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ASSESSING STAFF NURSES' STYLES OF INVOLVEMENT WITH THE FAMILIES
OF THEIR PATIENTS
CATHY M. BURNS
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
UMI Number 3083978
UMI Microfom 3083978
Copyright 2003 by ProQuest Infomaion and Learning Company
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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
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.
TABLE OF CONTENTS
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
LIST OF TABLES
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
LIST OF FIGURES
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
ASSESSING STAFF NURSES' STYLES OF INVOLVEMENT WITH THE FAMILIES
OF THEIR PATIENTS
Cathy M. Burns
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
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.
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.
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
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 &
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
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
-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.
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
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
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 &
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
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.
REVIEW OF THE LITERATURE
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
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
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
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.
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.
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
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
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
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 &
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
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
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
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.
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.
> The dependent variable is the nurse's style of involvement with family members
> 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
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.
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.
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.
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.
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.
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.
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 African 13 3.74 334 95.98
Latina- Hispanic 8 2.30 342 9828
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
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.
Nursing Education Distribution of the Sample
Nursing Degree Frequency (f)
Cumulative f Cumulative%
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.
Hospitalized Family Member Distribution of the Sample
Hospitalized Frequency (f) Percent (%) Cumulative f Cumulative %
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
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.
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
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.
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
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.
DATA ANALYSIS AND RESULTS
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.
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
Perception of 352 26.18 6.87 7.00 42.00
Perception of 353 21.99 6.52 7.00 41.00
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).
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-
2. Perception of .35*
3. Perception of .40* .67*
4. Role Breadth .46* .17 .17
5. General Self .36* .09 .12 .38*
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.
Correlation Matrix: Age, Marital Status. Education Nursing Experience, Nursine
Specialty, and Family Member Hositalizion
Variables 1 2 3 4 5
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
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.
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.
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*
Perception of I 0.466 .0661 7.041 .0000*
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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