The Framework of Systemic Organization: A Conceptual Approach to Families and Nursing

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Marie-Luise Friedemann

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    Foreword

    When I began my doctoral dissertation on family development processes in the mid-1970s, I approached the task with great anticipation. As a member of a new doctoral program in nursing, my mood went from anxiety, to nonbelief, to anger when I could not find linkages between existing nursing theory and family theory—most of which was developed external to nursing. The nursing perspective on family, including values and assumptions of the discipline transmitted across time, was virtually nonexistent. I believed then, as now, that nursing could use family theory external to nursing but that this theory must be reformed for our purposes. Because each discipline has its own societal mandate and perspective, theories external to nursing were not adequate to the task unless they were reformulated. Moreover, I believed then, as I do now, that nursing could and should not just reform existing theory external to nursing but should also develop its own family theory.

    It became clear to me that this could be accomplished in a variety of ways; for example, one might reform family theory external to nursing by using nursing conceptual models. In an equally plausible method, one might reform this theory using existing middle-range theory in nursing and/or practice theory. Likewise, one might develop a theory using some hypothetical deductive and/or inductive means. All of these efforts need to be examined in terms of theoretic criteria, such as internal consistency, as well as in multiple studies; the scrutiny of the marketplace would thus be brought to bear on these products. The good news today is that nursing scholars have accepted that challenge that lay before nursing more than 20 years ago. Nursing has labored long and hard to develop the nursing knowledge base needed to serve families. Today there are “family schools of thought” within nursing, excellent programs of research focused on testing family theory for nursing, and scholars such as Dr. Friedemann who have published textbooks designed to guide nursing practice, education, and research. I believe Dr. Friedemann's continuing family development within nursing might be seen as falling within the “crises” school of thought. With the indelible mark of an experienced nurse, Dr. Friedemann is concerned about how nurses might address assessment of families' diagnoses of problems, intervene to assist families with these problems, and evaluate the practice outcomes. This textbook is a welcome addition to family knowledge within nursing. Dr. Friedemann has developed family theory for nursing by using a variety of methods. The chapters are rich not only in practice implications but also in suggestions for research.

    Today there are threats to developing family theory in and for nursing. One of these is a nihilistic view within nursing that sees all theory as useless. Far from this view of 20 years ago, which in essence assumed that all nursing must develop theory-based family practice, these reactionaries would return to atheoretical practice, education, and even research. As bizarre as this sounds and as nondefensible this position is, good will come from this struggle internal to nursing. Because of this challenge, whole family schools of thought within nursing will become more tightly integrated with corollary programs of research, and we will have had the scholarly debates within nursing that will show us just how far nursing has progressed. Textbooks such as Dr. Friedemann's will be viewed 20 years from now as an excellent contribution to our struggle to develop family nursing science. But for now, let us revel in the breadth and depth of Dr. Friedemann's discussions of family from a perspective that is undeniably of nursing.

    Ann L.Whall, Ann Arbor, Michigan

    Introduction

    The family has been a central theme throughout the history of modern nursing. A focus on the family was already evident in 1876, when Nightingale wrote instructions for district nurses and home missioners (Miller Ham & Chamings, 1983). On the basis of a review of historical literature, Whall and Fawcett (1991) found that much had been written about the family over the years, but the development of formal midrange family theory that is useful in practice has started only recently and still needs much work. Since the 1980s, several nursing leaders have attempted to formulate family theories based on existing conceptual models or have adapted theories from other disciplines to nursing (Clements & Roberts, 1983; Fawcett, 1975; Whall, 1986). Even though definitions of nursing have become holistic and include family and community (Murphy, 1986), the theoretical formulations are not specific enough to serve as practice guidelines and models for family research and the formation of hypotheses.

    The framework of systemic organization is presented here as both a grand and a midrange theory. The theory originated from Wayne State University and was published initially in 1989 (Friedemann, 1989a). It includes philosophical underpinnings and propositions that form the basis of processes described at the midrange level. The nursing metaparadigm—environment-person-health nursing—has been expanded to include the dynamic concepts of family and family health to guide the explanation of systemic functioning of individuals, social and environmental systems, and interactions between them. These processes at the midrange level can then be made specific to various clinical situations and built into the nursing process. Furthermore, processes at the midrange level lend themselves to theory testing through research. In short, this framework bridges the various levels of theoretical abstraction and closes the gap between theory and nursing practice.

    As all viable conceptual frameworks, the framework of systemic organization has evolved through a process of both inductive and deductive thinking processes. It represents a synthesis of my life and professional experiences, my worldview and personality, and is enriched by insights from scientific literature and research. Consequently, bits and pieces of the writing of scientists and practitioners in nursing, such as Rogers (1980), King (1981), and Newman (1979, 1983), and family specialists and researchers, including Kantor and Lehr (1975), Minuchin (1974), Haley (1976), and Beavers (Beavers, 1981; Lewis, Beavers, Gossett, & Phillips, 1976), have been reformulated and become part of my universe of discourse. Today, the evolutionary process is by no means complete. The framework continues to experience growth and change through discussions with groups of professionals, students, and colleagues and through the findings of theory-based research.

