Effectiveness of Educational Programs for Clinical Competence in Family Nursing (2021) PDF

1038683 research-article2021 JFNXXX10.1177/10748407211038683Journal of Family NursingGutiérrez-Alemán et al. Research...

1038683 research-article2021 JFNXXX10.1177/10748407211038683Journal of Family NursingGutiérrez-Alemán et al. Research Journal of Family Nursing Effectiveness of Educational Programs for 2021, Vol. 27(4) 255­–274 © The Author(s) 2021 Article reuse guidelines: Clinical Competence in Family Nursing: sagepub.com/journals-permissions https://doi.org/10.1177/10748407211038683 DOI: 10.1177/10748407211038683 A Systematic Review journals.sagepub.com/home/jfn Teresa Gutiérrez-Alemán, MSc, RN1,2 , Nuria Esandi, PhD, RN1,2 , Miren I. Pardavila-Belio, PhD, RN1,2 , María Pueyo-Garrigues, PhD, RN1,2 , Navidad Canga-Armayor, PhD, RN1,2 , Cristina Alfaro-Díaz, MSc, RN1,2 , and Ana Canga-Armayor, PhD, RN1,2 Abstract Evidence shows that applying family nursing theory to practice benefits the patient, the family, and nursing professionals, yet the implementation of family nursing in clinical practice settings is inconsistent and limited. One of the contributing factors may be related to insufficient or inadequate educational programs focused on family nursing. This article presents a systematic review of the research that has examined the effectiveness of family nursing educational programs aimed at promoting clinical competence in family nursing. Six databases were systematically searched and 14 studies met the inclusion criteria, generating three themes: general study characteristics, educational program components, and outcome measures. These educational programs reported effectiveness in developing family nursing knowledge, skills, and attitudes, but did not evaluate the nurses’ actual acquisition and implementation of family nursing clinical competencies. This review offers relevant implications for research and for family nursing education, especially when designing and evaluating future educational programs. Future research must more closely address the process and outcomes of best educational practices in family nursing education and how these are applied and evaluated in actual practice settings. Keywords family nursing, education, systematic literature review, effectiveness, clinical competence Family nursing education first began in North America in the benefit not only the patient and the respective family unit but late 1970s with the introduction of textbooks written to guide also increase their own sense of nursing competence the application of family nursing theory in practice settings (Duhamel et al., 2015; Leahey et al., 1995; LeGrow & Rossen, (Friedman, 1981; Miller & Janosik, 1980; Wright & Leahey, 2005). Family nursing interventions have been shown to 1984). The Family Nursing Unit at the University of Calgary improve the physical and mental health of individual patients, (Canada; 1982–2007), developed by Dr. Lorraine Wright, disease self-management, symptom control, and the ability to focused on the education of master’s and doctoral students in develop healthier behaviors (Chesla, 2010; Gilliss et al., advanced family nursing practice, using a live supervision 2019; Rosland & Piette, 2010). Similarly, these interventions model (Bell, 2008). At the University of Montreal (Canada), may improve the health status of family members and Dr. Fabie Duhamel used a similar live supervision model for decrease their levels of anxiety and depression (Chesla, 2010; graduate-level family nursing education (Duhamel et al., Deek et al., 2016; Foster et al., 2016; Gilliss et al., 2019). 2015) at the Denise Latourelle Family Nursing Unit, later Furthermore, the perception of support received from nursing renamed the Center for Excellence in Family Nursing (1993– professionals is higher, thereby improving intra-family 2015). Family nursing scholars, Dr. Britt-Inger Saveman and Dr. Eva Benzein in Sweden at Kalmar University (now 1 University of Navarra, Pamplona, Spain Linnaeus University), also developed the Family Focused 2 Navarra Institute for Health Research, Pamplona, Spain Nursing Unit [Omvardnadsmottagning foer familjer] (2004– 2010), with an emphasis on family nursing research and edu- Corresponding Author: Nuria Esandi, Associate Professor, Department of Nursing Care for cation at the graduate level. Adult Patients, School of Nursing, Universidad de Navarra, Campus Evidence shows that nursing professionals who include Universitario, c/ Irunlarrea 1, 31008 Pamplona, Navarra, Spain. family nursing assessment and intervention in their care Email: [email protected] 256 Journal of Family Nursing 27(4) communication patterns and support (Svavarsdottir & the family within interviews/therapeutic conversations. Sigurdardottir, 2013; Sveinbjarnardottir et al., 2013). In addi- Accordingly, educational programs should promote a nurs- tion, various reports confirm that offering family nursing ing professional’s positive attitude toward involving the interventions has a positive impact on health care profession- family in the care process, which is essential for ensuring als, increases their self-esteem and job satisfaction, and there- that high-quality care is provided (Sveinbjarnardottir et al., fore improves the quality of nursing care (Duhamel et al., 2011; Wright & Leahey, 2013). 