642790

research-article2016
JFNXXX10.1 177/1 074840 716642 790Journal of Family Nursing Östlu nd et al.

Article

Journal of Family Nursing

2016, Vol. 22(2) 148–-171
A Family Systems © The Author(s) 2016
Reprints and permissions:
Nursing Approach for sagepub.com/journalsPermissions.nav
DOI: 10.1177/1074840716642790
Families Following a jfn.sagepub.com

Stroke: Family Health

Conversations

Ulrika Östlund, RN, OCN, PhD1, Britt

Bäckström, RN, PhD2, Britt-Inger
Saveman, RNT, PhD, FEANS3, Viveca
Lindh, RN, PhD3, and Karin Sundin, RNT,
PhD4

Abstract
Stroke in midlife is a life altering, challenging experience for the whole family
thereby necessitating a family approach to intervention. The aim of this study
was to describe the experiences of 17 family members living in Sweden,
including seven adult stroke patients (six males; one female) under the age
of 65 who participated in a series of three nurse-led family conversations
that were offered in each family’s home. These Family Health Conversations
(FamHC) were guided by the conceptual lens of Family System Nursing.
Individual, semi-structured, evaluative interviews conducted with each
participant one month after the FamHC were analyzed by qualitative content
analysis. The FamHC were described by family members as a unique
conversation that they had not previously experienced in health

1Uppsala
University/Region Gävleborg, Gävle, Sweden
2MidSweden University, Sundsvall, Sweden
3Umeå University, Umeå, Sweden

4Umeå University, Örnsköldsvik, Sweden

Corresponding Author:
Ulrika Östlund, Research Supervisor, Centre for Research & Development,
Uppsala University/Region Gävleborg, SE-801 88 Gävle, Sweden. Email:
ulrika.ostlund@regiongavleborg.se

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

Östlund et al. 149

care contexts. Family members described possibilities for relational

sharing and meaningful conversations as well as changes in family
functioning that support the suitability of FamHC for family stroke care.

Keywords
family intervention, therapeutic conversation, stroke, family nursing,
Family Systems Nursing, Family Health Conversations, Sweden

A core assumption of family nursing is that health/illness affects all

members of a family (Wright & Leahey, 2013). Family Systems Nursing is
an over-arching theoretical orientation concerned with interaction,
reciprocity, and relationships between the illness, the patient, the family,
and the larger sys-tems within which they reside (Wright & Leahey, 1990),
with a goal of sus-taining health and promoting healing (Bell, 2009; Bell &
Wright, 2015). Family Systems Nursing interventions are offered through
therapeutic con-versations that focus on strengths, invite curiosity and
reflection through the asking of interventive questions, and are respectful of
multiple realities. Attention is directed to the reciprocal influence between
illness and the fam-ily with particular emphasis on suffering experienced by
families in the con-text of illness (Benzein, Hagberg, & Saveman, 2008;
Wright & Bell, 2009; Wright & Leahey, 2013).

Family Involvement in Recovery From Stroke

The impact of long-term illness such as stroke on patients and their families is
an area of critical need in health care. Research suggests that the experi-ence of
a stroke in midlife is a life altering, challenging experience for the whole
family. Stroke is an illness that often results in a loss of independence in
physical, psychological, and social functioning (Greenwood & Mackenzie,
2010) for the person with stroke, which reciprocally affects the whole family
(Bäckström, Asplund, & Sundin, 2010). Long-term illness implies a change for
both the individual and the family necessitating the need to co-create a context
for living with the illness and also co-create alternative aspects of everyday life
(Årestedt, Persson, & Benzein, 2014). Support from the family has been found
to assist stroke rehabilitation and recovery, and thus family members are
encouraged to participate in the process of recovery (Lutz, Young, Cox, Martz,
& Creasy, 2011). Consequently, it is helpful when nurses view stroke patients
and family caregivers as the unit of care (Creasy, Lutz, Young, & Stacciarini,
2014).

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

150 Journal of Family Nursing 22(2)

Families experiencing stroke may be helped by nursing care that uses a

Family Systems Nursing approach. The family is considered to be the unit
of intervention (Greenwood & Mackenzie, 2010; Visser-Meily et al., 2006)
and the focus is on all affected family members. This offers the whole
family the possibility to reflect on the families’ changed situation and their
beliefs about many aspects of the illness experience of stroke including
beliefs about the future (Wright & Bell, 2009). To better understand what
family beliefs may support and encourage family well-being and healing
following stroke, nurses need to listen to families’ stories of their illness
experience (Årestedt, Benzein, & Persson, 2015).

Family Systems Nursing Interventions

The Calgary Family Assessment Model (CFAM), the Calgary Family
Intervention Model (CFIM; Wright & Leahey, 2013), and the Illness Beliefs
Model (IBM; Wright & Bell, 2009) are Family Systems Nursing practice
models for generalist and advanced practice influenced by the conceptual sys-
temic lens of Family Systems Nursing and operationalized through specific
interventions offered within a therapeutic conversation and the nurse–family
relationship (Bell & Wright, 2015). The CFAM, the CFIM, and the IBM have
been examined in a variety of research studies that have examined both the
process and content of these Family Systems Nursing practice models
(Duhamel, Dupuis, Reidy, & Nadon, 2007; Houger Limacher & Wright, 2006;
Moules, 2009; Robinson & Wright, 1995; Svavarsdottir, Tryggvadottir, &
Sigurdardottir, 2012; Sveinbjarnardottir, Svavarsdottir, & Wright, 2013; West,
Bell, Woodgate, & Moules, 2015). A recent integrative review of 17 research
reports of family nursing interventions derived from Family Systems Nursing
found that families reported cognitive, affective, and behavioral changes fol-
lowing therapeutic conversations with nurses (Östlund & Persson, 2014).

Development of Family Health Conversations (FamHC)

FamHC were developed in Sweden by Benzein and colleagues (2008, 2012) by
culturally adapting the practice models of CFAM, CFIM (Wright & Leahey,
2013), and the IBM (Wright & Bell, 2009; Wright, Watson, & Wright, 1996)
first developed and used in Canada. These practice models were adapted to the
Swedish context (Saveman, 2010; Saveman & Benzein, 2001) using several
sources of evidence such as those suggested by Rycroft-Malone and colleagues
(2004) which include information from the local context, patient experience,
clinical experience, and research. Swedish family nursing researchers refined
FamHC through research; examination of the literature;

