Assessing staff nurses' styles of involvement with the families of their patients


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Assessing staff nurses' styles of involvement with the families of their patients
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xi, 142 leaves : ; 29 cm.
Burns, Cathy M
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Counselor Education thesis, Ph.D   ( lcsh )
Dissertations, Academic -- Counselor Education -- UF   ( lcsh )
bibliography   ( marcgt )
theses   ( marcgt )
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Thesis (Ph.D.)--University of Florida, 2002.
Includes bibliographical references.
Statement of Responsibility:
by Cathy M. Burns.
General Note:
General Note:

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This dissertation is dedicated in loving memory to my husband, Richard R. Burns. His
faith and love supported me throughout this process. The bravery and determination he
showed during his fight against cancer will always be an inspiration to me.


I would like to extend my sincere appreciation to Dr. Ellen Amatea, chair of my

committee, who guided me through this process with patience, enthusiasm, and skill. She

set an example of caring that I will always remember and her unfailing instinct for just

the right phrase is a testament to her intelligence and grace. My sincere thanks go to Dr.

David Miller and Dr.-Silvia E-Doan, each of whom contributed their unique expertise to

refine my understanding of the research process. Additionally I am grateful to Dr.

Lovetta Smith for her friendship throughout these many years; her astute observations

and enduring calmness always helped to make the most difficult concepts understandable.

Several people have been a part of my journey towards achieving this goal. First

and foremost, my mother Chrissy and my sister Colleen, both of whom have traveled

down this same road, inspired me time and again through their confidence that I could

accomplish this lifelong ambition. My sister-in-law, Debbie, who daily required a report

of my progress, helped to bolster my determination to finish. I also received invaluable

support when I most needed it from my colleagues at work Mary Ann, Sherri, and Jen

and thank them for putting up with my anxieties and always telling me to just "get on

with it!"

Finally, I thank and bless my two children, Shane and Erin, and their spouses,

Michelle and Brian, who cheered me on through this process. Their love and faith in me

have enriched my life and sustained me through the ups and downs as I aspired to make

my dream a reality.


ACKNOWLEDGMENTS .................. ...................... ............................ iii

LIST OF TABLES... ............................. ... ... ............................. vii

LIST OF FIGURES ................. ......... .......................... ix

ABSTRACT ...................................................... ......... .


1 INTRODUCTION .........................................................1

Scope of the Problem............................... ...................................... 3
Purpose............................. ............... .......... ......... .......... .... ... ................. 10
Theoretical Framework......................... ..... .................................. 10
Need for the Study ............ ......... .................... ................-.................. 16
Research Questions .... ........................... .............................. .............................. 17
Definition of Terms..... ................. ....................... .......... ........ ._....... 18
Organization of the Study ...... .......................................................................... 19

2 REVIEW OF THE LITERATURE........ .........................................21

Introduction........................ ................... ............... ............. .............. 21
Changing Expectations for Family-Nurse Involvement ... ...................................... 21
Theories of Family Care ....... .... ....................... ........ 26
Research on Family Nursing Practice ....................... ... ................ .... 34
Theoretical Framework....... .............. ............. ....... ... 37
Summary.......................... ............ 57

3 METHODOLOGY ................ ....... ........ ...... ..... ......58

Statement of Purpose ... .... ....................................... 58
Hypotheses ......... ........ .... .........- ... ........... ... 59
Delineation of Relevant Variables................................... 59
Data Analysis ........._....._...._.... ........... 62
Description of the Population ....................... 62
Sampling Procedures ......__--..-..... ....... ............ 63

Subjects................. .............. .... ....... ... ........................ ....... 63
D ata Collection ............................................. ............... ..................................... 71
Instrum entation.......................... .......... ... ..... ... .................................... 71

4 DATA ANALYSIS AND RESULTS.......................... ........................ ...79

Analysis Procedures....................................... 79
Analysis Results ................................................. ......... ............ .................... 84
Hypothesis Testing................ .............................. .......................................... 91
Sum m ary...... .................................. ............................................... 101

5 DISCUSSION..................................... ............. ..............102

Overview of the Study ........................................ .................................................. 102
Research Sample ............................... ....................................... 103
Association Between Style of Role Involvement with Families and Degree of Family
Self-Efficacy Reported....................................................................................... 104
Association Between Style of Role Involvement with Families and Degree of
Perceived Organizational Support for Working with Patients' Families ............... 106
Association Between Style of Role Involvement with Families and Level of General
Self-Efficacy ............................................................................................................ 109
Association Between Level of General Self-Efficacy and Degree of Family
Self-Efficacy ........................... .......................................... ........... ............ 110
Association Between Style of Role Involvement with Families and Level of Role
Breadth Self-Efficacy....................... ............................................................. 112
Association Between Level of Role Breadth Self-Efficacy and Degree of Family
Self-Efficacy ....................... .... ............................. ......................................... 113
Association Between Style of Role Involvement with Families, General Self-Efficacy,
Role Breadth Self-Efficacy, Perceptions of Organizational Support, and
Perceptions of Family Self-Efficacy........ ..................................... 114
Association Between Style of Role Involvement with Families, Age, Marital Status,
Educational Level, Years of Nursing Experience, Nursing Specialty, and History
of Family Member Hospitalization................................................... ..... 116
Recommendations ........................................................................................ 117
Summary ............. ............... ......... .................. ............. 124


A LETTER TO PARTICIPANTS.... ............ .............. ........ ...125

B DEMOGRAPHIC DATA SHEET ... .... .. .............................. 126

C GENERAL SELF-EFFICACY SCALE -. ........... ................. 127

D ROLE BREADTH SELF-EFFICACY SCALE..- ..-. ........... ........128

E NURSE/FAMILY ROLE FACTORS SCALE ...................................................129

LIST OF REFERENCES ............................................ ........ ....................135

BIOGRAPHICAL SKETCH ........................................................ ............................ 142


Table page

I Nursing Specialty Distribution of the Sample .................................. ............. 65

2 Sex and Race-Ethnic Distribution of the Sample ......................................................66

3 M arital Status Distribution ........................... .......... ..................................67

4 Nursing Education Distribution of the Sample ......................................................68

5 Nursing Job Description Distribution of the Sample................................................68

6 Hospitalized Family Member Distribution of the Sample ........................................69

7 Age in Years Distribution of Sample.....................................................69

8 Years of Nursing Practice Distribution of Sample ..........................................71

9 Correlational Findings on the Nurse/Family Role Factors Scale Pilot ....................78

10 Descriptive Statistics of Sample on Each Measure............................ ................. 80

11 Correlation Matrix: Family Self-Efficacy, Perceptions of Organizational Support,
Role Breadth Self-Efficacy, General Self-Efficacy, and Styles of Family
Involvement ....................................... ..... .................................... 82

12 Correlation Matrix: Age, Marital Status, Education, Nursing Experience, Nursing
Specialty, and Family Member Hospitalization.......... ........................................83

13 Source Table for Simple Linear Regression Models to Test SFIS as Dependent
Variable............... ........................................................ .................................87

14 Source Table for Simple Linear Regression Models to Test FSES as Dependent
Variable.................................................. ..... ................................................. .......89

15 Source Table for Multiple Regression Model to Test the Main Effects with SFIS
as Dependent Variable and the Self-Perception Independent Variables ..................90

16 Source Table for Multiple Regression Model to Test the Main Effects with SFIS
as Dependent Variable and the Demographic Independent Variables.................... 90

17 Results of Hypothesis Testing .............................. .................. ...92

18 Comparison of Research Sample and National Sample .......................................104



Figure page

1 Family/Nurse Role Paradigm............................................... ..........................16

2 Diagram of Family Health and Illness Cycle............................. ......................... 27

3 Family Nursing: Individual Focus..................................... .................... 32

4 Family Nursing: Family is Focus................ ...... .............................32

5 Family Systems Nursing: Family as Unit of Care .................................................... 33

6 Family/Nurse Role M odel.......................................................................................56

7 Diagram of Statistically Significant Effects ....................... ..........................101

Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree ofDoctor of Philosophy



Cathy M. Burns

December, 2002

Chair: Ellen Amatea, Ph.D.
Major Department: Counselor Education

This study, based on the three theoretical frameworks social role theory, self-

efficacy theory, and theories of family health care, assessed the self-perception factors

and individual characteristics influencing staff nurses' style of involvement with patients'

families. Regression analyses explored the prediction of staff nurses' preference for

individual focused patient care versus family focused patient care from indicators of

family self-efficacy, general self-efficacy, role breadth self-efficacy, perceptions of

organizational support, and individual demographic characteristics. Results from the

multiple regression analyses of data from a sample of 353 registered nurses employed

full-time in a staff level hospital inpatient position revealed that family self-efficacy in

combination with role breadth self-efficacy, perceptions of organizational support, and

general self-efficacy accounted for a significant amount of the variance in reported

preferences for family focused patient care (35%). Interestingly, contrary to prior family

nursing studies, individual characteristics such as age, marital status, nursing specialty,

years of nursing experience, level of nursing education, and experiencing the

hospitalization of a family member did not contribute significantly to staff nurses'

preferences for family focused patient care. Suggestions for future research examining

the nurse's transition from viewing the family as a context for individual patient care to

viewing the family as the care agent should provide a better understanding of family and

healthcare systems.


Health care professionals have long recognized the importance of patients'

families in the healing process. However it was not until the late 1970s and 1980s that

more systematic attention began to be paid to how health care professionals might work

with families to enhance patient care. This new interest in families was spawned by

developments in family medicine, family therapy and family nursing. A variety of

innovative practices around involving families in the care of their family members' health

were developed and reported by family therapy and family medicine professionals

(Greiner, 1984; Wright & Leahey, 1988; Bell, Wright, & Watson, 1992; Elizur, 1996).

By the late 1990s the term "collaborative family health care" was coined by experts in the

fields of medicine, nursing, social work, hospital administration, and family therapy to

reflect the expanding scope of application of family systems concepts and family

therapists within the healthcare setting (Nichols & Schwartz, 1998).

The result of these developments was that more and more healthcare

organizations began to ask their staff to analyze their current practices with families, and

to create more family-sensitive health care practices. Coupled with this growing interest

in family-sensitive care have been the dramatic changes over the past two decades

occurring in the delivery of health care services designed to contain or reduce medical

care costs. These changes include reductions in the length ofpatient hospital stays,

development of outpatient day surgery clinics, and involvement of managed care

organizations in healthcare decision-making. Not only do these changes impact patients

and healthcare professionals, they also impact the families of patients who are now

expected to assume more of the responsibility for patient care (Coyne, 1995).

The family therapy field has been criticized for failing to acknowledge the impact

of physical illness on family dynamics, and the interest and abilities of other disciplines

working with families within the healthcare setting (Nichols & Schwartz, 1998; Bell et

al., 1992). As healthcare professionals began exploring the family dimensions of their

work, some family therapists enlarged the boundaries of their clinical work within

healthcare settings through psychoeducation. family consultation, and systems

consultation. Doherty and Baird (1986) and Christie-Seeley (1984), for example,

contributed models for how family therapists could collaborate with family physicians in

the delivery of family-centered healthcare. Evan Imber-Black (1988) and John

Schwartzman (1985) proposed models for family therapists to work with families who

were dealing with a variety of larger systems such as welfare, healthcare institutions and

schools. Wynne and his colleagues (Wynne, McDaniel & Weber, 1987) proposed a

model for family therapists working as systems consultants with healthcare organizations.

Central to these consultative models was the recognition that the family therapist

consulting with healthcare organizations must acknowledge the differences between the

family systems paradigm and the biomedical paradigm guiding the operation of these

institutions and must gather sufficient information to see how these paradigms influence

the actual delivery of services. Bloch (1986) states: "As professionals with a family

systems persuasion become more involved in consulting with healtbcare institutions they

would be well-advised to think through their own epistemological stance and to consider

the impact of that stance in the specific setting in which the work takes place (p. 140)."

Nowhere is this step more necessary than when family therapists are invited to consult

with healthcare organizations for the purpose of developing training programs in family

systems for their healthcare staffs. To effectively design training programs to fit the

needs of healthcare professionals, family therapists need to assess the current level of

practice and the values given to family-centered healthcare by the staff ofan


Because nurses often interact with patients and their families more frequently than

other healthcare professionals, they are often the recipients of family-centered training.

However, little is known as to bow nurses expect to be involved with the families of their

patients. Moreover, the extent to which nurses value the involvement of families in the

delivery of patient care or feel competent in interacting with family members around

patient care issues is unknown. Consequently, this study sought to assess the style of

involvement with patients' families that nurses prefer, and to identify the factors

influencing that style ofinvolvement.

Scope of the Problem

Changes in technology that have benefited and impacted healthcare organizations

have added to their complexity and the redesign of work roles. Nurses, along with other

healthcare providers, have found the need to respond to these changes and the stress

related to assuming new roles and expanding old ones. This redefinition of roles within

healthcare has created opportunities for growth and change (Hardy & Conway, 1978).

Traditionally, the typical professional health environment has stressed the role of

the healthcare worker as one who identifies the needs, plans the treatment/program of

care, and performs the service in a "doing to/for" manner. However, healthcare systems

are now emphasizing a partnership model of healthcare in which they are encouraging

more involvement by community members, allowing greater family involvement, and

focusing more on the family needs of the hospitalized patient (Courtney, Ballard, Fauver,

Gariota, & Holland, 1996).

Although nurses have been viewed as traditional partners in healthcare, in reality

they have determined courses of action with little input from patients and their families.

Acknowledging a partnership with the patient and his/her family, now a continual theme

in the changing health scene, necessitates revisiting the roles of nurses and other

healthcare workers with patients' families.

Healthcare workers' role conception with the families of patients has not been

widely reported in the literature. It has, however, been researched within the field of

pediatric nursing. The inclusion ofparents within that particular healthcare setting has

generated research describing the types of interventions needed during a child's

hospitalization. Although a worthy attempt to characterize nursing care, the actual roles

of the nurse with the family and the actual parental roles within the hospital setting are

still poorly defined (Brown & Ritchie, 1990). Additionally, the healthcare organization

itself may contribute to this ambiguity either by failing to provide guidelines to staff for

dealing with the patient's family or providing obscure guidelines.

Porter (1979) hypothesized in her study that the nurse's "professional role

conception" was directly related to his/her orientation towards more family-centered care

of children. She found that the main indicator determining whether the nurse included

the family as a primary unit of care was associated with the level of the nurse's

education; the higher the level of education, the greater the commitment to family-

centered care. Furthermore, in her study of healthcare workers Porter reported that the

multidimensional nature of working with families was in conflict with the "employee role

conception" that emphasized a high degree of structure and subordination. Consequently,

Porter concluded that while family-centered care has the potential for improving the

quality of health care, healthcare workers under utilize it.