    The framework of systemic organization is being taught to undergraduate, graduate, and doctoral nursing students at Wayne State University, numerous universities across the United States, and in German-speaking Europe. Likewise, a practice model derived from the framework (Friedemann, 1989b) is being used and tested in a variety of settings with families of acutely, chronically, and mentally ill clients; substance abusers; and families who have problems with parenting or coping with stress. Readers are asked to absorb and critically examine the thoughts and reasoning presented in this book, and if the truths about persons, families, and the role of the nurse correspond with their own, they may want to use this framework in their own creative way to grow as nurses and as people.

    This book is organized into five parts. Part 1 constitutes the theoretical presentation of the framework and discusses the major concepts and their relationships to each other. In Chapter 1, the metaparadigm constructs of environment, person, and health—supplemented with family and family health—are discussed in depth. The presentation of the construct of nursing—a complex process that involves the interaction of the nurse with the client(s) in need, the family, and their environment—is reserved for Chapter 2.

    Part 2 includes three chapters that explain the interaction of modifying factors with the family process. A fourth chapter is added to summarize issues concerning the function, process, and use of family research. Family structure (Chapter 3), family life span considerations (Chapter 4), and the influence of culture (Chapter 5) contribute to the many variations of families. The focus is on family health and healthy adaptation to changes. Chapter 6 addresses tenets of positivist-empiricist science and their influence on theoretical debates, the challenges of the operationalization of midrange theory, the confrontation of the quantitative and qualitative paradigms, and the use of triangulation.

    Problems nurses often encounter with families in crisis are described in the remainder of the book. Family processes related to all topics are presented theoretically with the help of clinical examples. Findings from existing researchers and theoretical discussions in the literature will be cited to validate the theoretical propositions and process descriptions.

    Part 3 focuses on crises from within the family system. The framework is applied here for the support of families struggling to find health in their own specific way. Chapter 7 discusses crises arising from developmental transitions and concentrates on possible difficulties families encounter as individuals reach various stages in their lives. Chapter 8 focuses on structural changes in the family. Crises resulting from family dissolution, adjustment to losses and structural change, and the merging of individuals and families in the formation of a new system are also addressed. Chapter 9 presents a broad view of addictions as they arise from and severely impair the family process. Crises with substance abuse, violence, and other addictions are explained as cyclical interpersonal processes encouraged and maintained by the family process as a whole and each individual's personal attempt to meet needs. Chapter 10 addresses methods of research and their usefulness and limitations in theory testing with families in crisis.

    Part 4 applies to crises with illness. Chapter 11 discusses the interaction of families and the acute care system and focuses on the nurse's role in addressing crises quickly and effectively. The focus of Chapter 12 is terminal illness and the preparation of the family for death. Chapter 13 discusses crises that can occur as families give care to chronically ill members, with special emphasis on the transition from home care to institutionalization. Chapter 14 deals with issues around caring for members with developmental disabilities, mental illnesses, and dementias and their devastating effects on families. Nurses are shown ways to assist families as they experience severe losses in their relationships with the afflicted individuals and how growth can be promoted within the process of caring. Chapter 15 relates to issues of research and measurement within the topic of families and illness.

    Part 5 addresses crises from the environment. Family reactions to external assaults or adverse conditions, such as violent crimes, problems with work, unemployment, poverty, and homelessness, form the content of this part. Chapter 20, the final chapter, focuses on research implications. The readers are also offered suggestions for the conduct of their own studies with the families in discussion.

    In absorbing the content of this book, the reader is guided toward a concept of nursing that unifies theory, clinical expertise, and research and pursues the one important aim of supporting the process of seeking health and well-being unique to each individual and family.

    Acknowledgments

    The development of a theoretical framework is an ongoing growth process. Without the critical thinking and excellent feedback of many nurses and students engaged in practice, teaching, and research at universities, health care institutions, and social service agencies locally, across the nation, and overseas, this book could not have been written. I wish to thank all the people who have applied this framework to real-life situations and reported the encouraging outcomes that nourished my enthusiasm and maintained my belief in the reality of a nursing process that truly reaches out to families and their members. I deeply appreciate the efforts of all teachers and researchers who use my publications to enhance the growth of their students and guide them in exploring the depths of the family process. These people have convinced me of the need for this book to explain and tie the various pieces together into a unified whole.

    Specifically, I extend my sincere thanks to my associates and students who have contributed their time to the refinement of the framework, treatment model, and assessment instruments: Dr. Rhonda Montgomery, Director of the Gerontology Center, University of Kansas, and longtime mentor and research associate; Dr. Adele Webb, faculty member at the University of Akron and research associate; Clementine Rice, Rosanna DeMarco, and Ann Smith, PhD candidates at Wayne State University who are involved in research with this framework; and Olivia Washington and Margie Miller, both faculty members at Wayne State University, College of Nursing, and instrumental in launching my treatment model in the community. Finally, very special appreciation goes to my husband, Heinrich, for his endless patience and hours of proofreading and critiquing the manuscript.

