28.2 Frameworks of Practice

Socioecological Framework

The social-ecological framework explores a range of social and environmental factors and intimate relationships that affect the family unit (Davidson et al., 2020). Social networks can include work relationships, school affiliations, religious affiliations, and connections to other community organizations. The environment includes neighborhoods, schools, and communities. This framework can help nurses better understand the relationships among the family, social networks, and the environment. See Socio-Ecological Perspectives and Health for a more detailed discussion.

The social-ecological framework can help community nurses provide health promotion and prevention to families (Figure 28.3). For example, a nurse working with a family to address alcohol abuse would implement interventions that target the individual, their relationships, their community, and society. At the individual level, the nurse would assess the person’s risk for alcohol abuse and provide appropriate education for the client related to life skills and decision-making. At the relationship level, the nurse would assess the effects of relationships on the client’s alcohol use and implement strategies to promote positive relationships with others to minimize or abstain from consuming alcohol. At the community level, the nurse would assess for factors that promote or facilitate alcohol use. Community interventions can include marketing campaigns promoting safe alcohol consumption and creating opportunities for alternate activities. Finally, at the societal level, the nurse can assess laws and regulations relevant to alcohol use and lobby for policies that limit the negative effects of alcohol on society.

Figure 28.3 Providing nutrition education and information on where to obtain healthy food in the community is an example of using the social-ecological framework to promote health. (credit: U.S. Department of Agriculture/Flickr, Public Domain)

Transactional Model

The transactional model considers relationships between family members and between families and outside organizations as reciprocal. Members of the family both influence and are influenced by others. Within the family, nurses can use the transactional model to examine relations between caregiver’s and children’s behaviors (Cherry et al., 2019). For example, the child of a caregiver with a substance use disorder who sleeps a lot during the day may learn that they must get themselves ready for school independently at a young age. Conversely, that caregiver acclimates to the child’s ability to manage their schooling and stops trying to be involved in the child’s education.

As discussed previously, families go through different life cycles or stages. At each stage, the family will interact with institutions outside of the family. For example, as the child grows, the parents or caregivers will interact with different teachers, coaches, and mentors who have relationships with the child throughout their development. A community nurse can utilize the transactional model to see how the family “transacts,” or interacts, with other people or groups. This observation can help the nurse understand whether the family can build healthy and meaningful relationships with people and organizations outside of the family.

General Systems Theory

The American Psychological Association (APA) (2023) describes general systems theory as an interdisciplinary conceptual framework that focuses on how individual entities or systems relate to and are organized with other systems. In other words, the individual is a system that exists within and among other systems that influence it. The family is considered a system comprised of various members whose thoughts, beliefs, and actions influence it. The family system is in turn influenced by other systems—including environmental systems, economic systems, educational systems, and so on. General systems theory helps nurses view families from a holistic perspective. Nursing care based on systems theory views the family as a unit in the context of the larger environment and seeks to effect change at the family level (Looman, 2019).

The family is a system with subsystems where family members tend to be connected by strong emotional bonds. For example, in families with two adult caregivers, the caregivers form a subsystem with a bond that differs from the bonds with any other individual in the family. The caregivers’ relationship with their children is another subsystem or bond. Siblings, if present, also form a subsystem that is different from the bond they individually share with their caregivers. Each of these levels or subsystems interacts within the whole system. Life events can affect these interactions and these subsystems. For example, when caregivers divorce and get remarried, these bonds change and alter the subsystems.

Systems theory can be useful to understand how families’ health is affected by outside sources. A family’s health is influenced by outside systems including the economic system and their environment. Accordingly, population health interventions recognize the interaction of these different systems to influence health. Healthy People 2030, the United States’ plan for public health promotion, sets health-related goals and objectives for families and communities—not just for individuals (Office of Disease Prevention and Health Promotion [ODPHP], n.d.). For example, some of Healthy People’s objectives relate to housing, homes, workplace, transportation, and other community needs that directly affect or influence families in those communities (ODPHP, n.d.).

Calgary Family Assessment and Calgary Family Intervention Models

Nurses use the Calgary Family Assessment Model (CAFM) and the Calgary Family Intervention Model (CFIM) to promote family health and functioning and address family illness concerns (Zimansky et al., 2020). These models were developed from clinical work and are readily applicable to nursing practice (Leahey & Wright, 2016). The Calgary Family Assessment Model studies a family’s structure, development, and function to assess its strengths, resources, problems, and illness (Zimansky et al., 2020). The assessment incorporates targeted questions as well as a genogram and ecomap to assess the family’s interactions within the environment. Genograms and ecomaps will be discussed later in this chapter.

The Calgary Family Intervention Model, derived from the CFAM, provides a framework for nurses to use in therapeutic conversations that target the family’s functioning as a system (Zimansky et al., 2020). The framework is based on three domains of family function: cognitive, behavioral, and affective (Mileski et al., 2022). Effective interventions incorporate all three domains. Nurses explain rationales (cognitive domain) when teaching new activities that lead to behavior change (behavioral domain). Families who implement the behavior change incorporate it into their family functioning (affective domain). For example, a nurse working with a family to develop healthier eating habits to decrease the family’s risk of diabetes can explain the benefits of eating fewer fast-food meals and incorporating more home-cooked meals into their week. Along with explaining the nutritional benefits, the nurse can work with the family to identify behavior changes that will allow them to meet this goal, like creating a schedule of favorite home-prepared dinners the family can use as a weekly menu plan. If this is successful, the family implements this suggestion and realizes a positive emotional benefit to their family, which can help reinforce the behavior. Perhaps the family realizes they enjoy picking out their favorite meals and preparing them together.

Leahey and Wright proposed a 15-minute family interview based on the CFAM and CFIM that nurses can use in various settings with time constraints (Wright & Leahey, 1999). They identify five parts of an effective interview: manners, therapeutic conversations, family genograms and ecomaps, therapeutic questions, and commending family and individual strengths.