Families' Impact on Health

Although healthcare professionals have long recognized the role that family

members have in contributing to the health of hospitalized children and have routinely

included parents in a child's hospitalization to facilitate the child's adaptation to illness or

necessary medical procedures, they have only recently begun to view families as

influential parmers in the patient care and health prevention of other patient age groups

(Young, 1992; Johnson, Craft, Titler, Halm, Kleiber. Montgomery, Megivern, Nicholson.

& Buckwalter, 1995; Denham, 1995). This recent focus on family involvement within

the healthcare arena has prompted members of the nursing profession to examine their

relationships with their patients' family members more fully (Denham, 1995).

Recognizing that families are frequently an integral pat of their practice, the nursing

profession has responded to this recent interest by examining its interventions and

knowledge base with the family members of its patients (Johnson et al., 1995).

In the past decade "family-centered care" and "family nursing" have been the

names given to the practice of including patients' family members in the delivery of their

nursing care. However, apart from identifying possible deficits in nurses' thinking

processes and practice, there appears to be no agreement about the status of family

members, their demands, and appropriate nursing responses (Callery. 1997).

Disappointingly, there is little acknowledgment of the rich history that nurses have

already created about relating to patients' families.

There is a paucity of literature describing, documenting, or evaluating nurses'

actual activities with family members. Because these experiences have often been taken

for granted by nurses, patients, patients' families, and other healthcare workers, literature

describing the interactions between nurses and families is almost nonexistent (Chesla,

1996). Indeed, these family/nurse interactions are often termed the "invisible work" of

the nursing staff. Jacques (1993). for example, suggests that while this invisible work

provides valuable connecting processes for the healthcare team members, patients, and

families, they are not described officially. Instead the "visible" tasks that are seen as

descriptive of nursing practice are the more technical ones. Such a practice reinforces the

impression that family nursing skills are routine and easily assimilated. Hence, nursing

interactions with families may not be viewed as nursing tasks and are thereby

undervalued (Jacques. 1993).

Chesla (1996) agreed that research has not adequately addressed nursing

interventions with families and that, moreover, the interventions that happen at the

bedside are virtually ignored. In her study, which examined the nature of family care

provided by 130 critical care nurses Chesla reported a broad range of nursing skill

concerned with family interaction and intervention, and a valuing of family participation.

Based on her findings, Chesla (1996) offered a distinction between nurses who delivered

actual care to the family and nuses who did not She observed that the nurses' ability to

deal with the technical demands of nursing as well as the relationship needs of the patient

and family required "exceptional personal power and clinical skills (p. 202)."

Callery (1997) also termed the caring of family members of patients as a "hidden

area of nursing work." He emphasizes that despite the use of terms like "family-centered

care" and "family nursing," there is no general agreement among nurses about the

individual nurse's role with a child's parents or the family's role in the care of his/her

child. He suggests that further research into this "hidden" care area would legitimize care

for family members and help to incorporate their care in staffing determination and

assessment for needed skills.

Nurse/Family Relationship

Nurses have been some of the first professionals to identify the importance of

family involvement in patient care. However, research exploring nurses' attitudes

towards family involvement in patient care has repeatedly shown contradictions between

the nurses' behavior towards the family members' participation and their assertions that

the family actively taking part is valuable (Brown & Ritchie, 1990). Their study reported

that although nurses say they value family-centered care, they also described conflicts

within their nurse/family relationships arising from their efforts to maintain control.

intervene in healthcare needs, and evaluate outcomes for their patients.

Problematic nurse/family relationships and interactions were also described by

Laitinen and Isola (1996), who found contradictory reports in the literature that suggested

some nurses obstruct family involvement while others embrace it Furthermore, these

researchers acknowledged that while there appeared to be a variety of different kinds of

relationships between family caregivers and nurses, knowledge of these relationships was

scarce and poorly documented.

Researchers exploring the nurse/family partnership from the perspective of

patients families have noted that parents are concerned that they are not able to negotiate

clear and/or satisfactory expectations of their role in the care of their children with the

nurse. In some studies that examined parental participation in the care of their

hospitalized children, researchers became aware of the parents' discomfort, insecurity,

and unwillingness to care for their children within the hospital environment This was

particularly stressful in a time when hospital staff has begun to transfer more of the care

to the family members (Coyne, 1995).

Family nursing advocates, in an effort to show that nurses impact families and

encourage healing by fostering hope and motivation, have also expressed concern about

the inconsistencies in family involvement and the absence of knowledge about how

nurses and families interact They underscore the variable aspects ofnurse and family

relationships (Callery, 1997; Chesla. 1996; Young, 1992). Chesla's (1996) examination

of nurses' work with families of hospitalized patients in a Cardiac Care Unit (CCU)

revealed that while nurses sometimes demonstrated high levels of skill and abilities in

supporting and encouraging the families, at other times the nursing staff seemed unaware

of and unresponsive to families' needs.

Robinson (1996), in her article about revisiting healthcare relationships, reported

that the actual relationship between family members and healthcare workers is not well

researched. Her study examined the feelings and beliefs of families (referred to as the

Family Nursing Unit (FNU) in Canada) who entered the healthcare system initially with

complete trust only to become disillusioned and distrustful ofb ealthcar professionals.

The FNU focused upon the relationship factors between the family members and the

nurse as the primary care agent She documented through her research that effectiveness

of care is heavily influenced by healthcare relationships and that the "nurse's relational

stance (p.167)" towards the family was a key factor in connecting with the family's

suffering and fostering healing.

Studies identifying positive attitudes towards parent involvement by healthcare

professions were found more frequently among the supervisors, instructors, and

administrators rather than the staffnurses, aides, and head nurses (Gill, 1993). However,

since the majority of family contacts occur at the patient's bedside, studies of this type

reinforce the importance of understanding both the "front line" nurse's view of their role

with families and their sense of efficacy in implementing that role.

The demand to increase involvement with families has been found to be

problematic by some nurses, however. A review of the literature indicates that many

nurses report that the absence of clear role conceptions with families has begun to cause

increased job dissatisfaction, stress, and confusion within the hospital setting (Porter,

1979; Brown & Ritchie, 1990; Gill, 1993; Coyne, 1995). Additionally, the new role

expectation to interact with parents and other family members can conflict with

traditional nursing role expectations to be the patient advocate, primary nurturer, and

decision-maker (Coyne, 1995).

Although many nursing professionals consider interactions with their patients'

families to be an integral part of nursing practice, there appear to be a wide variety of role

conceptions regarding the style of involvement with families. For example, many nurses

consider their role with the families to occur only for the purpose of providing better care

to the individual patient Others view the patients' family as a legitimate focus of care.

Because the nurse's conception of his/her role with the patient's family and his/her ability

to carry out that role is unclear, there is a need to identify the various ways the nurse-

family role might be conceptualized and the various factors influencing these varied role

conceptions. An essential exploration of these factors could provide valuable knowledge

to professionals involved in nursing education and in family therapy consultation to

address the effects of physical illness from a family perspective.

Purpose of the Study

The purpose of this study was to assess the self-perception factors and the

individual characteristics that influence staff nurses' styles of involvement with the

families of patients. Four self-perception factors were examined: family role efficacy,

role breadth efficacy, general self-efficacy, and perceptions of organizational support to

work with family members of patients. The following six individual characteristics were

also examined: age, marital status, educational level, years of nursing experience,

nursing specialty, and experiencing a hospitalized family member.

Theoretical Framework

To better understand the factors influencing the approaches nurses take with the

families of their patients, a theoretical framework was needed which addressed the degree

to which a nurse's style of involvement is influenced by individual internal factors, and

by the external dynamics of the larger organizational context in which the nurse is

employed. No one theory integrated these varied perspectives. Consequently, this study

was based upon three theoretical traditions: family nursing theory, social role theory, and

self-efficacy theory.

Family Nursing Theory

One of the most noteworthy developments of the past two decades is the attempt

made by nursing professionals to refine and expand the theoretical perspectives of

family-centered healthcare. Although historically nurses have been involved with

families through their patient care activities, it is only within the past decade that a

family-nursing specialty has developed which broadens the nurse practice model to

include families as the focus of primary care (Friedman. 1998). Although this specialty

has begun to define the nurse's role with the patient's family members, the many different

terms describing these roles give an indication of the varying concepts held within the

nursing profession about nurses' roles with families.

Friedman (1998) noted, in her review of the family nursing literature, that there

was often disagreement and confusion concerning the nature of the nurse's role with

families. She identified some of the different titles given to nurses' work with families

such as family healthcare nursing, systemic family nursing, family-centered nursing, and

family healthcare. She also reported that there was confusion as to how these roles

differed between community health nursing contexts and family therapy contexts.

The current study drew its theory of family nursing from a synthesis of the

nursing literature, conducted by nurse theorists Wright and Leahey (1999). They

identified two major types of nursing practice with families: "family nursing" and

"family systems nursing." Their research, based upon their observation and work,

specifically with the Family Nursing Unit (FNU) that was established in Canada, focused

upon the nature of the therapeutic bond between the nurse and the family (Robinson,


Wright and Leahey (1999) distinguished between these two types of nursing

approaches both in education and practice. "Family nursing" emphasizes two views of

family care: the patient as the main recipient of nursing intervention with the family as

background to nursing care and family as the main focus of nursing interventions equal to

or greater in need than the identified patient "Family systems nursing" instead of

utilizing an "either/or" focus, directs patient care from a "both/and" focus incorporating

the individual and the family together as primary care recipients who would benefit from

structural change in the family system. According to Wright and Leahey (1999), and in

this author's estimation, this level of nursing practice requires advanced training and

education in nursing theory, systems theory, cybernetics, and family therapy theory.

Because the researcher in this study sought to capture the perceptions of staff nurses with

a basic level of professional education and training, this latter type of family nursing

practice was not examined in this study.

Wright and Leahey's types of nursing practice reflect the possible variations in

(a) the ways that the nurse perceives the family, (b) the systemic view the nurse is

working within, and (c) the work environment and leadership factors that influence the

nurse (Friedman, 1998). Each of these conceptualizations suggests distinctly different

role expectations, training, and skill levels for the nurse. Consequently, social role theory

and self-efficacy theory provided useful theoretical frameworks for explaining the

relationship between work role expectations and the involvement of nurses in family-

oriented patient care.

Social Role Theory

Efforts to understand how nurses develop their role conceptions have been

informed by two major theoretical perspectives: the functionalist/structuralism role

theory and the interactionist/symbolic interactionist role theory (Hardy & Conway, 1978;

Biddle, 1986). Functionalist/sructuralism role theory posits an organic type of

relationship between the social structure and its roles. Role changes are precipitated by

the evolving society as well by the developmental needs of the organization or culture. In

contrast, the iterctionist/symbolic interactionist approach as proposed by Mead, posits

that roles are learned through social interactions that influence an individual's self-

concept and behavior (Hardy & Conway, 1978; Biddle, 1986). Empirical evidence

examining nurses' attitudes about their relationships with families, demonstrates that for

the vast majority, nurses are interested in further defining and understanding their roles

with family members (Seidl. 1969; Gill, 1993; Coyne, 1995; Callery, 1997).

Role theorists assert that role taking depends in part on social experience,

occupational experience, and the relevancy of the experience. Furthermore, role

acquisition is influenced by bow competent an individual feels in influencing others

through language and the ability to maintain his/her positional identity (Hardy &

Conway, 1978). These ideas suggest a link with Bandurm's (1977) self-efficacy theory,

specifically with the sources of self-efficacy such as mastery experiences, vicarious

learning, and verbal persuasion.

Bandura's Self-Efficacy Theory

According to Bandura, people's beliefs about their capabilities influence their

behavior, thinking processes, and motivation towards role taking and role formation. A

strong sense of self-efficacy contributes towards setting goals and attaining those goals

(Bandura, 1993). Bandura's theory of self-efficacy offers a valuable perspective for

understanding nurses' perceptions about their roles with families. Moreover, Bandura

(1993) acknowledges that learned skills are utilized well under stressful conditions only

when strong self-efficacy beliefs are present.

Sherer and Maddux (1982), early investigators of the concept of"generalized self-

efficacy," suggest that each individual brings generalized expectations into new situations

that help to determine his/her feelings ofproficiency. Although self-efficacy is generally

perceived within a specific area, a generalized sense of self-efficacy has been found by

researchers to be a valuable predictor of overall personal competence levels (Sherer &

Maddux, 1982; Schwarzer & Jerusalem, 2000). Consequently, a measure of general self-

efficacy was deemed important to include within this study since nurses with differing

levels of general self-efficacy may exhibit disparity in their roles with families.

Additionally, a type of self-efficacy termed "role breadth self-efficacy" has been recently

proposed and researched in terms of examining confidence levels that enable an

individual employee to expand his/her role within an organization (Parker, 1998).

Therefore, a measure of role breadth self-efficacy was included within this study to assess

nurses' initiative and proactive stance toward role expansion and its influence if any on

the styles of involvement with patients' family members

Most of the self-efficacy research in nursing has focused primarily upon assessing

perceived efficacy in conducting nursing tasks within specific practice areas or in nurse

preceptor relationships (Craven & Froman, 1993; Winmet, 1992; Richardson, 1993).

However, with the emergence of a family nursing specialty, nursing educators are

directing more of their attention to conducting training and research on improving nurses'

communication skills and interventions with the family members of patients (Wright &

Leahey, 1999).

Proposed Model

The variety of nursing practice, education, and work environments demands an

examination of basic nursing beliefs in the area of family involvement at the patient's

bedside. The following model (Figure 1) is presented as a possible paradigm identifying

self-perception factors that may influence a nurse's decision to involve the family in

patient care. Additionally, individual characteristics are represented from previous

research findings with nurses and families in the literature that have been shown to

impact nursing behavior and attitudes regarding family involvement in patient care.

It was the premise of this study that nursing practice on a unit staff level

interacted with the nurse's perception of generalized self-efficacy, role breadth self-

efficacy, and family self-efficacy to influence the style of nurses' involvement with

patients' families. Throughout this process, these beliefs can be impacted upon and

changed or influenced by moderating factors such as perceptions of organizational

support and individual characteristics such as the nurse's age, marital status, level of

education, years of nursing experience, nursing specialty, and having experienced the

hospitalization of a family member.

Core Factors Influencing Style o Nurse/Family Involvement

Factor I Factor II
Family role efficacy Organizational support
-Perceptions ofself-efficacy with family -Perceptions of the organization
assessment, interaction, counseling, to support and/or involve families
teaching of family members, in the care of patients
time management,

Factor HI Factor IV
Generalized efficacy Role breadth self-efficacy
-Perceptions of personal competence -Perceptions of effectiveness in
to deal effectively with stress one's organization

Factor V
Individual variables
-Age. Marital Status, Level of nursing education
-Type of nursing specialty, Years of experience as a nurse,
-Experience of one's own family member hospitalized

Styles of Involvement with Patient's Family

Style I Style II
Family nursing role conceived Family nursing role conceived
with an individual patient focus with a family focus

Figure 1 Family/Nurse Role Paradigm: Factors That Contribute to Nurses' Style of
Involvement with Families of Patients

Need for the Study

Collaborative family healthcare professionals hope to provide cost-effective and

humane care to patients. Medical family therapists who work in close collaboration with

physicians, nurses, and other rehabilitation specialists are trying to connect the

psychosocial and biomedical aspects of health care (Nichols & Schwartz, 1998).