  • Concluding Remarks

    This book has taken the readers on a journey through nursing with the framework of systemic organization. Initially, they were familiarized with the basic concepts and the dynamic process of systems: individual, family, and larger groups and organizations as well as the process of nursing. The theoretical section was followed by practical applications in a variety of nursing situations. On their journey, readers were exposed to healthy processes of individuals and families attempting to continuously regain congruence through the adjustment of values and behaviors working toward the desired systemic targets of stability, growth, control, and spirituality. These healthy processes were then contrasted with crises that stifled the growth of family systems and the development of the individuals within. Numerous examples guided the readers through the nursing process aimed at crisis resolution through supporting families in system change.

    I believe that a focus on systems larger than the individual is absolutely necessary in all types of nursing. Because physical disease is often intertwined with a difficult life situation, seemingly simple cases often turn out to be immensely complex. I hope that nurses in clinical settings who observe incongruence and crisis of individuals and families have found in this book the necessary tools to work on sharpening their skills of assessing situations, asking the right questions, finding existing strengths and resources, and supporting clients in pursuing a course toward better health. Experts in nursing have the opportunity to expand their understanding of the clients' life process to include all areas of family life as well as the environment, its culture, resources, dangers, and temptations. The framework of systemic organization provides the necessary structure to organize assessment data of complex situations, determine on what level to enter the system, set goals with the clients, and find ways to pursue them.

    Studying the case examples may have surprised many readers about seemingly unconventional approaches undertaken with families. Ever so often, behaviors that appear problematic on the surface turn out to be assets for families when their motivations and effects are examined in greater depth. Perhaps the most valuable merit of the framework of systemic organization is its guidance in examining values, beliefs, and motivations. Values and beliefs serve as the foundation out of which the life process evolves and as a backdrop for behavior patterns. Working with the framework of systemic organization, nurses avoid judging behaviors at face value without seeing them in the context of the dynamic overall life process. Thus, the framework promotes true cultural sensitivity, not through the knowledge about peculiarities of ethnic patterns pertaining to certain groups of people, but through the revelation of the role these patterns play in attaining the systemic targets of families in maintaining stability while adjusting to an environment that poses continuously changing demands. Cultural sensitivity reaches beyond ethnicity and race to a sensitivity to the many variations of human existence. The first step toward such sensitivity is the knowledge and appreciation of one's own peculiarities that can then reach out to the clients'. On the basis of the process of individuation, nurses working with the framework of systemic organization slowly transform their own culture in that they accept and value differences and experience growth through interactions with families and communities.

    This explains why nursing with the framework of systemic organization challenges neophytes and develops experts. It defies “cookbook” approaches to nursing as well as ready-made and good-for-all interventions. The framework individualizes care, not in terms of superficial demographic differences, but according to the clients' view of their world. The clients' world can open up to every nurse and reveal the secrets of humanity, the very essence that promotes growth within the nursing profession.

    Like the clinician, the researcher is driven by the same fascination for human nature and social interactions. The task of the researcher is the exploration of process, and knowledge is generated from the understanding of humans, families, clients, and nurses as complex, evolving, and constantly moving systems. That understanding drives the methods, all limited in many ways. If methods are used in combination, however, researchers can minimize shortcomings and optimize explanatory power. Therefore, through methods triangulation, a variety of creative methods is encouraged to generate in-depth knowledge. In research, truth is relative to the subjects' understanding of their world and the researcher attempts to capture that understanding. Common to all research designs is the necessity for subjects to play an integral part in the exploration process, because it is through the subjects that truth evolves.

    In short, the framework of systemic organization leads to innovative clinical approaches and research designs with families and family members, and it can be expanded to the environment of individuals, groups, and families. The broad systemic understanding of phenomena played out in families and organizations has the potential to assist nurses in assuming visionary leadership and guiding policymakers away from surface solutions to health and social problems, such as promoting the return to an antiquated family ideal unsuitable for many, and to turn them toward those policies that benefit both wealthy and poor individuals, traditional and nontraditional families, and people in urban and rural settings. Based on the tenets of this framework and the conviction that all nursing, by necessity, has to be family nursing, it is my sincere hope that nurses increasingly become ardent advocates of their patients' families and that researchers reveal to the world the essence of family life, human interaction, and the social process of groups and organizations.

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    About the Author

    Marie-Luise Friedemann is Associate Professor and Assistant Dean for the Area of Family, Community, and Mental Health Nursing at Wayne State University, College of Nursing, in Detroit. She has a master's degree in psychiatric nursing and a clinical background in community health nursing. Her specialty area is nursing and the health of families. Dr. Friedemann has researched the functioning of families—specifically, families with substance abusers, elders in nursing homes, and unemployed members—and has developed an assessment tool of family effectiveness. The theory of systemic organization has evolved since 1987 and forms the basis of all of Dr. Friedemann's teaching, research, and clinical work. Based on the theory is the Congruence Model, a structured approach to substance-abusing families that she has tested, taught to nurses and other professionals, and is currently using in her clinical work as an ANA-certified nurse family therapist.


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