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

Östlund et al. 151

meetings with families, nurses, and other health professionals; as well as

through engagement in national health political discussions concerning, for
example, appropriate nursing terminology to be used or not used. As a
result, in Sweden, the term Family Health Conversations is preferred over
the term, therapeutic conversations, as the latter is associated with the
Swedish trans-lated word “terapi,” not usually used within the domain of
nursing expertise. Other discussions that have influenced the cultural
adaption of existing fam-ily nursing practice models to Sweden have
focused on health-economics, evidence-based practice, and special care for
multi-disease and an ageing population. As a result, not only were linguistic
characteristics considered in development of FamHC but contextual and
conceptual aspects of existing family nursing practice models were also
addressed for cultural adequacy in the Swedish context.
In 2004, the Family-Focused Nursing Unit [Omvårdnadsmottagning för
familjer] at Kalmar University (renamed Linnaeus University) was estab-
lished by Dr. Britt-Inger Saveman and Dr. Eva Benzein to conduct research
and educate nurses in Family-Focused Nursing (Bell, 2015; Saveman,
2010). Families experiencing illness were invited to participate in research
conver-sations that were foundational to the development of FamHC. The
format of FamHC includes three family conversations, followed by a
closing letter. This program of FamHC research expanded to Northern
Sweden when Dr. Saveman moved to Umeå University. Together, the two
sites have, to date, offered FamHC to approximately 50 families with a
variety of health/illness concerns.
FamHC begin with the family’s stories and the focus of these are family-
driven (Östlund, Bäckström, Lindh, Sundin, & Saveman, 2015). FamHC
focus on health (Benzein et al., 2008) and build primarily on a salutogenetic
approach (Antonovsky, 1987) to shift the focus of the conversation from
dis-ease, disability, and poor functioning to positive aspects and well-being
(Mittelmark & Bull, 2013). Ricoeur (1992) has described the healing effect
of narration, and careful attention in FamHC is directed to problems and
dilemmas the families themselves identify during the narration of their sto-
ries. Reflection is emphasized (Andersen, 1995), and reflections are offered
by the two nurses who conduct the FamHC to assist family members to find
new alternatives or meanings. Similar to CFAM/CFIM and IBM (Wright &
Bell, 2009; Wright & Leahey, 2013), the purpose of FamHC is to create a
context for change in family health and to support the creation of new
beliefs, meanings, and relationship opportunities specific to the story
described by the family (Benzein et al., 2008).
Empirical findings about how families experience FamHC are beginning
to accumulate with families experiencing palliative care and chronic illness

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

152 Journal of Family Nursing 22(2)

(Benzein et al., 2008; Benzein, Olin, & Persson, 2015; Benzein & Saveman,
2008; Dorell et al., 2014; Dorell & Sundin, 2016; Östlund et al., 2015;
Persson & Benzein, 2014; Sundin et al., 2015). Recent evidence has also
documented the cost-effectiveness of FamHC (Lämås, Sundin, Jacobsson,
Saveman, & Östlund, 2015). These current findings indicate that family
members find FamHC to be a positive intervention that fosters a trusting
environment in which they can put their stories and experiences into words
and feel affirmed. Craig and colleagues (2008) suggested that knowledge of
the process of the intervention, from the perspective of both patients and
nurses, is important for a comprehensive understanding of nursing interven-
tion regardless of whether the intervention is new or previously developed
and then implemented in a new context. Family members’ evaluation of
their experiences of participating in FamHC can add to an understanding of
family nursing intervention and are therefore needed.

Study Aim
The aim of this study was to describe family members’ evaluation of the
experiences of participating in FamHC, offered to families experiencing the
stroke of an adult family member.

Method
This family nursing intervention study was part of a larger project evaluating
FamHC with families in the context of stroke rehabilitation. The core compo-
nents of FamHC and nurses’ fidelity to FamHC have been examined (Östlund et
al., 2015). Furthermore, what family members choose to focus on during the
FamHC offered post-stroke (Sundin et al., 2015), and the cost-effective-ness of
FamHC have also been studied (Lämås et al., 2015). The present study used a
qualitative descriptive design (Patton, 2002) to describe the fam-ily members’
experiences of participating in FamHC which occurred in the family home
following discharge from a stroke rehabilitation center. Before and during the
study, written and verbal information concerning the study aim, voluntary
participation, and assurance of confidentiality were given to the participants.
Ethical approval was obtained from the Regional Ethical Review Board in
Umeå, Sweden (No. 210-101-31M).

Participants
A total of 12 adult family members under the age of 65 who had recently
experienced a stroke (eight males and four females) were consecutively (Polit

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

Östlund et al. 153

Table 1. Demographics of the Participating Families.

Age, sex, and diagnosis Time between Participating family

of the family member diagnosis and first members’ relationship to
diagnosed with a Family Health the person diagnosed with
Family stroke Conversation a stroke (age)
A 53, male, cerebellar 8 months Wife (48)
infarction Son (16)
Son (18)
B 63, male, cerebral 10 months Wife (56)
infarction,
C 63, male, cerebral 12 months Wife (59)
infarction
D 61, male, cerebellar 7 months Cohabitant, female (56)
infarction Cohabitants’ daughter (36)
E 53, male, cerebral 5 months Son (32)
infarction
F 64, female, cerebral 3 months Son (40)
infarction
G 50, male, intracerebral 5 months Wife (48)
hemorrhage

& Beck, 2012) approached during their stay in a rehabilitation center and
invited to participate in the study. Seven of the stroke patients (six male and
one female) consented to participate. These participants were then asked to
identify close family members who shared the illness experience and who
they specifically defined as belonging to their family (Wright & Leahey,
2013). Seven families, consisting of a total of 17 family members including
the seven stroke patients, were included in FamHC following individual
informed consent. Exclusion criteria were families who did not speak and
read Swedish. For a description of the participants, see Table 1.

Family Nursing Intervention: FamHC

In this study, families in which an adult family member had been diagnosed
with a stroke participated in a series of three 1-hr nurse-led family-health
conversations held approximately every 2 weeks in each family’s home. The
schedule for these conversations was based on core components described for
the implementation of FamHC (Östlund et al., 2015). Six registered nurses, all
women aged 48 to 62 years old, conducted the FamHC. The nurses were also
researchers and teachers with varying theoretical knowledge and experience of
Family Systems Nursing and FamHC. They had participated in

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

154 Journal of Family Nursing 22(2)

university education about FamHC (Lindh et al., 2013) and were also teach-
ing family nursing. The six nurses conducted the FamHC in pairs, as the
presence of two nurses during FamHC is suggested to be enriching
(Benzein et al., 2008). The pairs were configured in different combinations
such that all of the nurses conducted FamHC with at least two families.
During the family conversations, one nurse took the major responsibility for
the conver-sation whereas the other was a co-participant, observing meta-
communica-tions and offering reflections on the content of the conversation
(Benzein et al., 2008).
The series of three 1-hr nurse-led family conversations focused topics
that the families considered important; the FamHC dialogue was focused on
iden-tifying and releasing resources within and outside the family. To
challenge current beliefs and create alternative ways for families to think
about their situation, reflective, interventional questions were offered
(Benzein et al., 2008; Wright & Bell, 2009; Wright & Leahey, 2013)
throughout the conver-sation series. In addition, suffering was
acknowledged along with family strengths and resources.
During the first FamHC, all family members were invited to listen to each
other’s stories and tell their own. The second conversation was intended to focus
on problems and beliefs identified in the first conversation. The third
conversation focused on family strengths and resources as well as the future. At
the end of each conversation, the nurses offered a reflection to the fami-lies.
Two or 3 weeks after the third and final conversation, a “closing letter” was sent
to the family (Bell, Moules, & Wright, 2009; Moules, 2009). In the reflections
during the conversations and in the closing letter, the nurses offered their
reflections on what had happened during the three conversa-tions, beliefs of
family members that were challenged, and the resources of the family that were
highlighted. All FamHC were carried out in the families’ homes following
discharge of the patient from a stroke rehabilitation center.