Exploring and understanding the beliefs held and practiced by those professionals within

these multidisciplinary relationships will enhance their efforts.

Nurses are the largest healthcare profession and, through their involvement within

many health care contexts, would benefit from collaboration with professionals from

family therapy, sociology, social work, and anthropology. The clinical competency,

knowledge base, and common interest in family care by all of these professions needs to

be recognized and more fully understood in preparation to facilitate family functioning

and health and illness (Bell et al, 1992).

Family nursing theory supports the concept that engaging families within health

professionals' practice can contribute to the health and welfare of their patients.

However, this positive and/or resourceful utilization of families within the healthcare

arena is largely dependent upon the style of involvement with patients' families which

nurses construct for themselves. Given the limited knowledge about how nurses

conceptualize their role with families and how they assess their competency in working

with families, the need for this study was recognized.

Research Questions

The following research questions were posed in this study:

1. Is there a relationship between the preferred style of role involvement with
families and the level of family role self-efficacy reported by staff nurses?

2. Is there a relationship between the preferred style of role involvement with
families and the degree of perceived organizational support for working with
patients' families?

3. What are the levels of generalized self-efficacy reported by staff nurses?

4. What are the levels of role breadth self-efficacy reported by staff nurses within
their organizations?

5. Is there a relationship between the preferred style of role involvement with
families and the staff nurses' reported general self-efficacy and role breadth

6. Is there a relationship between the preferred style of role involvement with
families and the staff nurses' individual characteristics such as age, marital status,
the level of nursing education, the type of nursing specialty, years of experience
as a nurse, and having had the experience ofone's own family member
hospitalized to the nurse's choice to endorse family-centered patient care?

Definition of Terms

For the purpose of this study, key constructs and terms are defined as follows:

Role. Role is a term used in the literature to refer to both the actual and expected

behaviors connected with a situation (Hardy & Conway, 1978)

Role expectations. Role expectations are specific to a position and identify the

attitudes, behaviors, and thinking processes required to maintain that role (Hardy &

Conway, 1978).

Role stress. Role stress or stain is an internal condition that result from vague,

conflictual, or unreasonable role demands and/or expectations (Hardy & Conway, 1978).

Perceived self-efficacy. Perceived self-efficacy is defined as people's judgments

of their capabilities to organize and execute courses of action required to attain

designated types of performances. It is concerned not with the skills one has but with

judgments of what one can do with whatever skills one possesses (Bandura, 1986, p.


Role breadth self-efficacy. Role breadth self-efficacy is defined as the

employee's perceived ability to expand work tasks in a broader and more proactive

manner (Parker, 1998).

Family. Family is defined as a social context of two or more people characterized

by mutual attachment, caring, long-term commitment, and responsibility to provide

individual growth, supportive relationships, health of members and of the unit, and

maintenance of the organization and system during constant individual, family, and

societal change (Craft & Willadsen, 1992. p.519)

Family-centered care. Family-centered care is a philosophy that nurtures families

in the caregiving role and believes that collaboration between families and healthcare

professionals promotes effective healthcare (Gill, 1993).

Medical family therapy. Medical family therapy is a comprehensive

psychotherapy that seeks to bring a biopsychosocial systems perspective to the treatment

of individuals and their families (Doherty. McDaniel, & Hepworth, 1994).

Family nursing. Family nursing is an evolving specialty area encompassing other

areas in nursing that includes the family as client within the nursing practice paradigm

(Friedman, 1998).

Family nursing process. Family nursing process is defined as a systematic

problem-solving process that is utilized when working with individuals, families, groups,

or communities (Friedman. 1998).

Organization of the Study

In Chapter 1 the theoretical framework, purpose, and need for this study are

described. In Chapter 2 a review of the related literature is presented. Chapter 3 consists

of a description of the methodology subjects, and research design. In Chapter 4 the


results of the statistical analyses of the data are reported. In Chapter 5 a discussion of the

results, the study's limitations, and suggestions for future research are presented.



In this chapter theoretical and research literature is reviewed critical to

understanding why nurses choose to involve families in the care of their patients. Three

major theoretical constructs are proposed as central to understanding a nurse's choice of

involvement with patients' families: (a) the nurse's construction of her/his nurse-family

role, (b) their sense of efficacy in implementing this role, and (c) the nurses' perceptions

of the family nursing role expected by members of their work environment.

Consequently, the theoretical and research literature concerning family-nurse

involvement, social role development, and role efficacy will be examined as frameworks

for understanding how nurses decide to involve family members in their nursing practice.

Changing Expectations for Family-Nurse Involvement

The biographical writings of Florence Nightingale, considered by most to be the

mother of nursing, depict her interest in encouraging the family members (wives) of the

soldiers she cared for during the Crimean War to be involved in their treatment and her

expectations that nurses would be involved with the families' of patients (Whall, 1999).

However, it was in the realm of health care of children rather than care of adults that a

nursing role with families has gained the most acceptance by families if not by nursing


A number of factors have contributed to the development of these expectations for

family involvement in children's healthcare. First, the nursing literature depicts a marked

change in the expectations parents have concerning the role they expect to play in their

children's healthcare. Most parents have moved from an expectation that their role will

be that of a distant spectator of their children's hospital care to that of a role in which they

will have increasing involvement and responsibility. The need to understand and define

the changing role expectations of both parents and nurses for greater family-nurse

involvement has generated a growing nursing literature depicting how nurses might

interact with parents and other family members of patients. As a consequence, a growing

number of nursing theorists and educators are encouraging nurses to expand their nursing

role with families by spending more time with parents, supporting and listening to them,

and providing more information to parents about their children's needs (Brown & Ritchie,


Despite the valuing ofparental participation, nursing researchers have noted that

many nurses report inherent conflicts and contradictions in implementing an expanded

role with patients' family members. Brown & Ritchie (1990) conducted a study in which

they interviewed twenty-five pediatric nurses in the nurses' homes about parent and nurse

roles and factors that influence those roles. They reported that the nurses they

interviewed had varying definitions as to what constituted family nursing care. In

addition the nurses they studied reported some reticence about and several negative

attitudes concerning parental involvement with patients.

This discomfort by nurses with increasing parental involvement has also been

noted by Seidl (1969). Utilizing a functional role theory perspective to explain the sense

of discomfort some nurses reported, Seidl suggests that the increasing participation by

parents in the care of their children threatens the nurses' status as they relinquish parts of

their roles to parents. Additionally, his study of 231 pediatric nursing personnel which

included nurse's aides, practical nurses, and registered nurses with varying degrees,

demonstrated that the higher the nurse's social position within the organization and their

level of educational training, the more accepting were their attitudes toward parental

participation. He noted, however, that higher social position and education usually

represented nurses in supervisory and administrative roles rather than nurses in direct

patient care roles.

Several nurse theorists, while acknowledging negativism among nursing staffing

relation to parental involvement, promote family-centered nursing practices and describe

particular nursing interventions with families. Luciano (1972) wrote a chapter in Nursing

Clinics of North America on "Staff Development: Toward the Implementation ofFamily-

Centered Care." She acknowledged that a dilemma existed between what nurses' say

about their attitudes relative to parental involvement and the changing philosophy in

pediatric healthcare toward involving the family in the child's care. Luciano suggests

that nursing administrators might support these changing role expectations by changing

the job descriptions to emphasize the functions of family interviewing, family care

planning, and teaching with parents.

Other nursing theorists suggest that the responsibility for making this role change

be on the individual nurse, claiming that all nurses must include the family as a unit of

care. Utilizing an interactionist role theory perspective, Eyres (1972), in her chapter in

the Nursing Clinics of North America on family-centered nursing stated that a "role is

conceived of as a constellation of behaviors that emerge out of interaction between self

and other. Nurses must learn to create their roles as they enter into each new relationship

with a patient.... and/or family ... that is most therapeutic for each (p. 28)." Although

her suggestions underscore the value of nursing care involving families, the assumption

that all nurses will embrace this redefinition of their professional role seems naive and

somewhat blind to the individual nurse's concept of nursing and his/her professional

goals. The following statement by Eyres (1972) addressed to nurses concerning their

contact with families exemplifies this mindset:

The nurse must accept the patient and his family as the people they are,
with a non-judgmental attitude of positive regard. The nurse need not
approve or sanction behavior with which she disagrees, but it is
essential that she allow family members to be themselves, and not
demand that they live up to her expectations. (Eyres, 1972, p.32)

While this sentiment appears congruent for a nurse who embraces family

involvement as a part of his/her practice role, it does not appear to recognize the

individual nurse's own interpretation of his/her role. Statements such as these abound

within the nursing literature and have prompted this study that seeks to explore nurses

reaction to the underlying assumption that individual nurses must include family care as a

part of their nursing role.

A critical review ofthe literature about nurses' involvement with families

continues to demonstrate that nurses and parents struggle with defining their relationships

within the present healthcare system. Coyne (1995) reviewed studies that addressed

expectations of parents' levels of participation in their children's hospital care, roles of

parents in the hospital, attitudes ofpediatric nurses towards parental participation, and

factors influencing both nurses' and parents' attitudes. She pointed out that parents also

grapple with the assumption that they should participate in their sick child's care. She

emphasized that these studies on parental participation, while reporting differences in

partnership levels and desires, have failed to examine possible reasons for this. Coyne

(1995) addressed the complexity in her review of the relationships between parent,

patient, and nurse and suggested the need for defining the role of each in the following


A partnership cannot occur without deliberate assessment of the
attitudes and expectations of both parents and nurses and a joint
commitment to the new relationship. (Coyne, 1995, p. 720)

Implicit in the family nursing studies of the past decade is a veiled recognition

that nurses are undecided whether their professional role should include the families of

patients. While much of the available research on family nursing depicts ways that

nurses might communicate with families and provides justifications for including families

in patient care, their titles speak to a tacit need to persuade nurses to include families

within the nursing sphere. Keywords such as "reconciling," "promoting," "changing

attitudes," "hidden areas of nursing work," and "demand or invitation to change" appear

in the titles of many of these studies. Such terms suggest that many nurses may not have

made up their minds whether to include families in their role conception (Chesla, 1996;

Young, 1992; Laitinen & Isola, 1996; Callery, 1997).

The perspectives presented in these studies however, do suggest important criteria

that could define possible forms that a nurse's role with the family members of patients

might take. Consequently, a review of the various conceptualizations of the family-nurse

role appearing in the nursing literature follows.

Theories of Family Care

Family social scientists and nursing theorists have developed a variety of different

theoretical models depicting the family's role in healthcare, the types of needs families

have for care from health professionals, and the levels of family care that health

professionals might provide. Four of these perspectives are presented below: (a) the

family health and illness cycle developed by Doherty and McCubbin. (b) the evolution of

medical family therapy described by Doherty, McDaniel, and Hepworth, (c) the

continuums of family nursing proposed by Hanson and Boyd, Marilyn Friedman, and

Marie-Luise Friedemann, and (d) the typology of family nursing approaches proposed by

Wright and Leahey.

Dohenv's Family Health and Illness Cycle

A variety of researchers have examined the impact of health crises on the mental

and physical health of family members. One model, developed by William Doherty and

his associates, synthesized various family and health research literature into a

complementary model known as the Family Health and Illness Cycle. This model

depicted in Figure 2, chronologues how families may encounter the healthcare system.

According to these authors, this model focuses on the family's experience with a

single illness. It does not depict the array of possible dynamics that might occur if a

family was experiencing multiple illnesses concurrently. The authors suggest that there

are important aspects of family health, such as cohesion, adaptability, problem solving,

and individual psychological processes, which are not accounted for and certainly can

influence this cycle (Doherty & Campbell, 1988). Pertinent to this study was Doherty

and Campbell's recognition that healthcare professionals tended to emphasize different

portions of this cycle hence contributing to a fragmentation of care. Moreover, families

responded to disappointments with the care received from health professionals by making

demands for greater family involvement and demonstrating a desire to oversee their own

care (Doherty & Campbell, 1988).

Figure 2 Diagram of Family Health and Illness Cycle-Read clockwise, beginning
with "Health Promotion and Risk Reduction." (Doherty & Campbell,

Evolution of Medical Family Therapy

During the 1970s and the 1980s interest in families and chronic illness fostered

investigation into applying the concepts of family systems theory and practice within the

medical setting. Working alongside physicians, nuses, and social workers within clinical

and teaching settings, family therapists demonstrated the value of these collaborative

relationships towards improving health in patients and their family members (Doherty,

McDaniel, & Hepworth. 1994).

The goals of medical family therapy aim to help the family cope with illness,

decrease conflict about managing certain aspects of care such as medication, increase

lines of communication with healthcare providers, encourage acceptance of medical

problems that cannot be cured, and assist the family through lifestyle changes (Doherty et

al., 1994). These reflect well-established precepts in the nursing profession and suggest

a collaborative partnership among family therapy and nursing. Medical family therapists

promote family consultation to explore the resources available to respond to the demands

of the illness. This consultation however, is based within an alliance with the medical

and nursing staff. Recognition is given to the devastating impact of chronic illness to the

family as expressed by Peter Steinglass, "it can be like a terrorist, who has appeared on

the doorstep, barged inside the home and demanded everything the family has (quoted in

Nichols & Schwartz, 1998, p. 342)."

Doherty, McDanieL and Hepworth (1994) describe the origins of medical family

therapy citing: (a) Minuchin's work with psychosomatic families, (b) Steinglass and his

colleagues' theory and research that showed family organization around alcoholism and

mental illness, and (c) Rolland's typology that examined family dynamics in chronic

disease. They further acknowledged family therapists' efforts to attend to families'

relationships with larger systems and stress that medical family therapy must include the

relationship with the related healthcare system and its providers of care. The "therapeutic

triangle" has been expanded in medical family therapy to a "pentagon" that consists of

the family therapist, the illness, the patient, the family, and the rest of the healthcare


Family Nursing Continua

Hanson and Boyd (1996), authors of Family Health Care Nursing: Theory,

Practice, and Research, note that there is disagreement and confusion in the nursing field

as to how a specific family nursing specialty would differ from other nursing specialties.

They acknowledge that community health nursing, maternal/child health nursing, and

mental health nursing have traditionally focused upon families in their delivery of care.

