What are the barriers/challenges described in your readings that you also face in your environments as you attempt to provide family focused nursi

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http://jfn.sagepub.com/content/15/4/461 The online version of this article can be found at:

DOI: 10.1177/1074840709350606

2009 15: 461Journal of Family Nursing Fabie Duhamel, France Dupuis and Lorraine Wright

Nursing Reflections for Clinical Practice, Education, and Research in Family Families' and Nurses' Responses to the ''One Question Question'':

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DOI: 10.1177/1074840709350606 http://jfn.sagepub.com

Families’ and Nurses’ Responses to the “One Question Question”: Reflections for Clinical Practice, Education, and Research in Family Nursing

Fabie Duhamel, RN, PhD,1

France Dupuis, RN, PhD,1

and Lorraine Wright, RN, PhD2

Abstract

The “One Question Question,” first coined by Dr. Lorraine M. Wright in 1989, is an interventive question designed to elicit family members’ most pressing needs or concerns within the context of a therapeutic conversation. In this article, two clinical projects analyzed the responses to this unique interventive question. The first project analyzed the responses of 192 family members experiencing illness who were asked the question in the context of a therapeutic conversation; families focused on their need to deal with the impact of the illness on the family. The second project examined responses of 297 nurses who were asked the question prior to a 1-week Family Systems Nursing training program; nurses wanted to know how to deal with conflictual relationships between families and health care professionals and how to offer families time-efficient interventions. The responses from both

1University of Montreal, Montreal, Quebec, Canada 2University of Calgary, Calgary, Alberta, Canada

Corresponding Author: Fabie Duhamel, Faculty of Nursing, University of Montreal, C.P. 6128, Succursale Centre-ville, Montreal, Quebec, H3C 3J7 Canada Email: [email protected]

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groups, which were markedly different, triggered reflections about teaching, research, and practice in family nursing.

Keywords

family nursing interventions, One Question Question, interventive questions, therapeutic conversations, family nursing practice, family and chronic illness

The “One Question Question” (OQQ) was first introduced by Dr. Lorraine M. Wright as an efficient assessment question to explore family members’ most critical concerns and/or challenges about a health issue (Wright, 1989). The usefulness of this question arose during therapeutic conversations between nurses and families at the Family Nursing Unit, University of Calgary (Bell, 2008; Gottlieb, 2007). From numerous clinical interviews at the Family Nurs- ing Unit, it was observed that this question often invited or helped family members express the source of their deepest concerns or suffering, trans- forming a useful assessment question into a powerful interventive question as well. The question is usually formulated as follows: “If you could have just one question answered through our work together, what would that one question be?” Wright (1989) suggests that the question invites the nurse to move quickly to the most pressing issue identified by the family, thus avoid- ing one of the most common errors in family nursing (Wright & Leahey, 2005), that is, only exploring those issues considered important by the health care professional. Thus, the OQQ becomes a useful tool to collect the most pertinent information and concerns in a brief therapeutic conversation (Martinez, D’Artois, & Rennick, 2007; Wright & Leahey, 1999). Such a tool is particularly important for clinical contexts, where time is considered a con- straining factor in conducting family assessments. Moreover, the question may be used in other contexts for various populations to identify their main concerns or challenges related to a particular topic.

This article reports on two separate clinical projects conducted at the University of Montreal, which examined responses to the OQQ from two different populations: (a) The Family Project analyzed the responses of fam- ilies to the OQQ who were dealing with health issues and who were offered supervised therapeutic conversations and (b) The Nurses Project analyzed the responses of nurses who were asked the OQQ by the first author prior to a 1-week Family Systems Nursing workshop/training program. The docu- mented responses from both groups provided a rich opportunity to identify the most pressing concerns and issues for each group. There was no association

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between the families who participated in the Family Project and the nurses who participated in the Nurses Project. Although the two projects were con- ducted and analyzed separately, and without the benefit of a scientifically based comparison between groups, it was both interesting and useful to identify areas of convergence and divergence between the groups’ answers which focused on families’ concerns about the experience of illness and the nurses’ learning priorities for including families in their clinical practice. Differences that exist between nurses and families’ perceptions about priori- ties could be one contributing factor to the challenges encountered in family nursing practice (Hundley, Milne, Leighton-Beck, Graham, & Fitzmaurice, 2000; Létourneau & Elliot, 1996). Hence, these two projects stimulated reflections within our clinical research team and generated ideas for practice, education, and research in family nursing. These two separate clinical proj- ects are not considered to be traditional research studies, therefore only a general qualitative description of each project is provided.