Data Collection
Semi-structured evaluative interviews (Polit & Beck, 2012) were conducted
individually with each of the 17 family members one month after the
FamHC were completed. To capture a family view, the evaluative inter-
views focused on each family member’s opinions about the entire family’s
experience of participating in the FamHC. The focus was on cognitive,
affective, and behavioral aspects as well as positive and negative experi-
ences of participating in the FamHC. The evaluative interviews also focused
on how participating in FamHC had contributed to any changes for the fam-
ily, and whether the family had been able to influence the FamHC.

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

Östlund et al. 155

Furthermore, questions were asked about the format (time and framing) of
the FamHC. A nurse researcher, not involved in offering the FamHC, per-
formed the follow-up evaluative interviews, which took 20 to 45 min, and
were conducted in the participant’s home. Interviews were recorded and
transcribed verbatim. Before the analysis began, the first author read
through the transcripts and checked them against the recordings, resulting in
only minor corrections.

Data Analysis
Data from the evaluative interviews were analyzed using qualitative con-
tent analysis (Patton, 2002) with an inductive approach (Elo & Kyngas,
2008). The interview transcripts were chosen as the unit of analysis
(Graneheim & Lundman, 2004), and all were read through to get a sense of
the text as a whole. The analysis was then conducted in several steps.
Meaning units, i.e., text containing aspects related to each other through
content and context (Graneheim & Lundman, 2004), covering the manifest
content of experiences from participating in the conversations were
searched for and marked. The meaning units were then extracted from the
transcripts and assembled in a new document. This new document was read
thoroughly to gain a deeper sense of the extracted data, and meaning units
were condensed, that is, the text was shortened without losing its content
and meaning. At this stage, it became clear that there were two domains,
one about the intervention format (time and framing) of the FamHC and the
other about possibilities created within the actual content and focus of the
FamHC. The following analysis was carried out separately for each of these
two domains.
Next, condensed meaning units were coded based on their content and
sorted into subcategories created from the similarities and differences
found. Subcategories were then further abstracted into categories
(Graneheim & Lundman, 2004). The analysis was an ongoing process in
which the research team discussed, until agreement was reached, how to
understand and struc-ture the evaluative interview content and label the
subcategories and catego-ries to describe the family members’ experiences.

Results
The results describe family members’ experiences of participating in
FamHC under two domains: format of the FamHC and possibilities created
in the FamHC. For an overview of the two major domains and categories
within each of them, see Table 2.

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

156 Journal of Family Nursing 22(2)

Table 2. Analysis Domains, Categories, and Subcategories.

Domains Categories Subcategories

Format of the Experiences related to Time frame and context
FamHC the framework of the A process from discomfort to comfort
FamHC Nurses’ role and approach during
FamHC
Family members’ role during FamHC
Experiences related to Conversation focus and content
the substance of the Reflections
FamHC Closing letter
Being part of a different A conversation different from those
kind of conversation usually held within the family
A conversation different from other
conversations held with health care
professionals
Possibilities Opportunities for Room for trust
created in sharing within the Room for narratives
the FamHC family Room for deeper conversation
Room for confirmation
Opportunities for Room for reflection
change within the Room for telling the story differently
family or telling a different story
Room for accepting multiple realities

Note. FamHC = Family Health Conversations.

Format of the FamHC

This domain included three categories—experiences related to the framework of
the FamHC, experiences related to the substance of the FamHC, and being part
of a different kind of conversation—and a total of nine subcategories.

Experiences related to the framework of the FamHC. This category

was abstracted from four subcategories.

Time frame and context. Family members talked about when, in the
stroke care trajectory, they would have preferred to start the FamHC. Some
wanted these family conversations earlier when the effects of the stroke were
most troublesome. Others thought the current timing was adequate because the
period immediately following the diagnosis of the stroke was busy with reha-
bilitation care and they appreciated the space following discharge from the

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

Östlund et al. 157

stroke rehabilitation center that was provided before the start of the FamHC.
Furthermore, family members reported that a 1-hr family conversation, the
time (about 2 weeks) between the conversations, and the number of conver-
sations (three) were appropriate and sufficient. There were family members,
however, who wanted at least one more conversation because they felt they
had approached a core issue only during the final conversation or they felt
alone in the process of new understanding brought about by the FamHC.
Family members reported the home environment was appropriate for con-
ducting the conversations, as it was calmer than the clinical setting of the
stroke rehabilitation center.

A process from discomfort to comfort. Meeting new people (the nurses)

in the home was described as causing minor distress until the family members
got to know the nurses. In the first FamHC, the family members reported it was
difficult to raise certain issues and to know how to act toward each other. Some
family members said they did not show their real selves, whereas oth-ers
“opened up” in the very first conversation. It gradually became easier to open
up for the rest of the family and also for the nurses. Toward the end of the
conversation series, family members began approaching a core issue and a more
honest picture of the situation and each other as illustrated by Patient C1: “I felt
it became easier and easier both for them and for us to open up.”

Nurses’ role and approach during FamHC. Family members described

it as a positive experience that someone like the nurses came to the family home
from outside and shared their views. The nurses added a structure to the con-
versations, in a natural way, which provided all family members an oppor-tunity
to talk. They fostered a pleasant atmosphere and harmonized with the family.
However, some family members expressed that they were not given as much
focus as other family members. The nurses were described as listen-ing without
expecting to be given any particular space for themselves, and as posing
relevant questions out of a genuine interest. On the contrary, some family
members reported that the nurses wanted to get answers to their pre-defined
questions, though in retrospect, those questions were described as helpful in
opening up new conversational threads. Family members reported that the
nurses ensured that the issues raised were put on the table, and ensured that a
thread was followed throughout the conversation. They helped the families to
avoid common negative ways of talking, gave feedback and confirmation, and
supported self-help, as illustrated by Teenage Son A4: “Everyone had room to
talk. If somebody talked more, they [the nurses] were very good at including
everyone in the conversation . . . I guess they wanted to know what everyone
thinks.”