These authors maintain that a nursing specialty focusing on the centrality of the

family is needed and that research supports the importance of this construct to

understanding illness behaviors, influential factors in illness, and maintaining and

promoting health regardless of the nursing specialty. They define family healthcare

nursing as:

The process of providing for the health care needs of families that are
within the scope of nursing practice. Family nursing can be aimed at
the family as context, the family as a whole, the family as a system, or
the family as a component ofsociety. (Hanson & Boyd, 1996, p.7)

Hanson and Boyd (1996) describe four different possible perspectives the nurse

might consider in formulating his/her role with patients' families. The first perspective

"family is the context," is the traditional approach of viewing the individual patient as the

center of nursing focus and the family as a resource or stressor. In contrast, the second

approach, known as the "family is the client," depicts the view of the nurse delivering

healthcare to and performing assessments on all members of the family. A third

approach entitled the "family as a system," is a perspective that stresses the focus of

nursing practice being that of assessing and intervening in the interactional system of

families. Finally, the fourth approach, that of the "family as a component of the society,"

suggests that the nurse view the family within the larger context of the community

similarly to viewing the family as situated within a religious, economic, and/or

educational institution.

In her book, Family Nursing: Research, Theory, and Practice, Marilyn Friedman

(1998) presented a continuum of differing perspectives on and definitions of family

nursing depicted by various writers in the field. These perspectives range from nurses

viewing the family only as the context for influencing the patient's health, to focusing on

the family's internal dynamics, structures, and functions as possible areas for nursing

assessment and intervention. Within this range she notes that nursing practitioners

sometimes see the individual family members and/or family subsystems as the

appropriate focus of a nursing assessment and intervention.

Marie-Luise Friedemann (1999), in her chapter "The Concept of Family," states

that a description of family nursing should begin with an exploration of the scope of

family nursing. She explains that the scope of family nursing practice should encompass

all nurses who have access to patients' family members. She then specified this domain

in the following terms:

Interpersonal family nursing can be practiced only by a nurse who sits
together with more than one family member and guides the
communication process through appropriate channels. The nurse leads
family members to express thoughts, and guides them towards
workable goals and necessary strategies. (Friedemann, 1999, p.15)

Friedemann (1999) conceptualizes the role of the family nurse as taking three

distinctively different forms. The first form, termed "individually-focused family

nursing," consists of the nurse establishing a relationship with and treating each

individual member of the family as the need arises. Although one family member is seen

as the client, the nurse should recognize that any family member can become a client and

thus it is necessary to involve the family members as a supportive network to facilitate

change. She acknowledges that system and subsystem change is the likely result of this

individual focus.

In the second form, that of "interpersonal family nursing," specific interventions

are directed at changing family processes of communication, decision making, and/or

limit setting in order to initiate subsystem behavior change. The third form of family

nursing specified by Friedemann, entitled "family system nursing," seeks to create family

system and structural change. It is in this form that the patients' family becomes the

client and the nurse's actions focus on intervening within the environment of the family.

Friedemann suggests that both the generalist and advanced practice nurse can and should

practice the first or second forms of family nursing. However, she proposes that only

those nurses trained in family therapy theory and practice should intervene at the level of

"family system nursing" with dysfunctional families (Friedemann, 1999).

Wright and Leahey's Typology of Family Nursing Practices

Wright and Leahey (1999) proposed a typology of family nursing practices in

their chapter entitled "Trends in Nursing of Families." They base their theory upon their

own clinical practice and a documented history of observing clinical nursing practice.

They report two distinctive types of family/nurse roles demonstrated in nursing practice:

one type focusing on the individual patient dealing with his/her illness within the context

of their family and the other type focusing on the family caregivers' efforts in coping

with their family members' illness.

The authors label each of these two types of family nursing under the rubric of

"Family Nursing." Whereas, one centers on the patient's illness within the family (Figure

3), the other stresses the impact of the patient's illness on the family (Figure 4).



Figure 3 Family Nursing: Individual Focus (Wright & Leahey, 1999).



Figure 4 Family Nursing: Family is Focus (Wright & Leahey, 1999).

Wright and Leahey (1999) identify one additional type of family nursing focus

which they state is not necessarily within every nurses scope of practice and training;

that of treating the whole family as the care recipient. This type of family nursing role

conception differs from the second type in that it is a simultaneous focus on both the

family and the individual client Figure 5 represents their view of the nurse relationship

focus when the family is the unit of care

Figure 5 Family Systems Nursing: Family as Unit of Care (Wright & Leahey,

Wright and Leahey (1999) viewed this type of family/nurse role as an integration

of nursing theory, systems theory, cybernetics, and family therapy and requiring

advanced training in these areas. Because the current study seeks to assess staff nursing

practice with a variety ofeducational backgrounds in preparation and training, this type

of family nursing will not be included as a style of nurse/family involvement to be

assessed by the study participants.

In conclusion, there are a variety of ways in which family nursing has been

conceptualized. It appears that theform of family nursing practice is related to the

nurse's conceptualization of who is his/her appropriate target for intervention and how

she/he believes they should interact with that intervention target. Additionally, the

climate and/or philosophy of the employing organization affect the extent of nurse's

family focus through positive and negative reinforcement and/or recognition (Friedman,


Research on Family Nursing Practice

Although nurses are theorizing about and involving families more frequently in

healthcare, there is a dearth of rigorous, empirical research describing how nurses

intervene with families in patient care and what are the constraints to such involvement.

There is even less evidence available regarding the effects of such interventions. For

example, Laitinen & Isola (1996) examined the perceptions of 369 informal caregivers as

to whether nursing staff promoted or inhibited their participation with their hospitalized

family member, and concluded that there was a deficit of empirical knowledge regarding

the nature ofthe relationship between families and nursing staffs. In a similar vein,

Chesla (1996) interviewed and observed the practice of 130 critical care nurses and

suggested that there was limited empirical evidence concerning the effects of nurses'

interventions with families.

What information is available on this topic is largely anecdotal in nature. Chesla

(1996) reported that nurses more often provided stories about family care with patients

who were infants, children, or had terminal illnesses. Conversely, there were fewer

stories by nurses about family involvement and contact with more acutely ill patients or

patients who had a long-term course of recovery. Consequently, Chesla suggested that

the "type of patient" served by a nurse is an influential factor in determining how nurses

relate to family members.

Callery (1997) conducted interviews with parents of 24 children discharged from a

surgical ward at a children's hospital He also spent 125 hours observing nursing

practice, reviewing nursing and medical records, and interviewing ten registered nurses,

one healthcare assistant, and the surgeon caring for the children in the study. He reported

that the nurses characterized their relationships with their young patients' parents as

frequently unpredictable and requiring ongoing negotiation of parental demands and

patient needs. The nurses he interviewed noted that it was often difficult to plan ahead

and organize their work conditions as a result of parent involvement In addition, some

nurses reported that they experienced considerable difficulty trusting parents' abilities to

take care of their children. This questioning of the parents' capacity to adequately care

for the health of their children was also reported by previously mentioned researchers

who found that nurses felt that they knew what was best for the patient and that their

professional right was to define the parent's involvement (Coyne, 1995).

Time was cited as a frequent factor influencing a nurse's interaction with patients'

families. In his interviews, Callery (1997) noted that nurses reported difficulty in making

time available to listen to parental concerns and to assess family members' needs when

having an already full schedule of patient care responsibilities. Additionally, some nurses

reported that when they took the time to spend with parents, they were perceived by

colleagues as wasting time or neglecting their other duties. Callery (1997) concluded that

this group of "nurses did not appear to have a common view about what the extent of

nurses' involvement in caring for parents should be. which parents should be treated as

legitimate clients, and how this aspect of care should be organized and managed (p.994)."

Several researchers have examined family members' perceptions of their

relationship with nurses and other healthcare workers. Coynes (1995) review of the

literature about parental participation in their children's care reported that some

researchers acknowledged there were parental complaints about the need to negotiate,

bargain and placate nurses in order to participate in the care of their children.

Additionally, some parents were described as experiencing extreme stress during their

child's healthcare crisis and feeling helpless, fearful, angry, depressed, and guilty.

Given these circumstances, it is not surprising that when parents are queried as to

which nursing interventions they found most helpful, most parents identified nursing

behaviors that contributed towards building a relationship with them as more helpful than

specific nursing techniques (Robinson, 1996). Robinson (1996), in her commentary

about revisiting healthcare relationships, focused on a grounded theory study that

occurred at the Family Nursing Unit (FNU) in Calgary, a unique educational and research

unit that helps families cope with health problems. This study explored the outcome of

"family systems" nursing interventions with families having difficulty managing chronic


She stressed that an outcome of this study revealed that certain nurse behaviors

promoted parental participation. One behavior was "the nurse's relational stance" which

she defined as the nurse's ability to show compassion but still maintain emotional

distance. A second behavior was the nurse's willingness to accept what family members

had to say, and a third behavior was the ability of the nurse to focus on the families'

strengths and resources (Robinson, 1996).

These nurse behaviors were consistent with the previously cited research of

Laitinen and Isola (1996) who found that the nurse behaviors most often mentioned as

valuable by family caregivers were those that built trust within the relationship such as

emotional and cognitive support, empathy, and friendliness. Although these studies have

identified the need for nurses to further define and examine their role with families, they

demonstrate that nurses and families have become partners in addressing the healthcare

needs of patients.

Theoretical Framework

This study is based upon several specific theoretical assumptions. First, the

choice to involve families in patient care is only examined from the perspective of

individual nurses. Second, only those features of nurses' thinking, decision-making and

actual behavior characteristic of different styles of involving themselves with their

patients' families will be examined in this study. Third, those factors that appear to

influence nurses' family involvement stance are of interest in this study. To this end, the

theoretical and research literature from the two theoretical traditions social role theory

and self-efficacy theory was examined. First, basic assumptions about role theory and

how these assumptions influence the design of the current study on nurses' beliefs, values

and clinical practice are reviewed. Then the assumptions of self-efficacy theory and their

applications in this study of nurses' professional practice will be examined.

Role Theory

Some role theorists use the term role to refer to characteristic behaviors (Biddle,

1986; Burt, 1982), others use it to designate social parts to be played (Winship & Mandel,

1983), and still others offer definitions that focus on scripts for social conduct (Bates &

Harvey, 1975). In addition, role theorists disagree as to the modes of expectations, which

they presume are responsible for generating these specific patterns of behavior, social

parts, or scripts. Some theorists assume that such expectations should be thought of as

norms (i.e. prescriptive in nature) characterizing the role context, other assume such

expectations to be beliefs internall subjectivity), and still others view them aspreferencer

(or attitudes). Moreover, some theorists (e.g. functionalists and organizational role

theorists) assume that the demands and expectations inherent in particular tasks or a

particular social position have a dominant influence in shaping an individual's role

performance. In contrast, other theorists (most notably the cognitive role theorists and

the symbolic interactionists) contend that the individual participant's anticipatory beliefs

shape their role performance. Although role theorists differ over their definitions of the

concept of role, their assumptions about roles, and their explanations for the locus of

influence of how a role develops and changes; most versions of role theory presume that

expectations, learned through experience, are the major generators of roles, and that

individuals are aware of the expectations they hold.

In this study, the assumption about role expectations offered by Biddle (1986) is

used to identify the salient constructs about roles used in this study. Biddle assumes that

role expectations can appear simultaneously in at least three modes of thought-norms,

preferences, and beliefs- which are learned through somewhat different experiences.

Paralleling Biddle's thinking, a number of social scientists have explored the role

expectations of nurses from the joint perspective of role expectations as "external"

norms, as role preferences, and as role beliefs. For example, Levinson (1959) described

the norms what he called "organizationally given role-demands" in his research study

examining the relationships between role, personality, and social structure. He reported

that the role demands described by nurses imposed by hospitals often fail in providing the

"structural requirements.. explicimess, clarity, and consensus (p. 174)" when defining a

position. Another important concept addressed in Levinson's (1959) writings is one of

"personal role-definition," a term he used to describe the process of adaptation within an

organization. He defined two levels of adaptation that apply directly to the investigative

objectives of this study: role conception at an ideational level and role performance at a

behavioral level.

Levinson (1959) emphasizes that although many social scientists assume that role

conception within a certain social position has uniformity, he cites researchers such as

Greenblatt, Williams, Gross, Mason, and McEache (Greenblatt, Levinson, & Williams,

1957; Gross. Mason & McEachem, 1958) who have demonstrated that in reality there are

vast differences in conceptions of roles within social situations. Furthermore, individual

role performance is the actual behavior exhibited based upon that role conception or role

definition. Presupposing previous investigations of role performance that demonstrate

variability in patterns, Levinson suggests that researchers should draw a distinction

between role conception, role performance, and role demands (Levinson, 1959).

In this study, it is assumed that role conceptions develop as a result of external

role demands, and individual role performance experiences. A reciprocal process is

conceptualized in which role expectations emerge during an interaction in which roles are

designated, assumed, and/or validated. Meleis (1975) for example, utilized role theory to

explore a possible theoretical basis for nursing diagnoses, and recognized that the

interactional dyad system between patient and family changes to a triad with the entry of

the nurse. Although Meleis was focusing upon the role change in the patient, her views

assume an equal role transition for the nurse as well as the family member.

Meleis (1975) expressed concerns about role insufficiency from the patients'

perspective defining it as difficulty in understanding and performing the goals associated

with the specific role behaviors. However, this is equally true for the nurse, who

struggles between role behavior, role expectations, organizational demands, and

incongruity in fulfilling role obligations and/or expectations. Meleis (1975) suggests a

process of intervention by the nurse to assist the patient in making the role transition of

patient that incorporates role clarification and role taking among other concepts. This

intervention seems equally necessary and relevant to the nurse as he/she interacts with

patients and their family members. In this study nurses were invited to identify their role

expectations about their encounters with the family members of their patients and their

sentiments and goals associated within their relationships with patients' families.

Specific studies on nursing role conceptions (or beliefs) exist within the literature

as early as 1955-1960 with the work of Habenstein and Christ, Corwin, and Kramer who

described and eventually categorized nursing role conceptions into three types:

professional, service traditional, and bureaucratic (Minehan, 1977). Corwin developed a

scale to compare the three different types ofrole conceptions based upon identified

nursing values such as "desire to do bedside nursing," "desire to serve humanity,"

"definition of nursing as a religious calling," "maintenance of professional standards,"

"punctuality," "strict rule-following," and "loyalty to the hospital authorities and hospital

physicians" (Minehan, 1977).

This scale has been utilized in several role conception studies within the nursing

field. Most recently it has been used to assess relationships between role conception

(professional, service, and bureaucratic), role deprivation, and self-esteem in

baccalaureate nursing students (Lengacher, 1994). Taunton and Otteman (1986), linked

their research on the role expectations of 581 staff nurses in the Midwest on the "multiple

dimensions of staff nurse role conception" to Corwin, and the later work of Kramer to

obtain a model of staff nurse role conception.

