Altered Family Processes Related to an Ill Family Member: A Validation Study

Nell Walker Brewer, MSN, RN and A. Michele Warren, PhD, RN

The purpose of this retrospective descriptive

survey was to validate the defining characteristics for altered family processes

related to an ill family nursing diagnosis. Using

Ferhing’s 12987) Diagnostic Cantent Validation Model, data were collectedfiom 58 registered

nurses. Clinical nurses submitted 24 defining

characteristics not identifi’ed by N A N D A nor found in the literature. Many of these characteristics expressed the same concepts in

different terms from those used by N A N D A . The results ofthis study give credibility to NANDAs conceptually stated defining characteristics and suggest further clinical research. Key words: Nursing diagnosis, defining characteristics, ill family member, altered family

processes

Nell Walker Brewer, M S N , RN, is Instructor, Department of Nursing, Garland County Community College, Hot Springs, AR; and A. Michele Warren, PhD, RN, is Professor, Department of Nursing, University of Central Arkansas, Conway, A R .

N u r s i n g diagnoses reflect the clinical phenomena which nurses diagnose and treat. Validation studies of the diagnoses are crucial to the development of nursing knowledge. Diagnoses are accepted by NANDA for test- ing and validation to discern if the diagnoses accurately identify and describe clients’ responses to health status. The validation process also includes determining whether the defining characteristics specified by NANDA reflect what nurses in clinical practice actually observe, which leads them to make a particular diagnosis.

The nursing diagnosis altered family processes describes “the state in which a usually supportive family experi- ences, or is at risk to experience, a stressor that challenges its previously effective functioning” (Carpenito, 1993, p. 306). This research focused not only on the diagnosis, but on the diagnosis and the specific etiology of an ill family member. An ill family member deeply affects the func- tioning of the entire family. Nursing’s focus should be on the family as a holistic unit and the individual as an interrelated subsystem of the family system.

Review of the literature shows that NANDA lists seven defining characteristics for altered family processes. A family exhibiting altered family processes cannot or does not: (a) adapt constructively to crisis; (b) communicate openly and effectively between family members: (c) express or accept a wide range of feelings; (d) meet phys- ical needs of all its members; (e) meet emotional needs of all its members; (f) seek or accept help appropriately; and (g) meet spiritual needs of all its members (Carpenito, 1993). NANDA considers two defitung char- acteristics as major, meaning that these characteristics are critical for the diagnosis and will be present 80% to 100% of the time when this diagnosis is made. These two char- acteristics are (a) A family system cannot or does not adapt constructively to crisis and (b) A family system

Nursing Diagnosis Volume 5, No. 3, July-September, 1994 115

Altered Family Processes Related to an Ill Family Member: A Validation Study

cannot or does not communicate openly and effectiidy between fain ily members. An eighth defming character- istic, that family members express somatic concerns, was suggested by Cohen, Titler & Craft (1989), based on their validation studv. At this point, howe\rer, the NANDA taxonomy does not include ths suggestion.

Even though alti7rt7d fizrlli/y processes was accepted by NANDA in 1982, the study conducted by Cohen and colleagues (1989) is the only \ralidation study of this diagnosis reported in the literature. Cohen’s study was limited to cxamining effects of illness on family members of patients hospitalized in critical care units. No pub- lished research was found on the diagnosis and etiology related to an ill family member.

The twofold purpose of this study was to examine the tralidity of the nursing diagnosis alferedfntrtily prmsses as related to an ill family member, and to examine the validity of the defining characteristics that lead nurses to make this nursing diagnosis.

Methods

The study ~ 7 a s a retrospective descriptive study, con- ducted in three acute care hospitak and two home health agencies. The authors oriented the nurses to the research and ascertained their willingness to participate. Those who 1.olunteered to participate were p e n a packet containing a questionnaire, a diagnostic content valtdation tml (DCVT), and a co\w leter. Questionnaires were omitted from the study if the nurse had not worked for a minimum of two years in an institution that used nursing diagnoses.

Instrument

The qucstinnnaire included personal data requesting demographic intormation, year of graduation from nurs- ing school, type of institution where employed, and area of clinical practice. Also, nurses were asked if nursing diagnosis had been included in their basic school cur- riculum m d when the!, had received their most recent instruction cm nursing diagnosis. Also, nurses were asked if thcv used nursing diagnosis in practice, if they

used the NANDA list, and if their employing institution used nursing diagnosis for documentation.