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

158 Journal of Family Nursing 22(2)

Family members’ role during FamHC. Family members expressed

that they themselves had an important influence on what was discussed
within the structure set by the nurses. As a family, they formed the
conversation content and direction in collaboration with the nurses.
Furthermore, they listened to each other and could spontaneously connect to
what they had heard through the conversations. However, some family
members said their ability to influ-ence the conversation was limited due to
aphasia, whereas others felt the nurses were directing them:

It felt more like it was all four of us together who decided, somehow, the
content. Things that Mom and I had said in the first conversation, they took
up the thread during the next conversation. So it was a conversation, which
just proceeded. (Adult Son F2)

Experiences related to the substance of the FamHC. This category

was abstracted from three subcategories.

Conversation focus and content. Family members described the FamHC

as focused on more than the ill family member and the situation around the ill-
ness. This systemic view, in which all family members were in focus, was
described as something that could lead to new insights. Family members, who
expected the conversations to be more about stroke, the family member who
had had a stroke, and concrete advice related to stroke care, first reported the
conversations included irrelevant issues. The conversations, however, were later
reported to be suitable as they progressed with a broader content. The content
was reported to be flexible, building on what was previously raised and
following “a thread.” Important and reasonable issues were raised, and talking
about them proved beneficial. However, some family members experienced that
the advice they received was not targeted to the individual family and that
nothing new was raised. Furthermore, at the end of the three conversations,
some still wished for more concrete advice and information:

What made it a little difficult was that it wasn’t just about me and my situation,
but we all three have illnesses making it easy to get into others’ situations as well.
Well, that might not be wrong but not what the time was scheduled for . . . It was,
however, fair and good that it was not just about me. (Patient D1)

Reflections. Family members reported that, even if unusual, it was posi-

tive and constructive when the nurses conducting the FamHC paused to offer
their reflections. Family members reported the reflections were signifi-cant and
interesting and even central to the conversations. The reflections

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

Östlund et al. 159

summarized their situations pretty well; the families could recognize them-
selves in them. However, some said that central issues were missed and that
some parts of the reflections did not really match their own experiences:

What we felt was nice at the end were the reflections that we were invited to
listen to. I thought it was very good, since we got to hear their views of me
and X [the husband who suffered the stroke] as people and how we are and
how they felt about us in general. (Wife G2)

Closing letter. Receiving the closing letter was a positive experience

and reported to be a significant completion of the conversation series. It was
described as a letter personally written to the family communicating close-
ness and warmth. Family members could recognize themselves as what was
written fit into their own experiences of the situation. Some, however, also
noted that the letter contained a description of the family that “didn’t really
feel like us.” The closing letter, a confirmation of what the nurses
understood and felt during the conversations, was said to present a view
from people outside the family, one that raised concerns and was felt to
open up a process instead of leading to defensiveness. Patient D1 offered,
“If we hadn’t gotten the letter, I would have felt it came to nothing . . . Now
it is tied up and we have closure, which I thought was good.”

Being part of a different kind of conversation. This category was

abstracted from two subcategories.

A conversation different from those usually held within the family. Family
members reported the FamHC differed from conversations normally held within the
family. It gave them an opportunity to sit down together as a family and talk. For
some, this was a new experience as their family did not usually gather to discuss
urgent matters; they sat down as a family only for meals. The FamHC were more
structured and focused and no one left the conversations before they were
concluded. The FamHC were also more neutral and held on equal terms in which all
points of view were considered valid. Family mem-bers described talking about
different issues than usual, including things that were implicitly known but not often
discussed: “We talk a lot at home, but it’s not the same [as talking with the nurses
present]. It can be difficult to go into certain things even if we have known each
other for years” (Patient C1).

A conversation different from other conversations usually held with health

care professionals. The FamHC were reported to differ from other conversations
with professionals in the health care field; they were considered a type of

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

160 Journal of Family Nursing 22(2)

discussion families had not previously taken part in. Conversations they had
experienced before with health care professionals were described as focusing
entirely on medical issues (i.e., diagnosis and treatment of the stroke) with no
allowance for feelings and experiences. The FamHC was less formal, more
relaxed, and held in a way that acknowledged equality among all participants
and focused on the family and not just the family member who had suffered the
stroke: “They came and were interested in us, at least showed an interest, and
they tried to help us. That was great” (Patient B1).

Possibilities Created in the FamHC

This domain incorporated two categories—opportunities for sharing within
the family and opportunities for change within the family—containing a
total of seven subcategories.

Opportunities for sharing within the family. This category was

abstracted from four subcategories.

Room for trust. Family members reported that an atmosphere was cre-
ated in which all family members not only had the chance to talk and listen
but they actually dared to do so. It was reported that even family members,
who tended to be quiet, participated in meaningful parts of the
conversations. However, it was also reported that some family members did
not dare to share their opinions due to a fear that this could lead to negative
consequences for another family member. Furthermore, family members
described that some significant issues concerning relational problems could
not be raised due to the way the relationships worked and the fact that very
sensitive issues could be difficult to talk about: “[Did you hold back?] Yes
of course, I always do, every day” (Patient B1).

Room for narratives. Family members reported that room was created to
tell their own stories and to listen to the others’ stories. This included narrating
not only the family story but also their own individual stories. Family members,
other than the person diagnosed with the stroke, had the opportunity to talk
about their own situations. They also appreciated the possibility of talking about
the situation of the ill family member. The ill family member also expressed the
significance of listening to other family members’ views on their situations:

Well, there were three family members in the conversation so it was good for me
to hear them saying things about my situation as well. Previously, there were just
short comments; now it was put into a context in another way. (Patient D1)

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

Östlund et al. 161

Room for deeper conversation. Family members reported that room for
deeper conversations was created. Deep emotions, such as fear and anxiety not
shown before because of mutual considerations, could now be expressed and
shared. Family members said they could be more open about their thoughts and
feelings, providing a means of relief. Distressing emotions arose during the
conversions when participants thought about their own dif-ficult situations. This
was initially described as negative, but was followed by expressing positive
experiences related to participating in the FamHC:

There have been a lot of feelings in the conversations—all of us were crying,

all four of us together. So you go deeper into things when they [the nurses]
are there, in contrast to when the two of us have to go through it. (Wife G2)

Room for confirmation. Family members reported that room for con-
firmation was created. Things implicitly known about family issues were
confirmed and the family members could see themselves from various per-
spectives. Verbal reflections could provide confirmation of their own views.
Furthermore, the family’s understanding of the situation was acknowledged
and the recovery of the family member who had suffered the stroke was
con-firmed:

When I saw myself from other perspectives, I thought it was a true picture of me
and therefore gave a little affirmation. It is probably not very often you tell each
other that this and this is good, maybe mother and father say this to each other, so
this becomes another way to affirm each other. (Teenage Son A4)

Opportunities for change within the family. This category was

abstracted from the following three subcategories:

Room for reflection. Family members reported that room for reflection
was created in the conversations. This meant they were given an
opportunity to think back and to think over their own roles. This inner
conversation was thought-provoking, was an eye-opener, and created new
insights: “There’s more ability to listen and then to process it yourself and
gain insights” (Patient D1).

