The purpose of this article is to familiarize nurses with the family strengths perspective and encourage them to incorporate family strengths into nursing practice. The concept of family strengths has been studied for several decades and describes a family that functions optimally in support of the individual members. When nurses use a family strengths theoretical framework in their nursing care instead of focusing on trying to improve deficits of family functioning, they pay attention to strengthening families. DeFrain and Stinnett (1992) have emphasized that a healthy family may be stronger in one area than another, and that strengths may overlap with each other.
Nursing care traditionally has been practiced within the complexity of families and has included culturally competent, holistic care (Campinha-Bacote, 1999; Leininger & McFarland, 2002; Munoz & Luckmann, 2005). It is well known that the family environment may have a positive or a negative effect on individuals in the family, depending on the family's values, beliefs, and ability to manage change. Historically, ecomaps, genograms, and family assessment tools have assisted nurses in better understanding family systems, subsystems, and relationships (Friedman, Bowden, & Jones, 2003; McCubbin & McCubbin, 1993; Smilkstein, 1978; Stanhope & Lancaster, 2004). When using a family strengths framework to design nursing care, nurses enhance their care by moving beyond culture and holism and plan their care based on an assessment of each family's strengths, thereby helping the families they serve enhance their strongest characteristics.
Background on Family Research
Research on successful families has been ongoing for decades (Woodhouse, 1930). An important pioneer in family strength research was Otto (1962, 1963), who provided psychiatrists, psychologists, counselors, social workers, and family educators with a framework for family strengths concepts. Otto examined types of personal interaction that family members believed contributed to the strength of their family. Family strength was viewed as the result of numerous factors, some of which tend to change over the lifespan. According to Otto, some important factors included (a) nurturing, (b) support, (c) parental discipline, (d) encouragement of growth and maturation of all family members, (e) spiritual well-being of members, (f) good communication, (g) problem-solving skills, and (h) meaningful participation.
In a subsequent study, Gabler and Otto (1964) noted many different definitions and interpretations of the family strengths concept. They examined the literature in social work, psychiatry, psychology, and sociology written between 1942 and 1962 and discovered that family strengths consisted of 15 categories of functioning (Table 1). They also found that 68% of family strength references fell into four categories: (a) family as a strength within itself, (b) strong marriage, (c) strength as parents, and (d) parents helping children to develop. In the 1970s, Stinnett and Sauer (1977) conducted the Family Strengths Research Project to examine characteristics of strong families. Participants were partners in first-time marriages, with both spouses living in the home with at least one child under the age of 21. Families selected to participate needed to have a high degree of marital happiness, satisfying parent-child relationships, and the ability to fulfill each other's needs. A survey of these families indicated that expressing appreciation, spending time together, good communication, and a sense of spirituality were essential components of a strong family.
Qualities of family strengths surfaced again with a national research study by Stinnett and DeFrain (1985). Newspapers throughout the United States were asked to "run a story" calling for families who consider themselves a "strong family" to participate in a research study about what makes families succeed. Six family strength qualities emerged from the data:
1. Commitment (focusing on promoting family welfare and happiness, balancing relationships, sharing responsibilities, not overcommitting to activities outside the home, and setting common goals)
2. Appreciation and affection (positive recognition in a positive environment to enhance personal self-worth)
3. Positive communication (respectfully using listening and conversation skills to discuss family issues without attacking each other)
4. Enjoyable time together (to enhance relationships and establish family identities)
5. A sense of spiritual well-being (a unifying force that brings meaning and purpose to guide lives)
6. The ability to cope with stress and crisis (uniting the family through good communication skills, adding humor to the situation, keeping things in perspective)
Today the study of family strengths has evolved internationally in other cultural contexts, with studies taking place with more than 24,000 family members in 28 countries (Asay, 2003; Casas, Stinnett, DeFrain, Williams, & Lee, 1984; Xie, DeFrain, Meredith, & Combs, 1996; Yoo et al., 2005). Consistent findings over the decades have reinforced the family strengths framework from culture to culture, finding that no matter the culture, family strengths are more similar than different. Collectively, researchers throughout the world have developed an International Family Strengths Network devoted to strengthening families on a global level by hosting conferences, sponsoring research projects, and developing cross-national programs (DeFrain et al., 2006).
Nursing's Use of the Family Strengths Concept
Families who experience psychosocial issues connected to acute or chronic illness rely on nurses to assist them in managing situational crisis, and nurses have a long history of studying psychosocial issues related to family functioning, family strengths, resilience, and coping with health conditions (Feeley & Gottlieb, 2000). These studies have confirmed that persons are best understood within their immediate social context or the family and that examining the entire family unit as opposed to studying each individual family member in isolation provides a strong foundation for a nursing care plan (Wright & Leahy, 2000).
The Child Family Expert Panel of the American Academy of Nursing also acknowledges the need to incorporate family strengths into nursing. In 1999, a panel of 12 subspecialty child-family nursing experts convened to discuss quality care and outcomes indicators for their population. After a systematic review and collaboration, core values and assumptions were identified, and family strengths surfaced as a quality and outcome indicator (Craft-Rosenberg, Krajicek, & Shin, 2002). The panel met again in 2001 and developed a questionnaire for consumers to use as a guide to help select a healthcare provider and assess the quality of care they receive (Betz, Muennich Cowell, Lobo, & Craft-Rosenberg, 2004).