The researcher used Fehring’s (1987) Diagnostic Content Validation Model to develop the DCVT used to identify the major and minor defining characteristics nurses employ for m a h g a nursing diagnosis. Defming diaracteristics ”refer to c h c a l cues-subjective and objec- tive signs or symptoms that, in a cluster, point to the nurs- ing diagnosis” (Carpenito, 1993, p.13). Interrater reliability figures for DCV tools developed from Fehring’s model range from 0.75 (Keenan, 1989) to 0.85 (Iverson-Carpenter, 1989). Reported alpha coefficients are 0.42 (Aukamp, 1989) and 0.95 (Murphy, 1989). The DCVT contained NANDA’s seven defining characteristics and one characteristic from the Cohen et a!. (1989) study. A place was provided where participants could h t and rank any additional characteris- tics they use to make the diagnosis of altcredfimily pr0cesst.s that were not included on the DCVT.

Analysis

In order to separate defining characteristics into major and minor designations, Fehring’s (1987) directions for using the DCV were followed. Each defining characteris- tic is rated on a five-point Likert scale (1 = least charac- teristic of the diagnosis, and 5 = most characteristic). Weighted ratios for each defining characteristic were applied to numbers on the Likert scale to obtain a Diagnostic Content Validation (DCV) score. The weights are : 1 = 0.0; 2 = 0.25; 3 = 0.50; 4 = 0.75; and 5 = 1.0. Scores for each characteristic on the DCVTs were aver- aged and those with an average DCV score of less than 0.50 were discarded as “not a defining characteristic.” The decimal was moved two places to the right to con- \rert the DCV score to a percentage. In NANDA’s revised Guidelines for Submission, a characteristic with a DCV score of 0.50 to 0.79 is considered a ”minor” defining characteristic; that is, it is a supporting indicator of the diagnosis and represents signs and symptoms that can be expected to be present 50‘% to 79%) of the time this diagnosis is made. A defining characteristic with an average DCV score of 0.80 to 1.0 is considered a ”major”

116 Nursing Diagnosis Volume 5, No. 3, July-September, 1994

defining characteristic. Major defining characteristics are signs and symptoms present 80% to 100% of the time in persons or groups with the hagnosis.

Results

One hundred DCVTs were distributed by the researcher. Thirty-three medical surgical nurses, 15 critical care, 11 home health, 2 obstetrical, and 2 pediatric nurses returned a total of 63 tools. Four completed DCVTs were omitted from the data analysis because the nurses did not meet the requirement that participants must be employed for a minimum of two years in an institution that uses nursing diagnoses. One DCVT was omitted due to incomplete data. Fdty-eight DCvTs were suitable for use.

The mean age of the RNs ranged 31-40 years; 94.8% were female; 89.7% were Caucasian; 48% were associate degree nurses; 24% were graduates of BSN programs. Two participants had master’s degrees. Nursing diagno- sis was included in the curriculum of 81.0% of the RNs. One-hundred percent had received instruction about nursing diagnosis either in their nursing school curricu- lum or in a workshop. Eighty-six percent of the RNs use nursing diagnoses in their nursing practice, although only 58% indicated they use the NANDA list. Since 1985, 81% of the RNs have received teaching on nursing diag- nosis; 45% of the RNs had instruction on nursing diag- nosis as recently as 1990. Frequencies, percentages, descriptive statistics and Fehring’s (1987) weighted ratios were used to analyze data.

As shown in Table 1, respondents validated all of the characteristics on the tool as ”minor” defining character- istics of the diagnosis; that is, they viewed these signs and symptoms present in 50%-79% of persons with the diagnosis. Fourteen defining characteristics not speci- fied by NANDA were added by study respondents as shown in Table 2.

Discussion

Nurses validated NANDA’s seven defining charac- teristics and one characteristic from the literature as

clinically accurate but not essential to make the diagno- sis alteredfamily processes related to an ill family member. NANDA designates two of the seven defining charac- teristics as major: (a) Family cannot or does not adapt constructively to crisis, and (b) Family cannot or does not communicate openly and effectively between family members. Nurses who participated in this study ranked none of the defining characteristics high enough to result in a DCV score of 0.80-1.0 which classifies the characteristic as ”major.” Participants in Gatto’s (1989) study to validate the nursing diagnosis sleep puttem dis- turbance also failed to identify any major characteristics as did participants in Schneider’s (1991) study to vali- date defining characteristics for ineffective airway clcar- ance. Participants in the Cohen and colleagues (1989)

Table 1. DCV Scores for the Defining Characteristics of - Altered Family Processes

Defining Characteristic

Family cannot or does not adapt constructively to crisis.