Room for telling the story differently or telling a different story. Family
mem-bers described room being created for telling their stories in a different
way than usual or even for telling a different story. They could express and find
words for thoughts and feelings and hear other family members put into words
implicit emotions, views, and memories never shared before. Furthermore,

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

162 Journal of Family Nursing 22(2)

the possibility of putting into words issues central to family relations was
experienced. Family members other than the ill family member described,
as a new experience, having the opportunity to tell the stroke patient their
own views and feelings from the moment of the stroke onset:

Maybe not so many new things, but it is still interesting and fun to hear when
they put it into words. Some of the things that they expressed you might have
imagined that they think or feel. (Wife A2)

Room for accepting multiple realities. Family members described

how the conversations opened up realization and acceptance of multiple
realities, that is, of various perspectives on the situation. They expressed,
accepted, and respected different opinions within the family and moved on
in the conversa-tions, realizing they did not all have to think the same way.
Furthermore, it was reported that facades that had been put up to hide less
favorable realities fell down, allowing a truer self to be revealed: “It was
positive to be able to go on even if you had different opinions. This is not
something to fight over; you have to respect different views” (Patient D1).

Discussion
The findings from this study provide important insights into the post-stroke
experiences of family members who participated in FamHC, suggesting that
these unique family nursing conversations are useful to families involved in
stroke care. The results highlight that possibilities such as sharing experi-
ences thoughts and feelings and changes within the families were created.
This adds to previous knowledge from evaluations of FamHC (Benzein et
al., 2008, 2012; Benzein et al., 2015; Benzein & Saveman, 2008; Dorell et
al., 2014; Dorell & Sundin, 2016; Lämås et al., 2015; Lindh et al., 2013;
Östlund et al., 2015; Persson & Benzein, 2014; Sundin et al., 2015), and
gives specific insight into the family members’ perceptions of the processes
that take place during the FamHC.
Within the domain, “Format of the FamHC,” family members described the
home to be a safe place for holding the FamHC. This could be due to the home
being a place that offers a sense of safety and control (see also Bateson, 1972).
Conducting the FamHC in the home might also be an appropriate setting to
challenge constraining beliefs as the complications due to stroke become more
apparent regarding practical tasks, roles, and relationships (Bäckström &
Sundin, 2007). To offer FamHC in the home milieu may make it more possible
to the view the family as a unit rather than as an individual patient and his or her
relatives, thereby making the communication more balanced (Ross &

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

Östlund et al. 163

Johansen, 2002). Furthermore, conducting these conversations in the home

might help to motivate change as the home environment reminds the family
experiencing stroke that they actively have to create a home with new
solutions (Bäckström & Sundin, 2009).
Regarding the time during the stroke care trajectory when the FamHC
should be implemented, different opinions were expressed, for example, it
was an adequate time or an earlier implementation would have been better.
These differences may be due to the various needs of the families in relation
to the onset of stroke. Previous studies have shown that the time from onset
of the stroke is relevant to how the family members come to know,
recognize, and acknowledge changes within the family (Bäckström et al.,
2010). The timing for introducing the conversations should consequently be
flexible and based on each family’s situation, needs, and preferences. The
FamHC could therefore be offered to families soon after the stroke, with an
option for them to initiate the conversations at a later date.
Most of the family members in this stroke care study reported that the
format of FamHC within three 1-hr conversations were sufficient. Limiting
the number of the conversations has previously been described by families
as contributing to a feeling of being trusted to continue to manage their lives
themselves (Benzein & Saveman, 2008). Family members described a pro-
cess that unfolded throughout the FamHC series: At the beginning, they felt
uncertain and thought the situation was unfamiliar, but soon it became
easier for them to open up and talk about what was important to the family.
This finding is similar to an evaluation of FamHC within a palliative care
context (Benzein & Saveman, 2008), in which couples reported it was
difficult to talk at the beginning, but, over the course of the conversation
series, they became comfortable and talked freely.
As conversation leaders, the two nurses added structure to the family
conversations and, at the same time, harmonized with the family. Also in
the study by Benzein and Saveman (2008), families described nurses con-
ducting FamHC as involved and able to adjust to the family. In the present
study, family members saw themselves and the nurses not only in their dif-
ferent roles but also as unique persons. This could be connected to how
nurses relate to others in a caring conversation (Fredriksson, 1999) by being
with and listening to the families’ narratives and supporting them in dealing
with their experiences of, for example, suffering. The FamHC were experi-
enced to have a broader focus than the ill family member and opened up
new possibilities. The Family Systems Nursing approach, central to FamHC
(Benzein et al., 2008), together with non-hierarchical participation
(Anderson & Goolishian, 1992), gave the family the preferential right to
decide what to talk about.

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

164 Journal of Family Nursing 22(2)

The reflections offered by the nurses were described as central to the posi-
tive experience of the FamHC. In adopting a systemic view, reflective think-ing
is emphasized and nurses are expected to listen to what the family really says
(Andersen, 1995; Benzein et al., 2008). Nurses’ reflections may help family
members begin their own internal conversations, understand what has
happened, and find new meaning. Within the reflections, nurses have the
opportunity to acknowledge suffering, use commendations (Houger Limacher
& Wright, 2006), and challenge families’ beliefs (Wright & Bell, 2009).
Receiving a closing letter was also described as a positive experience and
was seen as a significant completion of the conversation series. Receiving a
personally written letter communicating closeness and warmth written by
health professionals is likely an uncommon experience but seemed to be a
valuable part of the FamHC. The healing potential of closing letters has pre-
viously been documented in other research (Bell et al., 2009; Benzein et al.,
2008; Benzein & Saveman, 2008; Moules, 2009).
Within the domain “Possibilities created in the FamHC,” family members
described an opportunity for greater relational sharing being created within the
family. This is an important result as an important assumption underlying
FamHC is that meaning is created through relational activity. A feeling of trust
in FamHC in which all family members were given a chance to talk and listen
was experienced. Being in a trusting relationship has previously been described
as leading to families feeling free to talk about important and often challenging
issues (Benzein & Saveman, 2008).
In this study, family members consequently described how room was
cre-ated for them in which they could tell their own stories and also listen to
each other’s stories. Narrating and disclosing their experiences has the
potential to create the possibility of reaching an increased understanding of
themselves (Ricoeur, 1992) as well as of their family members (Ricoeur,
1995, 1996). Within FamHC, narratives are assumed to affect the healing
process and also to help participants reflect on their experience.
Furthermore, families can share deep emotions as a means of relief. The
FamHC have previously been described as a way for families to unburden
themselves of things they did not know they were carrying (Benzein &
Saveman, 2008). In the present study, family members reported that their
views, knowledge, and understanding were affirmed and acknowledged.
Within the domain, possibilities created in the FamHC, opportunities for
change were created, which is significant because the purpose of family nurs-
ing interventions is to invite change. Room for reflection was experienced as an
eye-opener; it created new insights and new patterns of relating. It is assumed
that our beliefs, even if they are often outside our awareness and un-reflected,
are the truth of a subjective reality that influences our thoughts,