It is interesting to note that these early studies of nurses' role conception seem to

depict the influences on role conceptions as external to the individual and inherent in

particular social positions and accompanying statues. Taunton and Otteman (1986) list

and describe their operational domains in a functional format such as "services to

patient," "management function," "accountability," "structure for practice," "protection,"

and "alliance." Patient services are the only areas that mention nurse contact with family,

and that is assumed to take place as a result of patient teaching and/or counseling.

Kramer, McDonnell, and Reed (1972) continued with this functional focus in their study

with 195 collegiate graduate nurses on why nurses left their profession. They attempted

to establish links to role "adaptation," "time competence." and "inner-directedness."

Many of the role conception studies conducted in the 1980s focused on discrepancies

between the professional and bureaucratic roles of nurses. For example, Ketefian (1985)

examined 217 practicing nurses of different specialties to test the relationship between

professional and bureaucratic role conceptions and moral behavior. Itano, Warren, &

Ishida (1987) compared professional and bureaucratic role conceptions and role

deprivation in a preceptorship program with 118 baccalaureate-nursing students.

These studies on nurse role conception and measurement suggest that nurse role

conceptions have shifted and the relevancy of certain nurse role conceptions from the

1950s may be questionable (Minehan, 1977). Consequently these earlier studies have

established that there is a real diversity of role expectations among nurses and that this

diversity may be a possible source ofjob stress and/or role conflict, especially in the

areas of professional and bureaucratic role behaviors (Taunton & Otteman, 1986).

Later research on nursing roles seems to have followed the shift sociologically

from functional role theory focus to interactional role theory by exploring a different set

of variables or characteristics believed to influence nurse role conception. Mentioned

earlier was Lengacher's (1994) study linking role conception to self-esteem. Gill's (1993)

study on health professional attitudes toward parent participation in their children's care

considered level of education and experience as defining factors.

The healthcare field has begun to recognize the importance of congruence

between the behavior of healthcare providers and their role concepts. Research during

the 1980s and 1990s demonstrate this concern, as it seems to focus on describing the

actual role or practice of nursing. Lawrence, Wearing, and Dodds (1996) coined the term

"nurses' cognitive representations of nursing" to describe their model of the positive and

negative features of nursing work. Their research surveyed 405 female nurses at two

Melbourne, Australia teaching hospitals who completed their Nurses' Workplace

Questionnaire (NWQ). They specifically highlighted the stressfulness of interactions

between hospital personnel, patient, and other healthcare workers. Unfortunately, they

did not include the family members of patients. The authors' focus on self-reports for the

purpose of obtaining a view of nursing from the "eyes of contemporary nurses" was an

influencing factor on this present study because it suggested the need for the profession to

be aware of the "interpretations placed on events by its practicing members (p383)."

Researchers, focusing on patient satisfaction and patient opinions concerning

their healthcare, such as Verschuren and Masselink (1997) have noted the impact of role

concepts and the process of collaboration between physicians and nurses. Their study

consisted of data collected from a set of pilot interviews with physicians, nurses, and

patients in an academic and a general Dutch hospital. The role concept in this study was

defined as the opinions healthcare providers had about their own tasks and function

within their organization. Verschuren and Masselink (1997) focused on the frequency and

type ofactivity physicians and nurses perform. The role concept of patient and family

were not included, however outcome measures did demonstrate inconsistencies between

nursing role behavior and role concept, particularly around levels of communication with


The differing levels of nursing education have contributed to role confusion and

some studies have attempted to clarify levels of nursing care and describe nursing

practice. Researchers such as Allender, Egan, & Newman (1995) have provided support

for measuring differentiation of role, especially with the staff nurse whose responsibilities

they found exceeded their job description in terms of nursing ability and underestimated

contributions by some nurses. This mirrors the importance of this study because nursing

practice has gone through many changes in previous decades and nurses are faced with

changing definitions of professional spheres (Lawrence et al, 1996).

Descriptive research, pertaining to the concept of role in nursing, developed and

tested professional and bureaucratic role measurement instruments. These wre aimed at

comparing the constructs of professional and bureaucratic role on the impact upon job

description, role deprivation, education and training, career decisions, and role adaptation

(Corwin & Taves, 1962; Kramer ct al., 1972; Minehan, 1977; Ketefian, 1985; Taunton &

Otteman, 1986; Itano et aL, 1987; Talotta, 1990; Lengacher, 1994). The majority ofthe

tools used in these studies were quantitative in nature and demonstrated differing degrees

of reliability and validity; however, qualitative methods were also utilized such as

interviews and observational methods.

Other quantitative instruments were developed to identify specific features

relative to nursing and/or healthcare professionals. Lawrence, Wearing, and Dodds

(1996) looked at the positive and negative aspects of"nurses' work spaces" with the

Nurses' Workplace Questionnaire (NWQ) with the outcome of understanding how their

environments, social position, and opportunities and hardships at work influenced nurses.

Although this study was instrumental in describing nursing ideas about their work and

work environment, it assumed that nurses' viewed family contact as within their realm of


Verschuren and Masselink (1997) designed questionnaires that focused on the

role conception of physicians and nurses. They were particularly interested in having

each group define tasks that represented their functions at work. Their response rate was

in the 80-90tL percentile and was thought to indicate to the authors the importance of

these issues to physicians and nurses. Interestingly, both physicians and nurses did not

list any behaviors that mentioned family interactions, family contact, or specific family

care activities.

Allender, Egan, and Newman (1995) examined role differentiation among staff

nurses, team leaders, and case managers They attempted to establish clarification

between these roles and define their parameters within professional nursing practice. The

Nursing Practice Inventory (NPI) they developed incorporated 6 dimensions and/or levels

of practice. There were several statements about collaboration with interdisciplinary

team members, and at least for the case manager, reference to a relationship extending

across "institution-home-community settings." However, none of their dimensions or

levels referenced families, family interactions, or nurses' ideas about their specific role

with family members of patients.

A recently developed and tested instrument emerging from job design theory was

published in response to a perceived need to address the changes in nurses' jobs amidst a

reconstructing healthcare system. The StaffNurse Job Characteristics Index (SNJCI) was

created to evaluate connections between core job dimensions depicted in the Job

Characteristics Model (JCM) and specific features of nursing practice (Tonges, Rothstein,

& Carter, 1998). The researchers of this model devised the SNJCI to describe the

characteristics of a nurse's job. This index was unique in that, unlike other instruments, it

actually included care directed at the family. The one hundred-item instrument contained

six statements (6%) that specifically addressed families and/or family interactions.

However, another way to consider this is that the majority of activities (94%) that these

researchers use to describe a nurse's job did not include care directed at families.

Questions arise concerning nurses' view of their work with families in the light of

the above research. Do nurses have a role with families? Do they perceive a role with

families that impact their other duties? How much of a portion of their work is

comprised of interacting and dealing with families? Are nurses' roles with families

hidden from each other and the organizations in which they practice? A comprehensive

search of existing nursing role literature confirmed that there were no specific

measurements that addressed nurses' conceptions of their role with the family members

of patients.

Self-Efficacy Theory

Interacting with the family members of patients in the best of situations is not an

easy process. Nurses are taught basic communications skills and techniques during their

education but, as in other aspects of nursing, the realities of practice and education can be

very different. As the practice field of the nurse expands to include a team and/or

interdisciplinary approach to healthcare, nurses are facing more opportunity and/demands

to interact with a variety of patient advocates including the family. The nurse's decision

to embrace or avoid contact with family members may depend upon a belief that his/her

competency in interacting with the family can be used to help create a positive outcome

for the patient and the family.

Albert Bandura's (1977) concept ofself-efficacy as a self-generated evaluation of

one's own skill provides an important framework for identifying those beliefs held by

nurses that may affect their choice to involve themselves with their patients' families.

Bandura (1977) differentiates between outcome and efficacy expectations in that he states

that an outcome expectation is defined as "a person's estimate that a given behavior will

lead to certain outcomes (p.193)." He goes on to explain that an efficacy expectation

differs in that it is based upon thinking one has the ability to perform the behavior that

causes the outcome.

Therefore, although nurses may have leased through their formal education that

involvement with family members is helpful to patient recovery or outcome, doubts or

questions about their abilities to interact and/or intervene successfully with family

members, may be more influential in shaping their decisions about inclusion of the family

in patient care. This factor could explain the previous reports in the nursing literature

concerning inconsistencies between what nurses believe to be their professional role and

what they report doing in actual practice.

Bandura (1977) posits that an individual's belief in his/her effectiveness

contributes towards the actual initiation of behavior; the choices of behavioral activity,

the amount of effort put forth, and even determines how long the individual perseveres in

their behavior. Low expectations of efficacy in working with families may be easily

overlooked within a healthcare work setting in which the valuing of an individual patient

focus is not conducive to involving the family's support and self-advocacy. Additionally,

nurses can easily rationalize or deny their lack of efficacy with families in favor of

addressing the greater technological and administrative demands of their work place.

According to Bandura (1977), the dimensions of efficacy expectations vary in

terms ofmagnitude, generality, and strength. The level of difficulty can determine a

person's interpretation of his/her efficacy with the expectations varying between the

simplest tasks to the most demanding. In addition, some experiences create expectations

that are interpreted by the individual as relevant only in that particular situation. Finally,

the strength of efficacy expectations influences behavior in that faltering efficacy beliefs

are influenced by or susceptible to negative experiences.

An understanding of these dimensions has important implications for both the

identification and assessment of family nursing self-efficacy beliefs. Efforts to assess

family nursing self-efficacy beliefs must assume that these beliefs are multi-dimensionaL

Furthermore, the previous review of relevant nursing literature suggests that demographic

variables are strongly correlated with greater family involvement. Those nurses with a

greater number of years of experience, head of a household, and having experienced the

healthcare system as a family member of a hospitalized person (i.e. hospitalized child)

had the most favorable attitudes toward family involvement (Coyne, 1995; Brown &

Ritchie, 1990; Seidl, 1969).

Given the history of nursing with families, it has surprised many researchers to

discover the varying behaviors among nurses with families, the deficit of documented

nursing/family interventions, and the lack of categorization given to nurse/family

interaction by nursing administration. Indeed, families themselves have voiced their

confusion when met with nursing personnel they thought would be supportive only to

find them express ambivalence and even hostility (Callery, 1997; Chesla, 1996; Laitinen

& Isola, 1996; Robinson. 1994).

Whereas nursing theory may purport allegiance to families and a commitment

towards including families within the realm of nursing practice, it is up to the individual

nurse to fulfill this promise. The confusion and disappointment that families too

frequently experience in their relationships with nurses may actually reflect weak self-

efficacy beliefs that undermine the commitment nurses have towards family care.

Bandura's (1993) theory endorses this idea:

There is a marked difference between possessing knowledge and skills
and being able to use them well under taxing conditions. Personal
accomplishments require not only skills but self-beliefs of efficacy to
use them welL (Bandura 1993, p.119)

Self-efficacy beliefs in nurses have been researched in various ways and with

many different nursing populations. The development of self-efficacy scales are

prominent within the literature and focus upon specific nursing specialties such as

pediatrics, critical care, medical/surgical care, and advanced nursing roles, such as nurse

practitioners (Craven & Froman, 1993; Wimett, 1992; Richardson, 1993; Shah,

Brunomess, Sullivan, & Lattanzio, 1997). Wimett (1992) assessed the perceived self-

efficacy of 157 medical/surgical nurses and specific organizational and personal

characteristics that influenced those beliefs. The most frequently reported threat to the

nurse's self-confidence was lack of knowledge and/or experience. The greatest boost to

confidence in their nursing abilities was receiving positive feedback from preceptors, as

well as support and kindness. Hayes (1998) also found a correlation with increasing self-

efficacy beliefs and mentoring by preceptors with 238 nurse practitioner students.

Nursing studies about self-efficacy has emphasized the relationship between self-

efficacy and increased motivation to assist patients, arranging follow-up care, and

sharpening self-awareness. Francke, Lemmens, Abu-Saad, and Grypdonck (1997) found

that nurse self-efficacy perceptions, along with attitudes on pain management, was one of

the factors influencing the nurse's utilization of a pain program with patients.

Madorin and Iwasiw (1999) successfully conducted a quasi-experimental study

with 23 baccalaureate nursing students utilizing computer-assisted instruction to increase

self-efficacy about caring for surgical patients. Additionally, other researchers such as

Kushnir, Rabin, and Azulai (1997) who examined the major sources of occupational

stress among pediatric oncology nurses, have recognized that nursing stress and burnout

are affected by "low professional self-efficacy."

Nursing researchers have demonstrated that providing oppormmities for

educational and clinical experiences that foster actual "hands-on" hearing influences

self-efficacy beliefs in nurses in a positive manner (Ford, Laschinger, Laforct, Ward, &

Foran, 1997; Wimett, 1992; Hayes, 1997; Shah et a., 1997). These studies reflect what

Pajares (1997) cited from Bandura's social cognitive theory that the most influential

source of a self-efficacy beliefwas one's "mastery experiences" and that to increase a

student's confidence and competence, teachers needed to provide genuine successful


Nursing has always been a proponent of education that provided realistic

opportunities to their students. Indeed, traditional nursing education began in diploma

schools that were situated, in most cases, in a hospital and the nursing students lived and

learned within that facility. More recently, nursing schools have been introducing family

theory and assessment content into their curriculums. However, with the onset of a

family-nursing specialty, there is recognition among nurses that interacting with families

in a productive and purposeful manner requires specific training and education (Wright &

Leahey, 1999).

The exploration of a nurse's role and perceptions of efficacy within that role has

received some attention throughout nursing research history. However, as previously

indicated, most research has focused upon role theory or self-efficacy theory. The

current study was designed to utilize both role theory and self-effcacy theory to

formulate a model for understanding and predicting nurse behaviors with families.

Social learning theory associates the development of perceptions about self-

efficacy with four sources ofinformation. These are enactive attainments or mastery

experiences, vicarious experiences, verbal persuasion, and physiological states (Bandura,

1982). These concepts as presented by Bandura through his research on self-efficacy

percepts are important to consider when examining nurses' roles with families of patients.

Applying Ozer and Bandura's (1990) precepts to nursing, it is reasonable to

assume that nurses who have had successful experiences with the families of patients will

have a greater sense of efficacy and are more likely to persevere in their relationship

building with families. Conversely, their self-efficacy beliefs will be undermined if they

have experienced difficulties with family members. Additionally, modeling of nurse-

family interactions by other nurses provides vicarious experiences that allow a nurse to

strengthen his/her self-efficacy beliefs. However, Pajares (1997) emphasizes that the

impact of peer modeling is influenced according to the comparable ability of the

individuals and their situations. The more similar in comparison, the more impact the

effect, either negative or positive, of vicarious experience on a person's self-efficacy


Another source of self-efficacy, verbal persuasion (Pajares, 1997), may occur

within a nurse's educational background. Nursing educators readily embrace a

relationship with families of patients. This is often a fundamental message in classes that

expound upon the history of nursing which identify that nurses have traditionally

involved themselves with the families ofpatients. There is much anecdotal information

that encourages nurses to feel that they have the capabilities necessary to work with

families. This type of verbal persuasion may indeed contribute to the development of

beliefs of self-efficacy in this area.