Family cannot or does not communicate openly and effectively between members.

Family cannot or does not express or accept a wide range of feelings.

Family cannot or does not meet emotional needs of all its members.

Family cannot or does not seek or accept help appropriately.

Family cannot or does not meet physical needs of all its members.

Family cannot or does not meet spiritual needs of all its members.

Farmly members express somatic concerns.

N = 5 8

DCV Score

0.79

0.72

0.69

0.68

0.63

0.62

0.59

0.56

Nursing Diagnosis Volume 5, No. 3, July-September, 1994 117

Altered Family Processes Related to an I11 Family Member: A Validation Study

Table 2. New Defining Characteristics of Altered Family Process Related to an I11 Family Member Suggested by Clinical Nurses

Defining Characteristic

Farnil!, members deny diagnosis of ill family member

Family members cmnot or do not acknonkdge importance of, or take aypropriatc steps toward, maintaining their own mental, emotional and physical health.

Famil!, cannot sty’ beyond financial concerns

Family members physically withdraw from ill family membtxr.

Communicatioii is focused on family needs rather than on ntmls o f ill family member.

Family cannot oI does not communicate openll- arid effecti~~ly {vith anyone.

Family mcniber. euprcss unrealistic ideals.

Famil! does not accept medical diagnosis.

Famil!. members d o not communicate well with the doctnr.

Family i i una\vare of support services avnilablt~ tor their iriclividual/family needs.

FainiLy members experience anxiety due to separation from i l l family member.

Famil!. docs not heck help due to financial concern‘..

Family rtqmids inappropriately to caregivvr-s.

Famil! does not pro\ icle relief for caregi\.ers.

.- is

DCV Score

1 .o

1 .o

1 .0

1 .o

1 .o

1 .0

1 .o 1 .0

0.75

0.75

0.75

0.75

0.75

0.50

stud\ also identified \LINDA’S ”major” defmng char- ci~teristic~ ‘1s ’muior” for the nursmg diagnosis ot a l f o d f i l t? / l l l l /V(’“ sit’s

Fehring’s model used in the current study as well as i n the Gatto (1989) and Schneider (1991) studies requires rating each characteristic on a scale of five options (1 to S), meaning a middle option (3) exists. The selection of the middle option, with an assigned ratio of 0.50, by nurses who were unsure may have led to only minor classifications in these three studies.

Participants in h s study identhed 14 additional defin- ing characteristics for making the diagnosis altered fainily ~ ~ r o c t ~ s s ~ ~ s related to an ill family member that are not identi- fied by NANDA or found in the literature. Thirteen of the 14 nurses who submitted an additional d e k g character- istic ranked the characteristic as either a 4 or 5, indicating each considered that defuung characteristic as very charac- teristic of the diagnosis. It is important to note that each of these major defining characteristics was submitted and rated by only one RN.

Much overlap is seen in the substance of these added characteristics, and those in the Cohen et al. (1989) study. Many defining characteristics from both studies overlap with NANDA’s defining Characteristics. Characteristics submitted by respondents in tlus current study are aligned in Table 3 to show their correspondence to NANDA’s list.

Nurses are el7idently not associating specific observed client responses with the much more inclusive defining characteristics designated by NANDA. NANDA’s defin- ing characteristics actually include the concept of the d e h - ing characteristics the clirucal nurses submitted. For exam- ple, the additional characteristics of ”anxiety due to separation from family member” and ”family expresses unrealistic ideals,” are logmdy a component of NANDA’s major defining characteristic of ”family does not adapt constructively to crisis.” One additional characteristic by study respondents, ”family members express anxiety,” was identified as a defining characteristic by Cohen and 1201-

leagues (1989). “Expressing concern regarding disruption of the farmly unit” (Cohen et al.), relates closely to ”fanuly members experience anxiety due to separation from ill f d v member,” whch was identhed by one nurse in this current study.