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

Östlund et al. 165

feelings, and behavior (Wright & Bell, 2009). Through reflection, beliefs
may become a part of our conscious awareness (Wright & Bell, 2009) and,
when challenged or confirmed through conversation, can create
opportunities for change in family health. Furthermore, Wright and Bell
(2009) promoted a process of self-reflection in which family members are
invited through the conversation “to think about their thinking,” which is
important for the co-evolution of new, more facilitating beliefs.
Telling a story in a different way through the FamHC or even telling a
different story was described in the present study. Family members found
words for and heard each other putting into words their thoughts and emo-
tions never shared before. The FamHC, then, can be seen as useful as the
conversations were aimed at helping families find alternative ways of talk-
ing about their situation and subsequently develop a new reality about pos-
sibilities in learning to live alongside the stroke (Benzein et al., 2008;
Wright & Leahey, 2013).
Although most of the family members in the present study experienced
the FamHC as positive, there was still the possibility of negative
consequences not revealed within the evaluation interviews. Some less-than-
positive expe-riences were expressed such as aphasia (as a result the stroke)
making it impossible to adequately use the conversation opportunities
provided by the FamHC. Family members also expressed that it was hard to
raise issues other than those introduced by the nurses, and distressing
emotions did occur dur-ing family conversations. In FamHC, the presence
of the nurse and the art of listening are crucial. The challenge for nurses
offering FamHC is to give space and priority to all family members and also
be the family members’ voice (see also Sakalys, 2003). Furthermore, it is
important for the nurses to invite an opportunity to “speak the unspeakable”
about the family experience of illness (Wright & Bell, 2009).

Methodological Considerations
To strengthen the trustworthiness of the study (Polit & Beck, 2012), three of the
authors performed the content analysis (U.Ö., B.B., K.S.) and the other (B.I.S.,
V.L.) audited and confirmed the relevance of the categories. All authors
participated in the process of interpretation. All the authors were reg-istered
nurses and doctorally prepared scholars and had in-depth knowledge of FamHC.
Even though FamHC uses a family systems approach, individual family
member evaluative interviews were performed and analyzed sepa-rately. The
strength of the individual interviews was that each family member had the
opportunity to reveal his or her opinions without consideration of the other
family members’ opinions. The weakness of the individual interviews

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

166 Journal of Family Nursing 22(2)

was the risk of forsaking a systemic perspective. However, the evaluative

interview questions were formulated and asked in a systemic way, that is,
they asked about the entire family’s experiences. Only seven family cases
from one part of Sweden were analyzed; this needs to be considered in
terms of the generalizability of the results. Nevertheless, the findings of the
evalu-ative interviews contribute to a richer understanding of families’
experiences of participating in FamHC.

Conclusion
This article adds knowledge about Family Systems Nursing and specifi-
cally about FamHC by providing and extending knowledge about the use-
fulness of family conversations in the context of long-term illness. FamHC
create possibilities for greater relational sharing and change in family func-
tioning. Therefore, this study supports FamHC as suitable for families in
which a family member has suffered a stroke. Previous studies with this
population of families have shown that family members do not dare to share
feelings and experiences with the stroke patient because they do not want to
agitate or make him or her sad (Bäckström & Sundin, 2007). A fam-ily
conversation such as FamHC offers a sense of relational sharing within the
family, along with a sense of not being alone, which may prevent feel-ings
of alienation. We believe these results may also be transferable to fam-ilies
experiencing other long-term illnesses. Future research about FamHC
should focus on the outcomes of these family nursing interventions and
their sustainability over time.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The authors disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This research was supported by grants
from the Strategic Research Program in Health Care-Bridging Research and Practice
for Better Health, Sweden.

References
Andersen, T. (1995). Reflecting processes; acts of informing and forming: You can
borrow my eyes, but you must not take them away from me! In S. Friedman
(Ed.), The reflecting team in action: Collaborative practice in family therapy
(pp. 11-37). New York, NY: Guilford Press.

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

Östlund et al. 167

Anderson, H., & Goolishian, H. A. (1992). The client is the expert: A not-knowing
approach to therapy. In S. McNamee & K. Gergen (Eds.), Therapy as social
con-struction (pp. 25-39). London, England: SAGE.
Antonovsky, A. (1987). Unraveling the mystery of health: How people manage stress
and stay well. New York, NY: Jossey-Bass.
Årestedt, L., Benzein, E., & Persson, C. (2015). Families living with chronic illness:
Beliefs about illness, family, and health care. Journal of Family Nursing, 21,
206-231. doi:10.1177/107484071557679
Årestedt, L., Persson, C., & Benzein, E. (2014). Living as a family in the midst of
chronic illness. Scandinavian Journal of Caring Sciences, 28, 29-37.
doi:10.1111/ scs.12023
Bäckström, B., Asplund, K., & Sundin, K. (2010). The meaning of middle-aged
female spouses’ lived experience of the relationship with a partner who has suf-
fered a stroke, during the first year postdischarge. Nursing Inquiry, 17, 257-268.
doi:10.1111/j.1440-1800.2010.00490.x
Bäckström, B., & Sundin, K. (2007). The meaning of being a middle-aged close relative
of a person who has suffered a stroke, 1 month after discharge from a rehabilita-tion
clinic. Nursing Inquiry, 14, 243-254. doi:10.1111/j.1440-1800.2007.00373.x Bäckström,
B., & Sundin, K. (2009). The experience of being a middle-aged close relative of a
person who has suffered a stroke, 1 year after discharge from a reha-bilitation clinic: A
qualitative study. International Journal of Nursing Studies,
46, 1475-1484. doi:10.1016/j.ijnurstu.2009.04.009
Bateson, G. (1972). Steps to an ecology of mind: Collected essays in anthropology, psy-
chiatry, evolution, and epistemology. Chicago, IL: University of Chicago Press.
Bell, J. M. (2009). Family Systems Nursing: Re-examined [Editorial]. Journal of
Family Nursing, 15, 123-129. doi:10.1177/1074840709335533
Bell, J. M. (2015). Growing the science of Family Systems Nursing: Family health
intervention research focused on illness suffering and family healing
[L’avancement de la recherché sur l’intervention infirmiere systémique en santé
familiale: bilan]. In F. Duhamel (Ed.), La santé et la famille: Une approche sys-
témique en soins infirmiers [Families and health: A systemic approach in
nursing care] (3rd ed., pp. 102-125). Montreal, Quebec, Canada: Gaëtan Morin
edit-eur, Chenelière Éducation. [In French]. English language translation
available from University of Calgary Institutional Repository, PRISM:
http://hdl.handle. net/1880/51114.
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
Bell, J. M., & Wright, L. M. (2015). The Illness Beliefs Model: Advancing prac-tice
knowledge about illness beliefs, family healing, and family interven-tions
[Editorial]. Journal of Family Nursing, 21, 179-185. doi:10.1177/
1074840715586889
Benzein, E. G., Hagberg, M., & Saveman, B.-I. (2008). “Being appropriately
unusual”: A challenge for nurses in health-promoting conversations with
families. Nursing Inquiry, 15, 106-115. doi:10.1111/j.1440-1800.2008.00401.x