In a qualitative nursing research study, Sittner, DeFrain, and Hudson (2005) examined the effects of high-risk pregnancies using a family strengths framework. Previous family relationships had a major impact on the women's ability to cope with the fluctuating circumstances of high-risk pregnancies. Six qualities of strong families emerged from the interview question "Tell me about yourself and your family." The ability to cope with stress and crisis during a high-risk pregnancy was the most common strength identified. The importance of family support and resilience was essential: one participant stated she has a "great family support group" and they were "always there." Another said, "We have a very close knit family on both sides and so they jumped right in there to help. It's made a huge impact on how well everything has gone." Most participants felt very fortunate to have families who were committed to help balance responsibilities during their high-risk pregnancy. Maintaining ongoing communication was very important so "everybody's informed" and then they would have "help if you needed it." Family members were kept current by attending prenatal visits, telephoning each other, and receiving frequent hospital or home visits. Families enjoyed spending time together by celebrating special occasions and "carving out time" to be with each other. The women appreciated the assistance they received from their family, friends, church, and healthcare providers. One mentioned that to help her cope she would "debrief by calling a good friend." Another mentioned her church was "taking care of them" by "checking up on us" and arranging meals for the family while she was on bed rest. Spiritual well-being was identified as a major source of strength for the families by statements such as the church is "a very, very big part of who we are as individuals and a family." One woman mentioned that "we have so many people praying for us" and another said "[we] are very strong in what we believe."
Family Strengths Assessment
When assessing family relationships, nurses can use the American Family Strengths Inventory (AFSI) (DeFrain et al., 2006). Participants are asked to place an "S" for strength beside the qualities they feel their family has achieved and a "G" beside those qualities that are an area of potential growth. If the particular characteristic does not apply to their family or is not a characteristic important to them, they place "NA" for not applicable. Family members doing this exercise are able to identify areas they would like to improve and areas of strength that will serve as the foundation for their growth and positive change together. This tool may be accessed at http://www.ianrpubs.unl.edu/epublic/live/nf498/build/nf498.pdf.
The AFSI was not created as a diagnostic tool but as an assessment tool for generating discussion among family members and with professionals on qualities that make a family strong (Stinnett, 1979; Stinnett, Sanders, DeFrain, & Parkhurst, 1982). It has been validated through research with more than 21,000 family members in the United States and 26 countries around the world (DeFrain & Stinnett, 2002). Cronbach's alpha for the AFSI was 0.7217 in a recent reliability analysis (Reese, 2002).
Clinical Implications
Three ways in which nurses can use the family strengths concept are (a) identifying strengths and providing feedback to family members, (b) assisting family members in developing strengths, and (c) calling forth family strengths to achieve goals or solve a problem (Feeley & Gottlieb, 2000). To assist families with the ability to cope with stress and crisis effectively in health-related circumstances, nurses can provide consistent information in the plan of care and encourage families to utilize community and counseling resources to prevent or minimize stressors. The key to positive communication is for healthcare providers to listen and establish a trusting relationship in which families feel free to share their viewpoint and accept professional advice without feeling ostracized for sharing their perspectives.
For some families, integrating spirituality into the plan of care assists them in coping with health and psychosocial adversities as they arise (Tanyi, 2002). It is important for nurses to understand that spiritual well-being may be organized religion or may be a purely personal spirituality that reflects the family's own beliefs, values, and rituals. Nursing assessment may disclose their preferences and requests. The role of the nurse is to acknowledge the family's spiritual perspective and implement nursing interventions that promote spirituality.
Nurses can help families to strengthen relationships in sickness and in health by first assessing the family's commitments to long-term relationships, which are built on honesty, dependability, and physical and emotional presence. If that commitment exists or is desired, it is more likely that families will cope successfully. Nurses can instruct families that enjoyable time together during an illness is also an important attribute in maintaining healthy relationships. Nurses can encourage families to be physically close, celebrate occasions, and remember special occasions of the past. Encouraging individuals and families to express appreciation and affection for assistance during an illness is respectful and promotes a caring relationship based on mutual trust and support.
In the academic environment, it is important for nursing students to be taught the family strengths framework and its application in acute and community settings. Historically, students have been taught to understand expected outcomes for an individual or population, assess their patients for variances, identify the proper nursing diagnosis, plan interventions, and evaluate their care management strategies. This same framework can be used for incorporating family strength assessment into the inpatient high-risk obstetric curriculum. Students can learn to use a new interview approach in which they ask patients to describe their family strengths, thus helping to reinforce the importance of family strengths in illness and health. Information obtained from the patient interview can be used to formulate nursing interventions that focus on incorporating family strengths into the plan of care. For example, a family might identify their strength as spiritual well-being, and the student nurse might then include a referral to pastoral care for the patient's hospitalization. Another patient might state that at home her family had enjoyable time together because they participated in family activities; this family strength then translates into compromised family coping as the nursing diagnosis. Planned interventions could then be privacy during family visits and including the family in the plan of care, which would promote family strengths and interaction throughout the hospitalization.
Further study and development of family strengths are required in theory, practice, and research. Little nursing research attention has focused on developing a plan of care that includes a family strengths assessment. Identifying the nature of family strengths opens a new arena for nurses to develop effective healthcare strategies and opportunities to implement family-focused interventions to provide holistic care.
Clinical Implications
* Consider assessing a family's strengths when planning nursing care for the family.
* Help families cope with stress and crisis effectively by providing consistent information.
* Be sure to listen and work toward establishing a trusting relationship with families.
* Acknowledge the family's individualized spiritual perspective and implement nursing interventions that promote their spiritual needs.
* Help families understand that enjoyable time together during an illness is important.
* Encourage families to be physically close and celebrate occasions.
* Encourage individuals and families to express appreciation and affection for assistance during an illness.
* Help nursing students understand the family strengths perspective.
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