NANDA’s defuung characteristic concerning communi- cation, ”family does not communicate effectively among

118 Nursing Diagnosis Volume 5, No. 3, July-September, 1994

Table 3. Relationship of Defining Characteristics for Altered Family Processes Related to an I11 Family Member Submitted by Clinical Nurses and Defining Characteristics Identified by NANDA

Defining Characteristics Submitted by Clinical Nurses

- Family does not provide relief for the caregiver

Family deny diagnosis of ill family member

Family members cannot or do not acknowledge importance of, or take appropriate steps toward maintaining their own mental, emotional and physical health

Family cannot see beyond financial concerns, does not seek help due to financial concerns

Family members physically withdraw from ill family member

- Family cannot or does not communicate openly and effectively with anyone

Family members express unrealistic ideals

NANDA’s Defining Characteristics

Family system does not adapt constructively to crisis

Family system does not meet emotional needs of members

Family system does not meet the physical need of all its members

Family system does not seek help appropriately

- Family system does not adapt constructively to crises

Family system does not meet emotional need of members

Family system does not meet physical needs of members

Family system does not seek or accept help appropriately

N = 5 8

Family system does not meet emotional need of members

Family system does not communicate openly between members

Family system does not adapt constructively to crisis

fatruly members,” might be expanded to include commu- nication with others outside the family, as addressed by two study respondents (see Table 2). The occurrence of concepts like communication, finanad concerns, and anxi- ety, submitted by c h i c d nurses in this current study, gives credibility to NANDA’s broad categories for major and minor defining characteristics for nursing diagnoses. Without broad categories the lists of characteristics for each diagnosis would be too long to be useful. At the same time

the all-inclusive nature of NANDA’s defining characteris- tics seems to be a problem for nurses to apply to client situ- ations since nurses chose the NANDA characteristics and submitted the same concept in different words.

Conclusions

Nurses in this study supported the findings of the Cohen and colleagues (1989) study by idenhfying more

Nursing Diagnosis Volume 5, No. 3, July-September, 1994 119

Altered Family Processes Related to an I11 Family Member: A Validation Study

cietining characteristics for the diagnosis than NANDA lists. Designation of characteristics as “major” and ”minor” h\ participants in this study and in the Cohen 5tLidL ditters from those NANDA designatations as ”innjor” d id ”niiiior” characteristics. These defining c h a r n c t t b r i s t ic 5 1-1 e e d f LI r t h e r ev a 1 u a t i on. Grant and Kiniie),’s 1991) suggestion to define NANDAs charac- teristics operation,illy may help to clarify them for nurses learning to use nursing diagnoses. In other Lvnrds, it ivould be helpful if NANDA defined a charac- teristic so that nurses would always interpret its compo- nents in the same ~vn! - . Diagnostic concepts must be linked to the real .rvorld, writh empirical referents that are edsily recognized aiid that permit investigation and mtasurc’ment. For example, nurses did not associate “mxiety” and ”unrealistic ideals” as conceptually a part of “adapting constructively to crisis.”

Implications for Future Research

A need exists foi further \ alidation studies of nltclrd h u i i d u proc( ’sw5 related to an ill famly member and other famil17 iiui sing diagnoses Research using a three-round Delphi teclultque employing a comprehensive h t of dehi- itig chaiacteiiitics might be the next logical step This approach c O U I ~ help i lanfv the duphcahon of characteris- tics nthc.rrmt in the 14 added characteristics by nurses m this studv ,tnd the Cohen and colleagues (1989) stud\

One nurse in this current study wrote that nursing diCignows are on patient charts m the hospital where she w o r k < , hut the! dre not really used in patient care I alidation o t nui sing diagnoses through research will .> d cl t ( 3 n LI r s in g ’ s 1\17 o tv I ed g e about the p hen ome n a nurwi dia;moie and treat This research should result in iiLirw5 using nursing diagnoses in clinical practice and ha\ mg contidencr that the nursmg diagnoses they select,

on the detining characterishcs, are appropriate th the propa~ed healthcare reform in our society

m d i t5 eiiipha\is nn prex enti1 e health care in the com- munit\ wtting, nui i es will be constantly involved with t‘trnilies, t>ither dii tlv or indirectly Nurse educators are current11 exploring M avs to expand home, family, and

community health content in their courses. Clinical nurses in acute care settings are being cross-trained for home health practice to meet the increasing demand. Research on development and implementation o f family nursing diagnoses will contribute to the theoretical core of nursing knowledge and consequently contributc to nursing science and nursing practice.

References

I20 Nursing Diagnosis Volume 5, No. 3, July-September, 1994