending as much time with them. This distress is causing them to misbehave more, which in turn causes L.H. to show more frustration and anxiety. Extended Family System Genograms. The process of creating a genogram with the client is an important part of the family assessment. Family genograms illustrate the wider family composition and changes that have occurred over time with some discrete psychosocial information (Wright & Leahey, 2012, p. 79). Figure 1 depicts the nuclear family that is being assessed and their extended family. Each person’s health history is also listed to allow providers to look for patterns of diseases that may have a familial link. Strengths. L.H.’s side of the family continues to gather for holidays, and they have maintained the traditions that she remembers from her childhood. L.H.’s sister, T.B., and her husband are close in age to L.H. and S.H., and they have children who are also close in age to B.H. and T.H........

Friedman Family Assessment: Bridging Family Ties, Community Resources, and Lingering Strains

The sisters became first-time moms around the same time, and sharing the experience made them very close. L.H. now considers her sister to be her best friend. L.H. feels supported by her family, especially by her mother and T.B. They have both made standing offers to babysit the boys whenever L.H. needs help. Her parents live on the other side of her subdivision, and T.B. and her family live less than ten minutes away, so she always has family nearby when needed. Problems. L.H. does not have a strong relationship with her youngest sister, B.D. They have never had a close relationship because of their eight-year age difference and B.D.’s jealousy of the strong bond that L.H. and T.B. share. L.H.’s husband has been estranged from his father since his parents divorced in 2012. S.H. and L.H. have had almost no contact with the rest of S.H.’s side of the family since his mother died in 2015. His relationship with his sister is very strained, largely related to her alcoholism and her behavior when she is drunk, which reminds him of the emotional abuse that his father has inflicted on his family over the years. Community Strengths. L.H. was grateful for the help and encouragement that she received from the Parents, Teachers staff that worked with T.H. when he was delayed in his speech development. However, he is now on track and excelling in vocabulary acquisition and comprehension, which means that he will no longer be in the Parents as Teachers program, and L.H. will be losing that resource. L.H. greatly respects and trusts her psychiatrist, who has been a stable, reliable resource for many years. Problems. L.H. feels disconnected from the greater community.

Friedman Family Assessment: L.H.'s Balancing Act between Work, Family, and Personal Struggles

The former satisfaction that she got from her work is gone, and now it is just another stressor. Her poor mood has also made her friends at work become more distant. S.H. feels stress from work and school because he wants to do his best at both, but when he is addressing one commitment, he is simultaneously taking time and attention away from the other. Ecomaps are used to visualize each family member’s connections or attachments to systems outside of the nuclear family. They act as a quick reference for identifying an individual’s sources of support and current or potential stressors (Rempel et al., 2007, p. 410). An ecogram of the family being assessed is depicted in Figure 2. Summary of the Interview L.H. is in a loving marriage, but she feels frustrated and overwhelmed about having to take on a lot of the parenting duties independently while her husband is in graduate school and continuing to work full-time. She stated that she feels disconnected from her husband, close friends, and family because she has no free time between her own full-time job and caring for her two sons. L.H. and her husband are both very stressed, which has resulted in what she calls frequent “petty” fights and what she describes as a “total breakdown in communication.” L.H. went on to say that she was having insomnia because of her chronically high stress.

Friedman Family Assessment: The Limitations and Implications of a Single-Perspective Evaluation

This lack of sleep made her feel distracted and exhausted all of the time, and she felt that this was what led to her making multiple mistakes at work recently. Her anxiety and depression are at an all-time high, per her accounts of her mental health history. Conclusion The family’s priority goals, provider interventions, and family action plan should be determined in a non-hierarchical, nurse-client collaboration during the family assessment, with the participation of as many family members as possible. Building trust and displaying respect for the family’s beliefs, values, and preferences is essential for this type of shared decision-making to occur (Thome & Arnardottir, 2013).

When an assessment must be completed with only one individual’s input, the nurse must recognize the limitations of a single person’s perception and factual knowledge of every family member’s health history, current status, and attachments to outside resources. It must be noted that this family assessment did not provide a holistic view of the family unit because only one person, L.H., was able to be interviewed. Each family member’s perspective is only one piece of the greater whole, dynamic family assessment.

This family’s care plan was based on a collaboration between L.H. and this nurse: Family Goals

• Improve communication between L.H. and S.H.
• Spend more quality time together as a family.
• Reduce the overall stress level in the home. Interventions/Education
• Encourage the couple to verbalize their feelings openly and clearly.
• Educate S.H. about the importance of finding work/life/school balance.
• Refer them to local therapists for individual and family counseling.
• Assist S.H. and L.H. to identify positive coping skills for each to use in times of stress.
• Suggest that they form an agreement on how the household and childcare duties will be divided to quell future arguments and make daily tasks less stressful for the whole family. Plan of Action
• They will talk to each other when they are upset instead of bottling up their emotions.
• They will schedule quality time each week to spend alone as a couple.
• S.H. will create a study schedule that gives him more free time with his family without impeding his success in school.
• They will utilize the help that her sister and mother have offered (e.g., babysitting).
• To reduce her stress, L.H. will make time every day to do something just for herself.
• Family meals will be planned out and prepped weekly to reduce stress at mealtimes.

Friedman Family Assessment: The Crucial Role of Continuous Follow-Up and Evaluation

Following Up After a nursing intervention is made, a follow-up with the family is necessary to evaluate if there was an effect on their functioning. Svavarsdottir, Tryggvadottir, and Sigurdardottir contend that the most important outcome of any nursing intervention is whether or not members of the family feel that they are functioning well (2012, p. 306). The family’s view of their functioning will determine if any adjustments need to be made to the family care plan. This process needs to be repeated at each visit, and the family assessment should be updated continuously as new information is obtained. 

References

1. Friedman, M. M. (1998). Family Nursing: Research, Theory, & Practice (5th ed.). Prentice Hall.
2. Wright, L. M., & Leahey, M. (2012). Nurses and Families: A Guide to Family Assessment and Intervention (6th ed.). F.A. Davis Company.
3. Stanhope, M., & Lancaster, J. (2014). Public Health Nursing: Population-Centered Health Care in the Community (9th ed.). Mosby.
4. Kuo, D. Z., Houtrow, A. J., Arango, P., Kuhlthau, K. A., Simmons, J. M., & Neff, J. M. (2012). Family-centered care: Current applications and future directions in pediatric health care. Maternal and Child Health Journal, 16(2), 297-305.
5. Svavarsdottir, E. K., Tryggvadottir, G. B., & Sigurdardottir, A. O. (2012). Knowledge translation in family nursing: Does a short-term therapeutic conversation intervention benefit families of children and adolescents in a hospital setting? Findings from the Landspitali University Hospital Family Nursing Implementation Project. Journal of Family Nursing, 18(3), 303-327.
6. Thome, M., & Arnardottir, M. E. (2013). Collaborative and family-focused care practices of Icelandic nurses in acute care settings: A cross-sectional study. Journal of Clinical Nursing, 22(17-18), 2536-2547.
7. Rempel, G. R., Neufeld, A., & Kushner, K. E. (2007). Interactive use of genograms and ecomaps in family caregiving research. Journal of Family Nursing, 13(4), 403-419.

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