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

168 Journal of Family Nursing 22(2)

Benzein, E. G., Hagberg, M., & Saveman, B.-I. (Eds.). (2012). Att möta familjer
inom vård och omsorg [Meeting with families in health and community care].
Stockholm, Sweden: Studentlitteratur. [In Swedish]
Benzein, E. G., Olin, C., & Persson, C. (2015). ‘You put it all together’ – fami-lies’
evaluation of participating in Family Health Conversations. Scandinavian
Journal of Caring Sciences, 29, 136-144. doi:10.1111/scs.12141
Benzein, E. G., & Saveman, B.-I. (2008). Health-promoting conversations about
hope and suffering with couples in palliative care. International Journal of
Palliative Nursing, 14, 439-445. doi:10.12968/ijpn.2008.14.9.31124
Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I., & Petticrew, M.
(2008). Developing and evaluating complex interventions: The new Medical
Research Council guidance. British Medical Journal, 337, a1655. doi:10.1136/
bmj.a1655
Creasy, K. R., Lutz, B. J., Young, M. E., & Stacciarini, J.-M. R. (2014). Clinical
implications of family-centered care in stroke rehabilitation. Rehabilitation
Nursing, 4, 349-359. doi:10.1002/rnj.188
Dorell, Å., Bäckström, B., Ericsson, M., Johansson, M., Östlund, U., & Sundin, K.
(2014). Experiences with Family Health Conversations at residential homes for
older people. Clinical Nursing Research. Advance online publication.
doi:10.1177/1054773814565174
Dorell, Å., & Sundin, K. (2016). Becoming visible - Experiences from families
participating in Family Health Conversations at residential homes for older
people. Geriatric Nursing. Advance online publication. doi:10.1016/j.gerin-
urse.2016.02.015
Duhamel, F., Dupuis, F., Reidy, M., & Nadon, N. (2007). A qualitative evalua-tion
of a family nursing intervention. Clinical Nurse Specialist, 21, 43-49.
doi:10.1097/00002800-200701000-00009
Elo, S., & Kyngas, H. (2008). The qualitative content analysis process. Journal of
Advanced Nursing, 62, 107-115. doi:10.1111/j.1365-2648.2007.04569.x
Fredriksson, L. (1999). Modes of relating in a caring conversation: A research syn-
thesis on presence, touch and listening. Journal of Advanced Nursing, 30, 1167-
1176. doi:10.1046/j.1365-2648.1999.01192.x
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. doi:10.1016/j.nedt.2003.10.001
Greenwood, N., & Mackenzie, A. (2010). Informal caring for stroke survivors:
Meta-ethnographic review of qualitative literature. Maturitas, 66, 268-276.
doi:10.1016/j.maturitas.2010.03.017
Lämås, K., Sundin, K., Jacobsson, C., Saveman, B.-I., & Östlund, U. (2015).
Possibilities for evaluating cost-effectiveness of family system nursing: An
example based on Family Health Conversations with families in which a
middle-aged family member had suffered stroke. Nordic Journal of Nursing
Research. Advance online publication. doi:10.1177/0107408315610076
Limacher, L. H., & Wright, L. M. (2006). Exploring the therapeutic family interven-
tion of commendations: Insights from research. Journal of Family Nursing, 12,
307-331. doi:10.1177/1074840706291696

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

Östlund et al. 169

Lindh, V., Persson, C., Saveman, B.-I., Englund, C., Idberg, K., & 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, 54-66. doi:10.5430/jnep.v3n2p54
Lutz, B. J., Young, M. E., Cox, K. J., Martz, C., & Creasy, K. R. (2011). The crisis
of stroke: Experiences of patients and their family caregivers. Topics in Stroke
Rehabilitation, 18, 786-797. doi:10.1310/tsr1806-786
Mittelmark, M. B., & Bull, T. (2013). The salutogenic model of health in health promotion
research. Global Health Promotion, 20, 30-38. doi:10.1177/1757975913486684 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. doi:10.1177/1074840709331639
Östlund, U., Bäckström, B., Lindh, V., Sundin, K., & Saveman, B.-I. (2015).
Nurses’ fidelity to theory-based core components when implementing Family
Health Conversations—A qualitative inquiry. Scandinavian Journal of Caring
Sciences, 29, 582-590. doi:10.1111/scs.12179
Östlund, U., & Persson, C. (2014). Examining family responses to Family Systems
Nursing interventions: An integrative review. Journal of Family Nursing, 20,
259-286. doi:10.1177/1074840714542962
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, 2014, Article ID 547160.
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: Lippincott Williams & Wilkins.
Ricoeur, P. (1992). Oneself as another. Chicago, IL: University of Chicago Press.
Ricoeur, P. (1995). Hermeneutics and the human sciences. Cambridge, UK:
Cambridge University Press.
Ricoeur, P. (1996). The hermeneutics of action. London, England: SAGE.
Robinson, C. A., & Wright, L. M. (1995). Family nursing interventions: What
families say makes a difference. Journal of Family Nursing, 1, 327-345.
doi:10.1177/107484079500100306
Ross, L., & Johansen, C. (2002). Psychosocial home visits in cancer treatment: A
qualitative study on the content of home visits. Cancer Nursing, 25, 350-357.
doi:10.1097/00002820-200210000-00003
Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., & McCormack,
B. (2004). What counts as evidence in evidence-based practice? Journal of
Advanced Nursing, 47, 81-90. doi:10.1111/j.1365-2648.2004.03068.x
Sakalys, J. A. (2003). Restoring the patient’s voice: The therapeutics of illness narra-
tives. Journal of Holistic Nursing, 21, 228-241. doi:10.1177/0898010103256204
Saveman, B.-I. (2010). Family nursing research for practice: The Swedish perspec-
tive. Journal of Family Nursing, 16, 26-44. doi:10.1177/1074840709360314
Saveman, B.-I., & Benzein, E. (2001). Here come the Swedes! A report on the dra-
matic and rapid evolution of family-focused nursing in Sweden. Journal of
Family Nursing, 7, 303-310. doi:10.1177/107484070100700308