However, Bandura (1977) cautions that since vicarious experiences and verbal

persuasion do not arise from authentic experiences, they may not instill strong efficacy

beliefs. Therefore, practice may be experienced quite differently from what is learned

through one's education. This may be related to the high disillusionment cited among

nurses when they actually begin their careers. It certainly may contribute to why nurses

fervently assert they want to enact a strong role with family members, yet they

demonstrate inconsistent nursing care and behaviors with the family members of patients.

Families can be a source of high stress within the healthcare setting. In most

cases, the family member is under stress and this is also communicated within the

situation. Bandura (1982) posits that one's physiological state or how one interprets their

emotional arousal in a stressful situation affects self-efficacy percepts. If the family

interactions create a tense and anxiety-producing climate, beliefs in one's abilities can

weaken and fear of the interaction or relationship increases. These sources of self-

efficacy beliefs are important to the understanding ofbehavior, particularly in this study,

which attempted to identify nurses' role perception with families and how well they

perceive they function in that role. Bandura(1982) stated it most succinctly: "if self-

efficacy is lacking, people tend to behave ineffectually, even though they know what to

do (p.127)."

Self-efficacy, as has been noted, has typically been conceptualized as domain

specific (i.e. as in explicit situations of functioning). Criticism of general self-efficacy

assessments by Bandura himself has been noted by Pajares (1997) as creating problems

of predictive relevance and clarity of exactly what is actually being assessed.

Furthermore, he suggests that general self-efficacy could "decontextualize" self-efficacy

into a generalized personality trait that in his opinion is different from Bandura's defining

of self-efficacy as a "context-specific judgment."

This researcher, while recognizing the need for a situation specific scale to

evaluate the styles of nurses' involvement with families, also found support in the

literature to incorporate a measure ofgeneralized self-efficacy. Tipton and Worthington

(1984) hypothesized and demonstrated a correlation between those individuals'

preconceived ideas of general ability to handle adverse situations and their behavior

and/or performance.

Other researchers have conceptualized and tested generalized perceptions of self-

efficacy. Sherer and Maddux (1982) hypothesized that general levels of mastery

expectations concerning new situations influenced clients to react differently to the

therapeutic process. Citing Bandura's research in 1977 that demonstrated the ability of

efficacy expectancies "to generalize to other than target behaviors (p.664)," Sherer and

Maddux (1982) hypothesized that individuals' previous success and failure experiences

should establish a "general set of expectations that the individual carries into new

situations (p.663)."

They tested this by developing the Self-Efficacy Scale (SES) to assess the

dimensionality and reliability of a general measure of self-efficacy. Construct validity

for their scale was determined by correlating personality characteristics related to

personal efficacy such as the Internal-External Control Scale, Ego Strength Scale,

Interpersonal Competency Scale, and a Self-esteem Scale. Although, they acknowledged

that these scales were not measuring the same basic features, the anticipated conceptual

associations were confirmed (Sherer & Maddux, 1982).

Generalized self-efficacy research has incorporated optimistic ideals such as

"hope," "personal resource beliefs," and "competence" (Schwarzer, Bjer, Kwiatek, &

Schroder, 1996) as well as "faith in self (Tipton & Worthington, 1984). This researcher

agrees that these can contribute to one's decision to initiate and maintain a behavior and

seeks to evaluate with this study the impact of generalized self-efficacy beliefs on nurses'

styles of involvement with the family members of patients.

Proposed Model

This study is based upon the belief that nurses have definite and specific

conceptions about their roles with families. Empirical evidence examining nursing

attitudes demonstrates that for the vast majority, nurses are interested in defining their

roles with the family members of patients. However, throughout this researcher's

twenty-six years of nursing experience and discussions with colleagues within focus

groups and educational classes, it was evident that nurses held differing ideas about

involving families in patient care. Constraints of poor organizational support were

frequently cited as a deterrent to reaching out to families in need of support and

information. Additionally, many nurses seemed unaware of the inconsistencies they

presented when discussing their "professional" beliefs about family care and their actual

"practice" experiences with families.

The desire to capture what nurses think about involving families in patient care

and what they actually do to accomplish this seemed a worthy area of investigation. The

nursing literature, as presented in this chapter, demonstrates that nurses' attitudes about

family involvement are frequently inconsistent with their behavior towards the family

members of patients. This researcher's personal experience suggested that several factors

were influential in making a decision to include the family member of the patient as a

focus of care. These were: (a) one's sense of support from other nurses, doctors, and

one's supervisor, (b) the experience level in one's present nursing position, and (c) one's

sense of competence in engaging families in conversation and interaction.


A review of the literature did not reveal an established method for investigating

nurses' perceptions of these factors. Therrefore, the Nurse/Family Role Factors (NFRF)

instrument was designed for use in this study. The NFRF is designed to identify nurses'

styles of involvement with patients' families from an individual or family focus, their

perceptions of organizational support to engage family members in patient care, and their

assessment of their level of competence about engaging and interacting with family


Based upon a review of the literature and the investigator's personal experience, a

model was formulated to describe nurses' beliefs and values about their roles with

families. The model depicts the factors influencing a nurse's preferred style of family

involvement. The interrelationship of the factors influencing the nurse's choice of either

an "individual patient focus" or a "family focus" style of involvement with families is

presented in diagram form in Figure 6 along with a description of the dependent and

independent variables measured within this study.

Educational level

> The dependent variable is the nurse's style of involvement with family members
of patients.
> The measured independent variables impacting the style are generalized self-
efficacy, role breadth self-efficacy, organizational support, and perceptions of
self-efficacy in interacting with family members.
> Individual characteristics such as age, marital status, educational level, nursing
specialty, years of nursing experience, and experience of having a hospitalized
family member, are shown as influencing styles of family involvement

Figure 6 Family/Nurse Role ModeL The Relationships Contributing to
the Style ofNurse/Family Involvement Described in This Study.



Nursing educators, nursing organizations, and patient advocates are encouraging

nurses to expand their roles with families. Nurses struggle with defining their

relationships with families within the present healthcare system and have varying

definitions as to what constitutes appropriate family nursing care. In conclusion, the

existing theory and research on family nursing practice, social role theory, and self-

efficacy theory suggests a set of related hypotheses. It is hypothesized that the form of

family nursing practice preferred by a nurse is related to the nurse's conceptualization of

who is his/her appropriate target for intervention (i.e. the patient and/or family), and how

she/he intervenes with families within the patient care setting and manages the constraints

to such involvement.

It is hypothesized that individual nursing beliefs about family participation shape

the nurse's role performance and promote and/or hinder family participation in patient

care. Furthermore, it is hypothesized that there are varied nurse-family role expectations

held by nurses that are influenced by external role demands and individual role

performance experiences. Finally, it is hypothesized that the decision to include families

in patient care depends upon a general set of success/failure expectations that a nurse

carries into each new situation and perceptions of how well she/he can interact and/or

intervene successfully with family members.


Statement of Purpose

The purpose of this study was to assess the self-perception factors and the

individual characteristics of staff nurses that influence their involvement with the families

ofpatients. It sought to assess staff nurses' preferred styles ofinvolvement with the

family members of patients, and to determine to what extent nurses viewed contact with

patient's family members as a valued part of their nursing practice and viewed

themselves as competent in carrying out that role.

Predictions concerning the factors influencing a nurses' choice of approach in

working with families were also tested. Specifically, the relationships among their

preferred style of family involvement and their assessment of competency within

stressful, expanded role situations, their perceptions of organizational support, and their

self-perceptions of efficacy in working with the family members of patients were

evaluated. The influence of six other characteristics known to affect nurses' involvement

with families was also evaluated in this study. These were: (a) nurse's age, (b) marital

status, (c) educational level, (d) years of experience in nursing, (e) nursing specialty, and

(f) experiences of hospitalization of a family member.

This chapter includes a description of the methodology used in the collection and

analysis of the data. The following is a report of the research hypotheses, relevant

variables, data analysis procedures, population, sampling procedures, instrumentation,

and data collection procedures.


In this study the following hypotheses were tested:

Hot There is no association between the style ofrole involvement with
families and the degree of family role self-efficacy reported.

Ho2 There is no association between the style of role involvement with
families and the degree of perceived organizational support for working with patients'

Ho3 There is no association between the level of general self-efficacy and the
style of role involvement with families reported.

Ho4 There is no association between the level ofgeneral self-efficacy and the
degree of family self- efficacy reported.

Hos There is no association between the level of role breadth self-efficacy and
the style of role involvement reported.

Hos There is no association between the level of role breadth self-efficacy and
the degree of family self-efficacy reported.

Ho7 There is no contribution to predicting nurse family role style and any of
the following variables: general self-efficacy, role breadth self-efficacy, perceptions of
organizational support, and perceptions of family self-efficacy.

Ho, There is no contribution to predicting nurse family role style and any of
the following variables: age, marital status, educational level, years of experience in
nursing, nursing specialty, and history of family member hospitalization.

Delineation of Relevant Variables

Dependent Variable

Style of nursefamily involvement The dependent variable in this study is the

nurse's style of involvement with the family members of patients. Family Nursing

Theory describes two distinctly different styles of involvement with families exhibited by

nurses. The first and most prevalent style is the "individual patient focus" in which the

patient is viewed as the recipient of nursing intervention and the family is considered

only in relation to its influence upon the care of the patient The second style is a "family

focus" in which the family is viewed as the recipient of nursing intervention and careful

consideration is given to how the family is impacted by the patient's illness (Wright &

Leahey, 1999). The Style of Family Involvement Subscale (SFIS) was used to assess

these two styles of nurse involvement with the family members of their patients.

Independent Variables

The following independent variables were assessed: general self-efficacy, role

breadth self-efficacy, perceptions of organizational support, and family self-efficacy, and

individual demographic characteristics.

Nurse's general self-efficacy. An individual's sense ofoverall personal

competence to handle stressful situations in a resourceful manner is believed to influence

the performance of one's behavior towards change, particularly in new and challenging

situations (Sherer & Maddux, 1982). In this study, the General Perceived Self-Efficacy

Scale (Schwarzer & Jerusalem, 2000) was used to assess the nurse's general self-efficacy.

Nurse's role breadth self-efficacy. Employees have reported that competence in

certain nontechnical activities such as long-term problem solving, setting goals, meeting

with colleagues and customers, and resolving conflicts within the work setting are

necessary in order to be effective within their organization. These determine the degree

of initiative an employee utilizes towards expanding his/her role (Parker, 1998). In this

study, the Role Breadth Self-Efficacy Scale (RBSE) (Parker, 1998) was used to assess

employee perceptions of competence.

Perceptions oforganizational support. Most organizations dictate that employees

carry out a variety of different responsibilities and maintain specific standards of

performance. Nurses report that hospital role demands often fail to provide clear

guidelines and/or expectations to their employees and that perceptions about work factors

affect nurses' roles with families and contribute to retention and satisfaction in nursing

(Levinson, 1959; Brown & Ritchie, 1990; Lawrence et al. 1996; Gill, 1993). In this

study, the Perceptions of Organizational Support Subscales (POSS' & POSS2) was used

to measure nurses' perceptions of organizational support as perceived at the individual

nursing unit level and the hospital administrative level It is designed to elicit nurse

perceptions about how supportive they think their present work setting is towards taking

the time and effort needed to interact and intervene with families.

Perceptions of self-efficacy in interacting with families. The belief in one's

ability to perform a task or activity influences one's behavior and decision to change.

Nursing literature suggests that mastery experiences either as prior positive experiences

with families or greater nursing experience contributes towards the likelihood that a nurse

will involve the family in patient care (Bandura, 1977; Coyne, 1995; Brown & Ritchie,

1990). In this study, the Family Self-Efficacy Subscale (FSES) was used to measure

nurses' perceptions of self-efficacy with the family members of patients. This scale

identifies common nursing interactions and interventions with family members and asks

the nurse to evaluate his/her ability to perform these.

Demographic Characteristics

A demographic information sheet (see Appendix B) was used to collect data about

the staffnurses' demographic characteristics that had been specifically reported in the

nursing literature to correlate with family-oriented care. The following characteristics

were assessed: age, marital status, level of nursing education, nursing specialty, length of

time in nursing practice, and the experience of having had a hospitalized family member.

Data Analysis

Multiple regression analyses were used to assess the extent of association of the

nurses' style of role involvement with families and the four self-perception predictor

variables and six individual demographic predictor variables. Data was collected and

analyzed on the following predictor variables: degree of family role self-efficacy

reported, degree of perceived organizational support for working with patients' families,

level of general self-efficacy reported, level of role breadth self-efficacy reported, nurse's

age, nurse's marital status, nursing educational level, years of nursing practice, nursing

specialty, and nurse's experience of a family member having been hospitalized.

Description of Population

The population for this study consisted of registered nurses in hospital inpatient

staff-level positions. The National Sample Survey of Registered Nurses, March 2000,

reported that 2,696,540 individuals are licensed as registered nurses in the United States

(Spratley, E., Johnson, A., Sochalsli, J., Fritz, M., & Spencer, W., 2000). Ofthese,

2,201,813 or 81.7% were employed in nursing as of March 2000. Approximately 12% of

those surveyed came from racial/ethnic minority backgrounds, 5.4% were male, and the

average age was 452 years. The registered nurse educational preparation of these United

States nurses included 223% with diplomas, 343% with associate degrees. 32.7% with

baccalaureate degrees, 9.6% with masters degrees and .6% with doctoral degrees. The

hospital setting was the most common work place at 59.1% and more than 60% ofUnited

States nurses were employed in staff-level positions. Additionally, of the registered

nurses in the United States employed within a hospital setting 58% reported working in

critical care units, step down/transitional units, or general/specialty units. They worked

mainly with medical/surgical patients and three-fourths reported spending greater than 50

percent of their time in direct patient care.

Sampling Procedures

An initial, presampling decision was made that the sampling frame would consist

of all staff-level registered nurses (N=1080) employed in a 570-bed private, not-for-profit

hospital located in the Southeastem United States. The nursing administration in this

hospital expressed the desire to survey all of their staff nurses as part of their ongoing

quality improvement initiative to expose staff nurses to research. Nurses working for this

hospital specialize in care for the critically ill and patients with complex health problems.

For purposes of this investigation registered nurse (RN) was a prerequisite for inclusion

in the sample.

The criteria for selecting the study sample were: (a) an age range from 20-65

years, (b) a registered nurse, (c) employed in an inpatient staffposition, and (d) working

with medical/surgical patients within critical care units, and/or general specialty units.


The sample consisted of 353 (32.7%) registered nurses. Out of a possible 1080

who received the study survey, a total of 373 (34.5%) participants returned it However,

the data from 20 (53%) participants was excluded due to their failure to fully complete

the survey or return it within the scheduled time. All of the nurses who were participants

in the study identified themselves as working in staff-level nursing positions within an

inpatient hospital environment.