Description of the Family Project The main objective of this clinical project was to examine families’ responses to the OQQ within the context of a therapeutic conversation to identify the most frequently reported concerns and questions of families experiencing and managing illness at home.

Context of the Family Participants The first two authors provide family nursing supervision to graduate students at an outpatient clinic called the Denyse-Latourelle Family Nursing Unit at the University of Montreal (modeled after the Family Nursing Unit at the Univer- sity of Calgary). All the teaching, supervision, and nursing practice at the University of Montreal is conducted in the French language. Families who come to this Family Nursing Unit present with challenges while living at home with a health problem such as chronic illness, child behavioral prob- lems, or separation/divorce issues. Each family participates every 2 weeks in a family meeting for a total of four to seven meetings. A graduate nursing student conducts the family interview (therapeutic conversation) within the context of a supervised clinical practicum in Family Systems Nursing. At the end of the first family meeting, the graduate student is encouraged to ask each family member the OQQ and chart each family member’s response to the question in the family’s file. Students often refer to these responses to guide the family assessment and interventions throughout their clinical work

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with the family. For the Family Project, family files were examined to obtain family members’ responses to the OQQ. In total, 192 family member res- ponses to the OQQ were retrieved, identified, and analyzed. All families signed an informed consent allowing the use of their file for clinical, educa- tional, and research purposes.

Description of the Nurses Project The main objective of this clinical project was to examine nurses’ responses to the OQQ at the beginning of a 1-week Family Systems Nursing training program offered by the first author, to identify their most pressing learning needs regarding the nursing of families.

Context of the Nurse Participants The clinical usefulness of the OQQ has led to its ritualized use in teaching/ learning contexts. Since 1998, a 1-week Family Systems Nursing workshop/ training program has been offered annually at the University of Montreal to a francophone population of practicing nurses, graduate nursing students, and academics. The aim of the program is to teach nurses how to assess and intervene with families using a systemic perspective. Nurses come from vari- ous clinical settings and attend on a voluntary basis. On the first day of the training program, participants are asked to respond to the OQQ focusing on their family nursing learning needs. Nurses’ responses to the OQQ are con- sidered to reflect the nurses’ main educational needs, concerns, and questions regarding their practice with families. These responses are then transcribed and serve to guide the content and process of the family nursing training programs/workshops. For the Nurses Project, the responses of 293 nurses to the OQQ were examined and analyzed. The educational background of the nurses varied from nursing diploma to graduate degrees, and every nurse had at least 3 years of clinical experience.

Process of Analyzing the Responses to the OQQ Although these two separate projects are not considered traditional research studies, the responses of both the nurses and families were submitted to a form of inductive content analysis that, at first, consisted of multiple readings and coding of each response to the OQQ by the research team. The same examina- tion process was used for both projects separately. The coding process was performed by a project assistant who had a bachelor degree in nursing. The list

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of questions and codes was then submitted to the first two authors, who col- laborated to validate and reach a consensus on the labeling of the codes. Then, the project’s nursing assistant classified the codes into sub-themes which were finally regrouped under a “theme question.” As an example, one family mem- ber’s response to the OQQ was, “How can I help my husband alleviate his stress?” which was coded as “Strategies to reduce stress.” This code was then classified in the subtheme “Stress and anxiety,” which was then listed as a theme question “What to do about?” because most of the questions related to stress and anxiety reflected families’ quest for strategies to cope with their feelings generated by the health problem. The subthemes were used not only as a “classification” system but also for calculation of the percentage of fre- quency. At the completion of this analysis procedure, another project assistant, a masters level nurse with expertise in family nursing, reviewed the total examination process for validation purposes. Only minor adjustments were suggested. The authors closely examined the findings to generate reflections about family nursing practice, education, and research.