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

170 Journal of Family Nursing 22(2)

Sundin, K., Pusa, S., Lundstedt, E., Wincent, N., Östlund, U., Bäckström, B.,
. . .Saveman, B.-I. (2015). What couples choose to focus on during nurse-led
Family Health Conversations when suffering stroke. The International Journal
for Human Caring, 19, 22-28.
Svavarsdottir, E. K., Tryggvadottir, G. B., & Sigurdardottir, A. O. (2012).
Knowledge translation in family nursing: Does a short-term therapeutic con-
versation intervention benefit families of children and adolescents in a hospi-tal
setting? Findings from the Landspitali University Hospital Family Nursing
Implementation Project. Journal of Family Nursing, 18, 303-327. doi:10.1177/
1074840712449202
Sveinbjarnardottir, E. K., Svavarsdottir, E. K., & Wright, L. M. (2013). What are the
benefits of a short therapeutic conversation intervention with acute psychiatric
patients and their families? A controlled before and after study. International
Journal of Nursing Studies, 50, 593-602. doi:10.1016/j.ijnurstu.2012.10.009
Visser-Meily, A., Post, M., Gorter, J. W., Berlekom, S. B., Van Den Bos, T., &
Lindeman, E. (2006). Rehabilitation of stroke patients needs a family-cen-tred
approach. Disability and Rehabilitation, 28, 1557-1561. doi:10.1080/
09638280600648215
West, C. H., Bell, J. M., Woodgate, R. L., & Moules, N. L. (2015). Waiting to return
to normal: An exploration of family systems intervention in childhood cancer.
Journal of Family Nursing, 21, 261-294. doi:10.1177/1074840715576795
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. (1990). Trends in nursing of families. Journal of
Advanced Nursing, 15, 148-154. doi:10.1111/j.1365-2648.1990.tb01795.x
Wright, L. M., & Leahey, M. (2013). Nurses and families: A guide to family assess-
ment and intervention (6th ed.). Philadelphia, PA: F.A. Davis.
Wright, L. M., Watson, W. L., & Bell, J. M. (1996). Beliefs: The heart of healing in
families and illness. New York, NY: Basic Books.

Author Biographies
Ulrika Östlund, RN, OCN, PhD, is a research supervisor at the Centre for Research
& Development, Uppsala University/Region Gävleborg, Sweden. Her research and
clinical interests focus on palliative care, dignity conserving care, and Family
Systems Nursing using mixed-methods research and implementation science. Her
recent publications include, “Nurses’ Fidelity to Theory-Based Core Components
When Implementing Family Health Conversations—A Qualitative Inquiry” in
Scandinavian Journal of Caring Sciences (2015, with B. Bäckström, V. Lindh, K.
Sundin, & B.-I. Saveman), “Possibilities for Evaluating Cost-Effectiveness of
Family System Nursing: An Example Based on Family Health Conversations With
Families in Which a Middle-Aged Family Member Had Suffered Stroke” in Nordic
Journal of Nursing Research (2015, with K. Lämås, K. Sundin, C. Jacobsson, & B.-
I. Saveman), and “Examining Family Responses to Family Systems Nursing
Interventions: An Integrative Review” in Journal of Family Nursing (2014, with C.
Persson).

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016

Östlund et al. 171

Britt Bäckström, RN, PhD, is a senior lecturer in the Department of Health

Sciences at Mid Sweden University in Sundsvall, Sweden. Her research focuses
mainly on Family Systems Nursing and high-tech patient simulation to encourage
nursing stu-dents’ clinical judgment. Her recent publications include, “The Meaning
of Middle-Aged Female Spouses’ Lived Experience of the Relationship With a
Partner Who Has Suffered a Stroke, During the First Year Postdischarge” in Nursing
Inquiry (2010, with K. Asplund & K. Sundin), “The Experience of Being a Middle-
Aged Close Relative of a Person Who Has Suffered a Stroke, 1 Year After
Discharge From a Rehabilitation Clinic” in International Journal of Nursing Studies
(2009, with K. Sundin), and “The Meaning of Being a Middle-Aged Close Relative
of a Person Who Has Suffered a Stroke, One Month After Discharge From a
Rehabilitation Clinic” in Nursing Inquiry (2007, K. Sundin).
Britt-Inger Saveman, RNT, PhD, FEANS, is a professor in the Department of Nursing
at Umeå University, Umeå, Sweden. Her research focuses on Family Systems Nursing,
elder abuse, disaster nursing, and injury prevention. Her recent publications include,
“Nurses’ Fidelity to Theory-Based Core Components When Implementing Family Health
Conversations—A Qualitative Inquiry” in Scandinavian Journal of Caring Sciences
(2015, with U. Östlund, B. Bäckström, V. Lindh, & K. Sundin), “Refinement and
Psychometric Re-Evaluation of the Instrument Families Importance in Nursing Care—
Nurses Attitudes” in Journal of Family Nursing (2011, with E. Benzein, Å. Engström, &
K. Årestedt), and “Family Nursing Research for Practice: The Swedish Perspective” in
Journal of Family Nursing (2010).

Viveca Lindh, RN, PhD, is a senior lecturer in the Department of Nursing at Umeå
University, Umeå, Sweden. Her research and clinical interests focus on pediatric
nurs-ing, pain management, and Family Systems Nursing. Her recent publications
include, “Children Undergoing Radiotherapy: Swedish Parents’ Experiences and
Suggestions for Improvement” in PLoS One (2015, with C. Ångström-Brännström et
al.), “An Initiative to Teach Family Systems Nursing Using Online Health-
Promoting Conversations: A Multi-Methods Evaluation” in Journal of Nursing
Education and Practice (2013, with C. Persson, B.-I. Saveman, C. Englund, K.
Idberger, & U. Östlund), and “Young People’s Experiences With Scoliosis Surgery:
A Survey of Pain, Nausea, and Global Satisfaction” in Orthopaedic Nursing (2013,
with A. C. Rullander, H. Jonsson, & M. Lundström).
Karin Sundin, RNT, PhD, is an associate professor in the Department of Nursing at
Umeå University, Örnsköldsvik, Sweden. Her research focuses mainly on Family
Systems Nursing in stroke care, parents’ health care, and elderly care. Her recent
publications include, “Becoming Visible—Experiences From Families Participating
in Family Health Conversations at Residential Homes for Older People” in Geriatric
Nursing (in press, with Å. Dorell), “What Couples Choose to Focus on During
Nurse-Led Family Health Conversations When Suffering Stroke” in The
International Journal for Human Caring (2015, with S. Pusa et al.), and
“Experiences With Family Health Conversations at Residential Homes for Older
People” in Clinical Nursing Research (2014, with A. Dorell, B. Bäckström, M.
Ericsson, M. Johansson, & U. Östlund).

Downloaded from jfn.sagepub.com at UNIV OF TENNESSEE on June 5, 2016