Geographic location. The 570-bed private, not-for-profit hospital in which this

study occurred was located in the Southeastern United States. This hospital specializes in

care for the critically ill and complex health problems. As a major academic health

center teaching hospital it provides exclusive support to six colleges. This hospital

houses over 45 departments, 20 physician practices, a children's hospital, and various

administrative support services.

Nursing specialty. Nursing specialties within this sample reflected the critical

care mission of the hospital. The majority of respondents cited that they worked in staff-

level positions in intensive care units, both adult and neonatal. Initially, adult and

neonatal responses were separate categories, however, since data analyses showed little

or no difference in their responses they were combined into the critical care category.

Within the critical care specialty, 50% (175) nurses identified Critical Care as their

primary specialty. Of the remaining half of the sample 25% (88) identified their nursing

specialty as Medical/Surgical, 7% (26) Obstetrics Nursing, specifically, Mother/Baby,

5% (17) Pediatric Nursing, 5% (16) Emergency Room Nursing, 4% (13) Oncology

Nursing, 4% (13) Operating Room Nursing, and 1% (5) Psychiatric Nursing. Table 1

includes the frequency distribution by nursing specialty for the sample.

Table 1

Nursing Specialty Distribution of the Sample

Nursing Specialty Frequency (f) Percent (%) Cumulative f Cumulative %

Medical/Surgical 88 24.93 88 24.93

Pediatrics 17 4.82 105 29.75

Critical Care 175 49.58 280 79.32

Psychiatric 5 1.42 285 80.74

Mother/Baby Unit 26 7.37 311 88.10

Oncology 13 3.68 324 91.78

Operating Room 13 3.68 337 95.47

Emergency Room 16 4.53 353 100.00

Sex and race. Of the 353 registered nurses in the sample, 86% (305) were female

and 14% (48) were male. The racial and/or ethnic distribution of the sample consisted of

92% (321) white-European descent, 4% (13) black-African descent, 2% (8) Hispanic

descent, 1% (4) Asian descent, and.6 % (2) other. Table 2 includes the frequency

distribution by sex and race-ethnicity for the sample.

Table 2

Sex and Race-Ethnic Distribution of the Sample

Sex Gender Frequency (f) Percent (%) Cumulative f Cumulative %

Female 305 86.40 305 86.40

Male 48 13.60 353 100.00

Race Ethnicity Frequency (f) Percent (%) Cumulative f Cumulative %

White- European 321 92.24 321 92.24

Black Afican
Black African 13 3.74 334 95.98

Latina- Hispanic 8 2.30 342 9828

Asian Descent
Asian Descent 4 1.15 346 99.43

Other 2 0.57 348 100.00

Marital status. The marital status reported by the registered nurses within this

sample were 68% (241) married, 21% (72) single, 10% (34) separated or divorced, and

1% (5) widowed. Table 3 includes the frequency distribution by marital status for the


Table 3

Marital Status Distribution

Marital Status Frequency (f) Percent (%) Cumulative f Cumulative %

Married 241 68.47 241 68.47

Single 72 20.45 313 88.92

Separated/Divorced 34 9.66 347 98.58

Widow 5 1.42 352 100.00

Education. The registered nurse educational level of the 353 nurses in the sample

ranged from Diploma level preparation to Doctoral level preparation. Of the 353 men

and women in this sample, 5% (17) had diploma degrees in nursing, 50% (178) had ASN

degrees, 41% (145) had BSN degrees, 3% (12) had MSN degrees, and 0.3% (1) had a

PhD degree. Table 4 includes the frequency distribution by nursing education for the


Job description. The 353 subjects for the sample were in staff-level nursing

positions. There was a small percentage of surveys returned from nurses who assumed

both staff-level and other nursing level positions. Their responses were included if at

least fifty percent of their position was on the staff-level. Of the 353 nurses in the

sample, 98% (345) were employed in a staff-level inpatient nursing position, 2% (8) were

employed on the staff-level for at least fifty percent of their time. Their additional

responsibilities included Case Manager, Nursing Instructor, and Charge Nurse. Table 5

includes the frequency distribution by nursing job description for the sample.

Table 4

Nursing Education Distribution of the Sample

Nursing Degree Frequency (f)

ASN 178

BSN 145

MSN 12

Diploma 17


Percent (%)






Cumulative f Cumulative%

178 50.42

323 91.50

335 94.90

352 99.72

353 100.00

Table 5

Nursing Job Description Distribution ofthe Sample

Nursing Job Frequency (f) Percent (%) Cumulative f Cumulative %

Staff level 345 97.73 345 97.73

Other 8 2.27 353 100.00

Experiencing a hospitalized family member. The occurrence of experiencing a

family member's hospitalization in this sample pertained to either one or more family

members with 45% (150) of respondents identifying more than one family member. Of

the 353 nurses in the sample, 95% (334) reported a history of at least one or more family

members experiencing an inpatient hospitalization, and 5% (19) reported that no family


member had ever been hospitalized Table 6 includes the frequency distribution by

hospitalized family member for the sample.

Table 6

Hospitalized Family Member Distribution of the Sample

Hospitalized Frequency (f) Percent (%) Cumulative f Cumulative %
Family Member
Yes 334 94.62 334 94.62

No 19 5.38 353 100.00

Age. The age of the registered nurses in the study ranged from a low of21 years

of age to a high of 60 years of age. The mean age was 39.98 years. Of the 353 nurses in

the sample, 3 did not list their ages and are not included in the distribution table. Of the

remaining 350 nurses, 18% (64) were between the ages of 21-30, 34% (119) were

between the ages of 31-40,33% (115) were between the ages of 41-50, and 15% (52)

were between the ages of 51-60. Table 7 includes the frequency distribution by age for

the sample.

Table 7

Age in Years Distribution of Sample

Age* Frequency (f) Percent (%) Cumulative f Cumulative %

21-30 64 18.28 64 18128

31-40 119 34.00 183 52.28

41-50 115 32.86 298 85.14

51-60 52 14.86 350 100.00

*Represents sample with 3 missing values

Years of nursing practice The number of years spent in nursing practice ranged

from a maximum of 40 years to a minimum of 6 months. The average number of years in

nursing practice was 13.75. Of the 353 nurses in the sample, .9% (3) nurses reported less

than a year of nursing experience, 25% (89) reported 1-5 years of experience, 16% (55)

reported 5-10 years of experience, 18% (64) reported 10-15 years of experience, 15%

(51) reported 15-20 years of experience, 14% (50) reported 20-25 years of experience,

8% (27) reported 25-30 years of experience, 3% (10) reported 30-35 years of experience,

and 1% (4) reported 35-40 years ofexperience. Table 8 includes the frequency

distribution of the nurses in this study by the number of years in nursing practice.

Table 8

Years of Nursing practice Distribuon of sample

Nursing Practice Frequency (f) Percent (%) Cumulative f Cumulative %
< 1 3 .86 3 .86

1-5 89 2521 92 26.07

5-10 55 15.58 147 41.65

10-15 64 18.13 211 59.78

15-20 51 14.45 262 74.23

20-25 50 14.16 312 88.39

25-30 27 7.65 339 96.04

30-35 10 2.83 349 98.87

35-40 4 1.13 353 100.00

Data Collection Procedures

A nursing administration designee gave each registered nurse in the study a

survey. Each survey packet contained the following: a letter describing the nature of the

study and thanking the participant in advance for their participation in the study; a

demographic questionnaire, the General Perceived Self-Efficacy Scale; the Role Breadth

Self-Efficacy measure; the Nurse/Family Role Factors (NFRF) scale; a refrigerator

magnet containing an appreciation message for nurses; and an inter-departmental self-

addressed return envelope. Respondents were asked to return completed questionnaires

to the researcher in the inter-departmental self-addressed return envelope provided.

Confidentiality was insured by the use of a coding system on the return envelope and in

which no names appeared on the questionnaire data. Participation was voluntary. Prior

to the initial mailing, permission was granted from the University of Florida Human

Institutional Review Board.


The data gathering tools for this study was comprised of: (a) a demographic

questionnaire designed to assess age, sex, marital status, ethnicity, nursing educational

level, nursing specialty, and history of family hospitalization, (b) the General Perceived

Self-Efficacy Scale, (c) the Role Breadth Self-Efficacy (RBSE) measure, and (d) the

Nurse/Family Role Factors (NFRF) scale.

The General Perceived Self-Efficacy Scale

The General Perceived Self-Efficacy Scale (Appendix C) measured the

independent variable, general self-efficay. This scale was selected for this study

because of its usefulness in predicting beliefs that one can cope effectively in a variety of

stressful situations. General self-efficacy theorists suggest that personal expectations and

differences in perceived successful experiences are a major factor in behavioral change

and can be discerned through different levels of generalized self-efficacy expectations

(Sherer & Maddux, 1982).

The German version of this scale was originally developed by Jerusalem and

Schwarzer in 1981 as a 20-item instrument and subsequently reduced to a 10-item

version in 1992. Since its development the scale has been used in several research

studies where it yielded estimates of internal consistency ranging from alpha =.75 to .90.

Evidence of convergent and discriminate validity was provided by strong positive

correlations with measures of similar constructs of optimism and positive self-esteem and

was negatively correlated with measures of depression and anxiety (Schwarzer &

Jerusalem, 2000). Bilingual native speakers adapted the English and German versions of

the ten self-efficacy items in 13 other languages. The first English sample consisted of

219 arthritis patients in Great Britain, the second English sample was with 290 Canadian

university students, and the third English sample was composed of 1,437 website

respondees 15-25 years old, 78% of whom were from North America. Item analyses

were performed separately for each scaled adaptation. The internal consistency estimates

derived from Cronbach's alpha were satisfactory with the highest reported at .91 for the

Japanese version and the lowest reported at .78 for the Greek version; the English version

was .90. Unidimensionality and homogeneity of each scale was established through one-

factor solutions and multigroup confirmatory factor analysis such as chi-square, root

mean square residuals, and various goodness of fit indices (Schwarzer, 1997).

Role Breadth Self-Efficacy

Measurement of the independent variable, role breadth self-efficacy, was

measured by the Role Breadth Self-Efficacy (RBSE) measure (Appendix D). This

instrument was selected because of its innovative approach towards the role expansion of

employees within modem organizations. Nursing literature suggests that involving

families in patient care requires initiative, determination, and an expansion of one's role

(Courtney, R., Ballard, E., Fauver, S., Gariota, M., & Holland, L., 1996; Robinson, 1996;

Wright & Leahey, 1999). Parker's (1998) goal in developing this scale was to "represent

important exemplar elements of an expanded role that apply across jobs and hierarchical

levels." Furthermore, she proposed in two separate field studies "organizational

interventions such as job enrichment, work redesign practices, and job related training

enhanced the employees' perception of role breadth self-efficacy, and contributed to

employees' sense of control and increased mastery experiences" (Parker, 1998).

She tested the validity of her instrument by using a confirmatory factor analysis

with RBSE, and two related constructs, self-esteem, and proactive personality as a three-

factor model and reported factor-loading estimates for all of the items as significant at the

.001 level, with standardized coefficients greater than .45. Further evidence of the scale's

validity was achieved from a one-way analysis of variance between professional and

nonprofessional employees that showed there were significant differences in proactive

and integrative work skills (F= 44.18, p<.001), and a planned comparison showed that

nonprofessional employees had significantly lower RBSE scores than professional

employees (t=7.21, p<.001) (Parker, 1998).

Since this measure asks the respondent to evaluate beliefs conducive to a

proactive stance within his/her organization rather than actual experience, it seemed a

good match for this present study as the ability to be proactive, integrative, and

interpersonal within an organization may contribute to the willingness to involve families

within patient care areas, especially if the organization has not provided a supportive

environment thus far.

Nurse/Family Role Factors Scale (NFRF)

The Nurse/Family Role Factors Scale (NFRF) (Appendix E) measured three

variables: (a) the dependent variable styles of family involvement, (b) the independent

variable perceived family self-efficacy, and (c) the independent variable perceived

organizational support. The NFRF scale was designed to describe objective

characteristics of nurses' activities with families. To determine nurses' perceptions of

their work with families, it was crucial to design a measure that could depict the multi-

dimensional nature of nurses' interactions with the family members of their patients.

The NFRF scale is a 43-item self-report questionnaire comprised of three

subscales generating an overall profile of nurse involvement with families and factors

potentially influencing that involvement.

The Style of Family Involvement Subscale (SFIS) is composed of twelve

statements organized as a six-point Likert-type summated rating scale in which the

respondent nurse is asked to indicate the extent to which each statement represents what

he/she believes is "not true" to "true" of his/her personal perception of his/her nursing

practice with families. The items in this subscale are representative of typical nursing

behaviors with families in this researcher's own experience and as identified in nursing

literature. Wright and Leahey's (1999) examples of "individual patient focus" nurse

behaviors and examples of"family focus" nurse behaviors were utilized in the

formulation of this subscale to identify common nurse/family actions and relations within

the hospital setting. To derive the individual score, the numbers circled by each

respondent is summed to give an overall score. A range of scores below 36 would

represent a preference towards viewing the family through the lens of individual patient

care needs and a score above 36 would indicate a preference towards viewing patient care

within the context of the family's needs.

The Perceived Organizational Support Subseale (POSS) consists of fourteen

statements organized as a six-point Likert-type summated rating scale in which the

respondent nurse is asked to indicate the extent to which each statement represents what

he/she believes is "not true" to "true" of his/her personal perception of encouragement to

interact and support families in his/her work or unit setting (7 items) and organization or

hospital setting (7 items). To derive the individual score, the numbers circled by each

respondent is summed to give an overall score. A score at or below 14 would indicate

little or no unit/organizational encouragement towards nursing efforts at including

families in patient care, and a score above 14 would indicate that the work unit and/or

hospital has clearer communication about its expectations of nurses working with family

members and demonstrates encouragement of family involvement

The Family Self-Efficacy Subscale (FSES) consists of 17 statements organized as

a six-point Likert-type summated rating scale in which the respondent nurse is asked to

rate from "not confident" to "completely confident" his/her perceptions of efficacy in

dealing with families. The items in this scale epitomize prevalent occurrences between

nurses and families. They represent typical situations with family members in this

researcher's own experience and as identified in nursing literature when the nurse has an

opportunity to encourage family participation in healthcare provided he/she feels capable

of doing so. To derive the individual score, the numbers circled by each respondent is

summed to give an overall score. A range of scores below 54 would indicate a lack of

confidence in including families in healthcare and getting involved in their needs and a

range of scores above 54 would indicate greater confidence in interacting and intervening

with family members. The NFRF scores were used to evaluate factors influencing the

degree of preference towards involving families in patient care and to determine the

degree of competency felt by staff nurses in dealing and/or interacting with families.