Findings The Family Project: Family Members’ Responses to the OQQ

The theme questions and their sub-themes for family members’ responses to the OQQ are listed in Table 1, which includes the distribution of responses (in the form of questions) for each theme, sub-theme, and corresponding per- centages of the total responses. Family members’ responses to the OQQ during a therapeutic conversation resulted in three major themes: (a) “What to do about the illness and its impact on the family?” (b) “What is ahead of us?” And (c) “What and who can help us?” The sub-themes offer specific ideas about the issues that were most concerning for these families experienc- ing illness.

What to do about the illness and its impact on the family? A total of 42% of the total number of the family members’ questions reflected the need for strat- egies to deal with the challenges of the illness. Seven subthemes of questions within this major theme are shown in Table 1: (a) the impact of the illness on the partner and significant others, (b) illness management, (c) children reac- tions to the illness, (d) relational problems between family members, (e) the role of the caregiver, (f) children with behavioral problems, and (g) stress and anxiety related to the illness.

Under this theme, we included questions about dealing with family mem- bers’ reactions to the health problem. More specifically, these questions refer

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to the protection of self and others, especially the partner, from negative con- sequences (e.g., feelings of guilt or depression) of chronic illness on the family. Other questions dealt with the families’ need to know more about how to manage symptoms such as fatigue, pain, and irritability—symptoms that affect healthy family members as well as the patient. Another source of family concern was how to deal with children’s reactions to the illness. For example, parents who were ill wondered how to explain the severity of their illness to their young children. Others wanted to know how to best help chil- dren express or deal with their emotions. The fourth subtheme question, “how to deal with relational problems within the family,” referred to how family members can better understand each other or how they can repair broken relationships because of the tension generated by the illness. In terms of the role of the caregiver, seven responses referred to questions on “how” to be a better caregiver for the ill person. As for families who consulted the

Table 1. Families’ Responses to the One Question Question

Theme Questions Number Frequency (%)

1. “What to do about . . . ?” Looking for 81 42.2 strategies to deal with the:

a. Impact of illness on partner and 28 14.6 significant others

b. The illness itself 16 8.3 c. Children’s reactions to illness 15 7.8 d. Relational problems within the family 8 4.2 e. The role of caregiver 7 3.7 f. Children with behavioral problems 4 2.1 f. Stress and anxiety related to the illness 3 1.6 2. “What’s ahead of us?” Uncertainty about: 64 33.3 a. Long term impact of the illness on 20 10.4

marital and family life b. Existential and spiritual questions 20 10.4 c. Evolution of disease and facing death 19 9.9 d. Normality 5 2.6 3. “What and who can help us?” Resources 47 24.5

and information about: a. Illness and treatment 25 13 b. Psychological support 8 4.2 c. Reasons for the family meetings and 8 4.2

usefulness d. Instrumental assistance 6 3.1 Total 192 100

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Family Nursing Unit for their children’s behavioral problems, questions pertained to behavioral management. Finally, the last sub-theme included family members’ questions about how to reduce feelings of stress and anxi- ety in one’s own self and in others.

Examples of specific family members’ questions within this theme of “What to do about the illness and its impact on the family?” were as follows:

How can I relieve my guilt related to the depression that my illness causes in my husband?

How do I protect myself as a spouse? My wife (who has multiple sclerosis) doesn’t want any more visitors at

home. How do I explain to her that it is important for me? How can I alleviate my wife’s pain? How can I avoid that my illness has a negative impact on our children’s

development? My child is 9 years old, what do I tell her about my illness? Should I

show her that I am strong? How can I be a better caregiver for my wife? Should I continue to “walk on egg shells” when dealing with my

daughter? What attitude should I have toward her? How can I help my husband relieve his stress related to the illness?

