642790

research-article2016
JFNXXX10.1177/1074840716642790Journal of Family NursingÖstlund et al.

Article
Journal of Family Nursing
2016, Vol. 22(2) 148­–171
A Family Systems © The Author(s) 2016
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DOI: 10.1177/1074840716642790
Families Following a jfn.sagepub.com

Stroke: Family Health

Conversations

Ulrika Östlund, RN, OCN, PhD1,

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

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

1Uppsala
University/Region Gävleborg, Gävle, Sweden
2MidSweden University, Sundsvall, Sweden
3Umeå University, Umeå, Sweden
4Umeå University, Örnsköldsvik, Sweden

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

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Östlund et al. 149

care contexts. Family members described possibilities for relational sharing

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

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

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

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

Family Involvement in Recovery From Stroke

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

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150 Journal of Family Nursing 22(2)

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

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

Family Systems Nursing Interventions

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

Development of Family Health Conversations (FamHC)

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

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Östlund et al. 151

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

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

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152 Journal of Family Nursing 22(2)

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

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

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

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

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Östlund et al. 153

Table 1.  Demographics of the Participating Families.

Age, sex, and diagnosis Time between Participating family

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

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

Family Nursing Intervention: FamHC

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

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154 Journal of Family Nursing 22(2)

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

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

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Östlund et al. 155

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

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

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

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156 Journal of Family Nursing 22(2)

Table 2.  Analysis Domains, Categories, and Subcategories.

Domains Categories Subcategories

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

Note. FamHC = Family Health Conversations.

Format of the FamHC

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

Experiences related to the framework of the FamHC. This category was

abstracted from four subcategories.

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

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Östlund et al. 157

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

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

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

Nurses’ role and approach during FamHC.  Family members described it as

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

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158 Journal of Family Nursing 22(2)

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

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

Experiences related to the substance of the FamHC. This category was

abstracted from three subcategories.

Conversation focus and content.  Family members described the FamHC as

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

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

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

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

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Östlund et al. 159

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

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

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

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

from two subcategories.

A conversation different from those usually held within the family. Family

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

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

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160 Journal of Family Nursing 22(2)

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

Possibilities Created in the FamHC

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

Opportunities for sharing within the family.  This category was abstracted from
four subcategories.

Room for trust. Family members reported that an atmosphere was cre-

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

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

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

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Östlund et al. 161

Room for deeper conversation. Family members reported that room for

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

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

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

Room for confirmation. Family members reported that room for con-

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

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

Opportunities for change within the family.  This category was abstracted from
the following three subcategories:

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

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

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162 Journal of Family Nursing 22(2)

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

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

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

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

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Östlund et al. 163

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

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

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164 Journal of Family Nursing 22(2)

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

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Östlund et al. 165

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

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

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166 Journal of Family Nursing 22(2)

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

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

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

Declaration of Conflicting Interests

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

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

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

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Östlund et al. 171

Britt Bäckström, RN, PhD, is a senior lecturer in the Department of Health Sciences
at Mid Sweden University in Sundsvall, Sweden. Her research focuses mainly on
Family Systems Nursing and high-tech patient simulation to encourage nursing stu-
dents’ clinical judgment. Her recent publications include, “The Meaning of Middle-
Aged Female Spouses’ Lived Experience of the Relationship With a Partner Who Has
Suffered a Stroke, During the First Year Postdischarge” in Nursing Inquiry (2010,
with K. Asplund & K. Sundin), “The Experience of Being a Middle-Aged Close
Relative of a Person Who Has Suffered a Stroke, 1 Year After Discharge From a
Rehabilitation Clinic” in International Journal of Nursing Studies (2009, with K.
Sundin), and “The Meaning of Being a Middle-Aged Close Relative of a Person Who
Has Suffered a Stroke, One Month After Discharge From a Rehabilitation Clinic” in
Nursing Inquiry (2007, K. Sundin).
Britt-Inger Saveman, RNT, PhD, FEANS, is a professor in the Department of
Nursing at Umeå University, Umeå, Sweden. Her research focuses on Family Systems
Nursing, elder abuse, disaster nursing, and injury prevention. Her recent publications
include, “Nurses’ Fidelity to Theory-Based Core Components When Implementing
Family Health Conversations—A Qualitative Inquiry” in Scandinavian Journal of
Caring Sciences (2015, with U. Östlund, B. Bäckström, V. Lindh, & K. Sundin),
“Refinement and Psychometric Re-Evaluation of the Instrument Families Importance
in Nursing Care—Nurses Attitudes” in Journal of Family Nursing (2011, with E.
Benzein, Å. Engström, & K. Årestedt), and “Family Nursing Research for Practice:
The Swedish Perspective” in Journal of Family Nursing (2010).
Viveca Lindh, RN, PhD, is a senior lecturer in the Department of Nursing at Umeå
University, Umeå, Sweden. Her research and clinical interests focus on pediatric nurs-
ing, pain management, and Family Systems Nursing. Her recent publications include,
“Children Undergoing Radiotherapy: Swedish Parents’ Experiences and Suggestions
for Improvement” in PLoS One (2015, with C. Ångström-Brännström et al.), “An
Initiative to Teach Family Systems Nursing Using Online Health-Promoting
Conversations: A Multi-Methods Evaluation” in Journal of Nursing Education and
Practice (2013, with C. Persson, B.-I. Saveman, C. Englund, K. Idberger, & U.
Östlund), and “Young People’s Experiences With Scoliosis Surgery: A Survey of
Pain, Nausea, and Global Satisfaction” in Orthopaedic Nursing (2013, with A. C.
Rullander, H. Jonsson, & M. Lundström).
Karin Sundin, RNT, PhD, is an associate professor in the Department of Nursing at
Umeå University, Örnsköldsvik, Sweden. Her research focuses mainly on Family
Systems Nursing in stroke care, parents’ health care, and elderly care. Her recent
publications include, “Becoming Visible—Experiences From Families Participating
in Family Health Conversations at Residential Homes for Older People” in Geriatric
Nursing (in press, with Å. Dorell), “What Couples Choose to Focus on During Nurse-
Led Family Health Conversations When Suffering Stroke” in The International
Journal for Human Caring (2015, with S. Pusa et al.), and “Experiences With Family
Health Conversations at Residential Homes for Older People” in Clinical Nursing
Research (2014, with A. Dorell, B. Bäckström, M. Ericsson, M. Johansson, & U.
Östlund).

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