Five clinical "expert" nurses were chosen based upon their professional and

educational experiences to review the Nurse/Family Role Factors (NFRF) scale for face

validity. These experts were representative of a variety of nursing specialties such as

medical/surgical, psychiatric, critical care, pediatric, and gerontological. Their previous

nursing experiences ranged from 25 years and higher in staff nursing care, advanced

practice nursing care, and nursing education and research. The purpose of the research

study and the NFRF was explained to each reviewer and sent via the Internet along with

an instruction sheet and request for follow-up feedback. The researcher consolidated the

responses from the nursing experts and revised the instrument to reflect their

recommendations. Of the 44 original items, four were reconstructed based on the

feedback. No items were dropped and the NFRF was revised with 44 items total.

Measures of reliability were obtained through a pilot study with 27 registered

nurses employed in a hospital inpatient staff-level position. An item analysis was

performed for each question and subscale, including the mean, standard deviation, and

range of response for each item in the subscales. Internal consistency of each subscale

was evaluated by determining the coefficient alpha to measure the degree ofwhich the

items in each subscale measured a homogenous construct The internal consistency,

using Cronbach's alpha, of the NFRF subscale, Locus of Role Development (LRDS)

yielded an overall coefficient alpha of.59. Due to the low coefficient factor and

feedback from the expert-nursing panel that reviewed this instrument, this subscale was

removed from the instrument, as it did not appear to contribute meaningfully to the

overall measurement of nurse-family involvement The intemal consistency of the

NFRF subscale, Perceived Organizational Support Subscale (POSS) yielded an overall

coefficient alpha of.60. An examination of this subscale revealed that the terms work

unit and hospital were used interchangeably. Since these terms requested responses

about separate concepts, i.e. the nurse's actual nursing unit practices versus the hospital

philosophy; it was decided to expand this subscale to more clearly describe actions of

both their nursing unit and their hospital's philosophy towards involving families in

patient care.

The internal consistency of the NFRF subscale, Family Self-Efficacy Subscale

(FSES) yielded an overall coefficient alpha of.82. All 17 items yielded individual

correlations greater than .78 and reflected the full-range of potential responses. The

internal consistency of the NFRF subscale, Style of family Involvement Subscale (SFIS)

yielded an overall coefficient alpha of.69. Since all 12 individual correlations for the

items in this scale were greater than .60, this scale was found acceptable in measuring the

concept of nursing styles of family involvement The correlational analyses for the

Nurse/Family Role Factors Scale pilot is presented in Table 9.

Table 9
Correlational Findings on the Nurse/Family Role Factors Scale Pilot

NFRF Subscales Cronbach Coefficient Alpha

LRDS Locus of Role Development 0.59

POSS Perceived Organizational Support 0.60

FSES Family Self-Efficacy Subscale 0.82

SFIS Style of Family Involvement 0.69

Demograhic Questionnaire

Relevant individual characteristics were elicited by the demographic

questionnaire (Appendix B). The questionnaire asked the respondent to report his/her

age, sex, ethnicity, marital status, level of nursing education, nursing specialty, length of

time in nursing practice, type of nursing position the respondent is presently holding, and

the history, if any, of having one's family member previously hospitalized.


Analysis Procedures

The purpose of this study was to examine the association of four self-perception

variables and six individual characteristics to staff nurses' style of role involvement with

families of patients. Three of the self-perception variables focused on the nurse's

reported perception of self-efficacy in the following areas: (a) coping effectively in

stressful situations, (b) level of role breadth within their work setting, and (c) interacting

and intervening with family members of patients. The fourth self-perception variable,

perceived organizational support, focused on the nurse's perception of encouragement to

interact and support families within his/her unit and hospital setting. The individual

demographic variables evaluated for their possible association in nurse/family

interactions were age, marital status, educational level, years of experience in nursing,

nursing specialty, and history of family member hospitalization.

The sample for this study included 353 registered nurses who were employed in a

staff-level inpatient nursing position. Items from the Styles of Family Involvement

Subscale (SFIS), an instrument created for this investigation, assessed the style of family

role involvement. Nurses' perceptions of competency, both personal and work related,

were measured using the General Perceived Self-Efficacy Scale (Schwarzer & Jerusalem,

2000), the Role Breadth Self-Efficacy (RBSE) measure (Parker, 1998), and the Family

Self-Efficacy Subscale (FSES), an instrument created for this investigation. Perceived

organization support towards family interaction and involvement in patient care was

measured by the Perceived Organizational Support Subscale (POSS' and POSS2), also an

instrument created for this investigation.

The response variable and the four predictor variables measured in this study and

for which data was analyzed were as follows: styles of family involvement reported,

degree of family role self-efficacy reported, degree of perceived organizational support

for working with patients' families, level of general self-efficacy reported, and level of

role breadth self-efficacy reported. Descriptive statistics for these dependent and

independent measures are summarized in Table 10.

Table 10
Descriptive Statistics of Sample on Each Measure

Measure n Mean S.D. Minimum Maxmum

Styles of 353 48.12 8.64 17.00 67.00

General Self 353 32.74 3.57 20.00 40.00

Role Breadth 353 42.13 10.30 10.00 60.00
Self Efficacy

Perception of 352 26.18 6.87 7.00 42.00
Org, Support
Unit Setting

Perception of 353 21.99 6.52 7.00 41.00
Org. Support

Table 10-Continued

Family Self 353 77.34 13.00 35.00 102.00

The analysis of data for this study was accomplished utilizing the Statistical

Analysis System (SAS) version 8. The style of family involvement as measured by the

SFIS score was designated as the response variable and family self-efficacy (FSES),

general self-efficacy (GSES), role breadth self-efficacy (RBSE), perception of

organizational support (POSS), age, marital status, educational level, years of experience

in nursing, nursing specialty, and history of family member hospitalization as predictor

variables. To examine the relationships among the variables in this study, correlations

were computed for all possible pairs of variables. There were no correlations between

the self-perception measures and the demographic variables. The correlations between

the self-perception measures are shown in Table 11.

Family self-efficacy was significantly related to all the self-perception variables

with correlations ranging from .36 to .46. Nurses' perceptions of organizational support

on their unit correlated significantly with family self-efficacy (.40) and with perceptions

of hospital support to involve families (.67). Nurses' perceptions of organizational

support from their hospital, in addition to correlating with the perceptions of

organizational support on their nursing unit, also was positively associated with family

self-efficacy values (.35). Role breadth self-efficacy correlated with family self-efficacy

values (.46) and also correlated with general self-efficacy values (38). General self-

efficacy in addition to correlating with role breadth self-efficacy also was positively

associated with family self-efficacy (.36).

Table 11
Correlation Matrix: Family Self-Efficacy. Perceptions of Organizational Support, Role
Breadth Self-Efficacy. General Self-Efficacy, and Styles of Family Involvement

Variables 1 2 3 4 5
1. Family Self-
Efficacy (FSES)

2. Perception of .35*
Org. Support
Unit Setting

3. Perception of .40* .67*
Org. Support
Hospital Setting

4. Role Breadth .46* .17 .17
Self Efficacy

5. General Self .36* .09 .12 .38*
Efficacy (GSES)

6. Styles of .57* 31* 35* .30* .17


The correlations between the demographic variables are shown in Table 12.

Nurses' age was significantly related to the number of years of nursing practice with a

correlation of.78. The level of nusing education was significantly related to the number

of years of nursing practice with a correlation of.22. There were no other significant

correlations among the demographic variables.

Table 12
Correlation Matrix: Age, Marital Status. Education Nursing Experience, Nursine
Specialty, and Family Member Hositalizion

Variables 1 2 3 4 5
1. Age

2. Marital Status .04

3. Education .08 -0.05

4. Nursing .77* -0.01 .21

5. Nursing .02 .01 .08 .06

6. History of -0.04 -0.05 -0.03 -0.05 .00
Family Member


The regression analysis tests the relationship in terms of strength and significance

between the response (or dependent) variable and the predictor (or independent)

variables. It determines how important the independent variables are in explaining the

variation in the dependent variable. A series of simple linear regression models were

conducted to evaluate the first six hypotheses and a multiple regression model was

conducted to evaluate the seventh and eighth hypotheses for strength of association and

interactions with the predictor variables.

A Type I error rate of.05 was established and the decision to accept or reject the

null research hypotheses resulted from achieving a significant effect on the expected

value of the dependent variable. Source data were rounded to the nearest hundredth.

Analysis Results

A series of simple linear regression models were initially used to evaluate

hypotheses 1-6, and a multiple regression model was used to evaluate hypotheses 7-8.

Input variables were each of the self-efficacy values, the nurse's perception of how

supportive his/her unit and the hospital was in encouraging family involvement with

patient care, and the individual demographic variables. The output variable was the SFIS

score for styles of family involvement related to nurse-patient oriented focus versus

nurse-family oriented focus.

For all six simple linear regression models, the regression equations were

significant, however, in five of the models there were assumption violations that required

either the use of an alternate regression model and/or transformation of the data in order

to improve the linear predictions. The first simple linear regression model in which the

Styles ofFamily Involvement was the dependent variable and Family Self-Efficacy

perceptions (FSES) the independent variable, the equation was significant (F = 172.8,

>F = .0000). Of the total variance of the styles of family involvement endorsed by staff

nurses, 33% (R2 = 3298) is accounted for by their perceptions of family self-efficacy.

The second simple linear regression model in which the Styles of Family

Involvement was the dependent variable and Unit Perceived Organizational Support

(POSSi) the independent variable, the equation was significant (F = 35.90, P>F =.0000).

Of the total variance of the styles of family involvement endorsed by staff nurses 9% (R2

S.0930) is accounted for by their perceptions of support on their nursing unit to interact

and involve family members. However, there was a constant variance assumption

violation and the efficiency of the regression analysis is questionable since 2.37% of the

variation in the squared residuals is associated with variation in the predicted styles of

family involvement thereby suggesting that the styles of family involvement variation

were not the same for all observations.

The third simple linear regression model in which the Styles of Family

Involvement was the dependent variable and Hospital Perceived Organizational Support

(POSS2) the independent variable, the equation was significant (F = 49.58, e>F .0000).

Of the total variance of the styles of family involvement endorsed by staff nurses, 12%

(R2 = .1238) is accounted for by their perceptions of support from a hospital

organizational level to interact and involve family members. However, there were

assumption violations (curvilinearity) within this model that suggested the relationship

was nonlinear and that quadratic curvilinear terms added to the model may linearize the

relationship between the styles of family involvement and perceptions of hospital

support. This new quadratic regression model was conducted and was significant (F =

29.91, p>F = .0000) accounting for 14% (R2 = .1460) of the variance in styles of family

involvement for staff nurses.

The fourth simple linear regression model in which the Styles of Family

involvement was the dependent variable and General Self-Efficacy perceptions (GSES)

the independent variable was significant (F = 10.44, >F = .0014) Of the total variance

of the styles of family involvement endorsed by staff nurses, 2% (R2 .0289) is

accounted for by their perceptions of general self-efficacy. However, there were

assumption violations (curvilinearity and outlier) within this model that suggested the

relationship is nonlinear and that cubic curvilinear terms added to the model in addition

to deleting an outlier observation may linearize the relationship between the styles of

family involvement and perceptions of general self-efficacy. This new cubic regression

model with the deletion of an outlier observation was conducted and was significant (F =

6.676, p>F = .0002) accounting for 5% (R2 = .0544) of the variance in styles of family


The fifth simple linear regression model in which the Styles of Family

Involvement was the dependent variable and Role Breadth Self-Efficacy perceptions

(RBSE) the independent variable was significant (F = 34.80, p>F = .0000). Ofthe total

variance of the styles of family involvement endorsed by staff nurses, 9% (R2 i .0902) is

accounted for by their perceptions of role breadth self-efficacy. However, there were

assumption violations (curvilincarity. outlier, and response scaling) within this model that

suggested the relationship is nonlinear and that quadratic curvilinear terms, the deletion

on an outlier observation, and increasing the power of the response variables may

linearize the relationship between the styles of family involvement and perceptions of

role breadth self-efficacy.

This new quadratic regression model with the deletion of an outlier observation

and transformation of SFIS values by 1.5 was conducted and was significant accounting

for 10% (R2 .1031) of the variance in staff nurse styles of family involvement with

patients' families. Table 13 shows the sources of variance in the simple linear regression

models to test Styles of Family Involvement (SFIS) as the dependent variable.

Table 13

Source Table for Simple Linear Regression Models to Test SFIS as Dependent Variable

Source df Coefficient Standard t-value value
Estimate Error of
Family Self I 0.382 .0290 13.14 .0000*

Perception of I 0391 .0653 5.992 .0000*
Org. Support
Unit Setting

Perception of I 0.466 .0661 7.041 .0000*
Org. Support

General Self 1 0.411 .127 3.231 .0014*

Role Breadth 1 0.252 .0427 5.899 .0000"

The sixth simple linear regression model, in which Family Self-Efficacy (FSES)

was the dependent variable and General Self-Efficacy (GSES) the independent variable,

was significant (F 49.47, p>F= .0000). Of the total variance in the degree of family

self-efficacy reported by staffnurses, 12% (R2 .1235) is accounted for by their

perceptions of general self-efficacy. However, there were assumption violations,

(curvilinearity, outlier, and response scaling) within this model that suggested the

relationship is nonlinear and that cubic curvilinear terms, deletion of an outlier

observation, and increasing the power of the response variables may linearize the

relationship between the degree of reported family self-efficacy and perceptions of

general self-efficacy. This new cubic regression model with the deletion of an outlier

observation and transformation ofFSES values by 1.7 was conducted and was significant

(F = 24.45, 2>F = .0000) with general self-efficacy now accounting for 17% (R2 =.1741)

of the variance in the degree of family self-efficacy reported by staff nurses.

The seventh simple linear regression model, in which Family Self-Efficacy

(FSES) was the dependent variable and Role Breadth Self-Efficacy (RBSE) the

independent variable, was significant (F = 95.60, p>F = .0000). Ofthe total variance in

the degree of family self-efficacy reported by staff nurses, 21% (R2 = .2141) is accounted

for by their perceptions of role breadth self-efficacy. However, there were assumption

violations (constant variance, outlier, and response scaling) and the efficiency of the

regression analysis is questionable since approximately 1% of the variation in the squared

residuals is associated with variation in the predicted family self-efficacy values, thereby

suggesting that the family self-efficacy score variations were not the same for all


A new linear regression model with the deletion of an outlier observation and

transformation of FSES values by 1.7 was conducted and was significant (F = 99.37, 2>F

= .0000) with non-constant variance; role breadth self-efficacy now accounted for 22%

(R2= .2211) of the variance in staff nurses' perceptions of family self-efficacy. Table 14

shows the sources of variance in the simple linear regression models to test Family Self-

Efficacy (FSES) as the dependent variable.

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