What is ahead of us? The second most important theme of family member responses to the OQQ (33.3%) were questions for which there are no clear answers. The questions related to (a) the long-term impact of the illness on family life, (b) existential issues and spirituality, (c) the progression of dis- ease and facing death, and (d) normality. More specifically, the responses to the OQQ reflected family members’ concerns about the long-term impact of the illness on their family life, their work, and marital and parental relation- ships. Uncertainty related to the progression of the illness generated questions about the future, the possibility of a remission, relapse, or cure for the patient, and/or an increase/decrease of the caregiver’s burden. The progression of the illness and long-term impact on each family member’s health status, and on family life, also triggered questions relating to existential, philosophical, and spiritual issues, particularly with regard to the meaning and purpose of life. There are no easy answers, if any, to these questions. Within this theme of uncertainty, there were some questions that referred to the notion of “normal- ity.” Family members reported unusual behaviors, thoughts, and /or emotions in reaction to the illness, and were concerned with their normalcy under the circumstances.

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Examples of family members’ questions in this theme of “What is ahead of us?” were as follows:

Will he ever walk again? Will we still be a couple in the future? How much longer will he live? Can we still plan projects together? When will we be able to leave on a family vacation? Why has this happened to us? Why does suffering exist? If we were such good parents, as you say, why did we lose our daughter? Why do I have cancer? How can we live and be happy with someone who has multiple sclerosis? Is it normal to always have a lump (emotional) in my throat? Is it normal, at this phase of my illness, that I do not want to see my

children’s spouses anymore?

What and who can help us? The third theme of family members’ responses to the OQQ concerned the need for information and resources about (a) the illness and treatment, (b) psychological support, (c) the family meetings that were offered to them (in the Denyse-Latourelle Family Nursing Unit), and (d) assistance with instrumental tasks. Questions under this theme revealed family members’ need for more information about the nature of the illness, etiology, treatment, the role of stress in the progres- sion of the illness, and the impact of treatment. The search for reliable support was another source of concern. Family members inquired about the availability and accessibility of resources related to both instrumental as well as psychological needs.

Examples of family members’ questions within this theme of “What and who can help us?” were as follows:

Could an emotional trauma have triggered the illness? What are the benefits of taking such a medication? Why didn’t the hospital offer to put me in touch with people who are

experiencing the same thing, so I can prepare myself for this? Why do people around us distance themselves from us as if the illness

was contagious? What about these family meetings, will they promote a sense of well

being in our marital relationship?

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Why can’t I receive more help for cleaning my house and doing my errands?

Why can’t we get the name of a resource person to phone, if needed, once we are back home?

The Nurses Project: Nurses’ Responses to the OQQ There was a great variation of answers in nurses’ responses to the OQQ at the beginning of a one week workshop/training program in Family Systems Nurs- ing. However, four theme questions in response to the OQQ did emerge and are listed with the frequency and percentage of total responses in Table 2. The themes were as follows: (a) “How to intervene in specific clinical situations?” (b) “What are the most efficient family interviewing skills?” (c) “What is the nurse’s role in family care and in relation to the other professionals?” and (d) “ How do we involve the family in the care of the patient?”

How to intervene in specific clinical situations? The most frequent type of nurses’ questions pertained to the need to be effective and brief when dealing with challenging situations related to (a) conflictual relationships between families and professionals, (b) families with specific health problems (e.g., schizophrenia, noncompliant families), (c) conflicts between family mem- bers (e.g., display of anger, aggression), (d) ethical questions, confidentiality issues, and transmission of information, (e) loss and grief, (f) crisis situation, perception of suffering, (g) family members in “denial,” (h) placing a parent in a nursing home, and (i) feelings of guilt and overprotection.

In this first theme, we noted that the largest percentage of responses (14.6% or 43 questions) was related to conflicts between family members and health professionals. These questions pertained to the difficulty in dealing with families whom the nurse perceived as being “demanding,” continually dissatisfied, complaining about the care, lacking respect, and/or showing arrogance and anger. The next most frequent set of responses to the OQQ reflected the nurses’ need to learn more about specific health issues or problems and how to deal with families experiencing these problems. These issues included reconstituted families, noncompliant families, and diagnoses such as schizophrenia and psychosomatic symptoms.

Conflict between family members was another important source of ques- tioning for nurses, especially when the family members expressed anger or hostility toward one another in front of the sick family member. The next most common responses focused on ethical issues of confidentiality and sharing patient information with family members, documentation of family

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concerns in patient charts, and end-of-life decisions. Regarding these issues, nurses’ concerns were embedded in the following types of questions:

How do we approach family members who are unreasonable, want their way no matter what, and become aggressive toward nurses?

How can nurses prevent burn-out when families show continuous dis- satisfaction and make unrealistic demands?

Table 2. Nurses’ Responses to the One Question Question

Number of Theme Questions Questions Frequency (%)

1. “How to intervene in specific clinical situations?” 130 44.2 Looking for strategies to deal with:

a. Conflictual relationship between families 43 14.6 and professionals

b. Families with specific health problems 19 6.5 (schizophrenia, noncompliant)

c. Conflicts between family members 15 5.1 (anger, aggressiveness)

d. Ethical questions, confidentiality issues, 14 4.7 and information transmission

e. Loss and grief 13 4.5 f. Crisis situation, perception of suffering 11 3.7 g. Family members in “denial” 8 2.7 h. Placing a parent in a nursing home 4 1.4 i. Feelings of guilt and overprotection 3 1.0 2. “What are the most efficient family 107 36.7

interviewing skills?” How to . . . a. Engage, assess, and intervene with families 69 23.5

in an efficient manner b. Explore the impact of the illness 17 5.7

on the family c. Explore and challenge beliefs 12 4.0

and cultural issues d. Interview children 9 3.0 3. “What is the nurse’s role in family care and 29 9.8

in relation with the other professionals?” 4. “How do we involve the family in the care 27 9.3

of the patient?” Total 293 100

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How do we deal with families who refuse the prescribed treatment for their child?

How do we intervene when conflicts between family members affect the patient’s health?

What type of information regarding the patient’s health issue can offer to the family without impinging on confidentiality rights?

Another set of nurses’ questions under this same theme were related to emotionally difficult situations such as families who face a crisis and/or a loss and who express grief and suffering. Nurses inquired about strategies to explore, prevent, and comfort family members’ emotional suffering. They also requested guidance to help families whom they perceive as being “in denial” and not responding to their expectations. Nurses also had questions about how to support families who experience hardship when having to place their loved one in a nursing home. Feelings of guilt and perceptions of overprotection in families were another source of concern when working with families. All these concerns were expressed in the following questions:

What is the best way to intervene when the family is in crisis or in shock after learning about a serious prognosis or the death of a loved one?

How do we deal with family members when they are in denial that their loved one is dying?

How can we alleviate families’ suffering and help them accept the placement? How can we help them with their feelings of guilt?

How do I interview a family? Almost one third of nurses’ questions related to the skills required to conduct a family interview (107 questions). The four subthemes included how to (a) engage, assess, and intervene with families; (b) explore the impact of the illness on the family; (c) explore and challenge beliefs and cultural issues; and (d) interview children.

1. How to engage, assess, and intervene with families? In this sub- theme, nurses’ questions reflected their learning needs about which family members should be present in family meetings, and

when, what kind of questions to ask the family in order to collect pertinent

information, how to identify “the real problem” in the family, how to resolve different problems within the family,

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how to reassure family members and strengthen their relationships, and how to challenge family members’ beliefs.

Specific examples of questions in this theme are as follows: “How do we keep neutral when parents do not agree?”; “How can I feel more at ease in a family meeting?”; “How do we explore a family problem without jeopardizing our trusting relationship with the family?”; “How do we help families adapt to their illness?”

2. How to explore the impact of the family on the illness? Through their OQQ, nurses expr

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