2015; Leahey et al., 1995; LeGrow & Rossen, 2005; Simpson An evidence-based analysis of the family nursing educa- et al., 2006). tional programs developed to date, at the international level, Accordingly, the International Family Nursing Association could be highly informative, given the importance of educa- (IFNA) recently developed the IFNA Position Statements on tion for the development of family nursing clinical compe- Generalist and Advanced Practice Competencies for Family tence (Bell, 2010) and its possible relationship with the Nursing (IFNA, 2015, 2017). These competencies focus on inconsistent implementation of family nursing in clinical practice guidelines for care for families and for individuals practice. To the best of our knowledge, no systematic review within families. has been performed for this purpose. Nevertheless, the implementation of a family care Therefore, we aimed to conduct a systematic review to approach remains inconsistent in clinical practice (Duhamel, examine the effectiveness of family nursing educational pro- 2010; Duhamel et al., 2015; Hanson, 2005; LeGrow & grams aimed at promoting clinical competence in family Rossen, 2005), and an individual perspective of patient-cen- nursing. tered care and a focus on pathology continues to persist in nursing practice (Canga et al., 2011; Duhamel, 2010). This context highlights the challenges of implementing family Objective nursing in health care settings and the difficulties in translat- To identify, evaluate, and summarize the available evidence ing family nursing knowledge into clinical practice (Bell, on educational programs in family nursing and to analyze 2010, 2014; Duhamel, 2017; Leahey & Svavarsdottir, 2009; their effectiveness in developing competency in family Moules et al., 2012). nursing. A possible contributing factor for this gap between theory and clinical practice may be a deficiency in the education of professionals to achieve competence in family nursing Method (Chesla & Stannard, 1997; Duhamel, 2010, 2017; Duhamel A systematic review of research articles focused on the effec- et al., 2015; Wright & Leahey, 2013). Indeed, a large number tiveness of family nursing educational programs was carried of nurses recognize the need for more education in family out using the criteria developed by the Joanna Briggs Institute nursing (Duhamel et al., 2015; Ekstedt et al., 2014; Talbot (JBI; Tufanaru et al., 2017). et al., 2000). This demand is also supported by the IFNA (2015) Position Statement on Generalist Competencies for Inclusion and Exclusion Criteria Family Nursing Practice, which upholds the importance of teaching theoretical knowledge and skills based on practice Inclusion criteria. The following inclusion criteria were used and evidence in family nursing educational programs, which to select the articles: (a) Population: licensed nurses, regard- are then developed clinically through supervised practice less of health care context, specialization, or level of qualifi- experiences (IFNA, 2013, 2017, 2018). cation; (b) Objective/Intervention: to study the effectiveness Competency-based education is complex, requiring the of family nursing educational programs in achieving compe- integration of knowledge, skills, and attitudes for competent tence in family nursing; and (c) Design: randomized con- and effective clinical performance (Cowan et al., 2007; trolled trials (RCTs), non-RCTs, and quasi-experimental, Duhamel et al., 2015; Meiers et al., 2018; Wright & Leahey, pretest–posttest, and cross-sectional studies. 2013). More specifically, such competency-based education should include theoretical frameworks that provide a knowl- Exclusion criteria. Studies with qualitative methodology were edge base and guidelines in family nursing practice excluded and, in the case of mixed methodological design, (Duhamel, 2017; Wright & Leahey, 2013). Similarly, the qualitative data were excluded. Regarding the population, acquisition of clinical skills is an essential element of family studies where the sample consisted of professionals from nursing competency (Wright, 1994). Wright and Leahey other disciplines or exclusively involving nursing students (2013) differentiated three types of family nursing skills: (a) were discarded. perceptual, referring to the nurse’s ability to make relevant observations about the family; (b) conceptual, referring to Search Strategy the nurse’s ability to give meaning to and make sense of their observations; and (c) executive, referring to observable The literature search was performed in March–April 2019. therapeutic family nursing interventions that the nurse offers According to the JBI recommendations, the search strategy Gutiérrez-Alemán et al. 257 Table 1. Kirkpatrick’s Four-Level Framework. Level 1: The participant satisfaction measurement of training. The degree to which participants find the program favorable, Reaction engaging, and relevant to their jobs Level 2: Learning The extent to which participants improve knowledge, increase skills, and/or change attitudes as a result of attending the program Level 3: The extent to which a change in behavior has occurred because the participant attended the educational program (it Behavior is commonly referred to as transfer of learning). In other words, the degree to which participants apply what they learned during training when they are back on the job Level 4: Results The degree to which targeted outcomes occur as a result of the program Source. Extracted from D. Kirkpatrick and Kirkpatrick (2006). was performed in three phases (Aromataris & Riitano, 2014). Data Extraction and Summary In the first phase, an initial search was performed in MEDLINE and Cumulative Index to Nursing and Allied The standardized data extraction tool from the JBI- Health Literature (CINAHL) to identify index terms and MAStARI was used for data extraction. The heterogeneity keywords. In the second phase, a comprehensive search was of the studies, regarding the characteristics of the study performed in the databases PubMed (see Supplemental design and those of the participating populations, pre- Material 1), CINAHL, PsycINFO, Web of Science-Core cluded a meta-analysis (Delgado, 2010). Therefore, the Collection, and Cochrane Library, applying the following results are presented descriptively, classifying them into search terms: nurse, educational intervention, family nurs- three main themes: (a) general study characteristics, (b) ing, clinical competence, knowledge, skills, and attitudes. educational program components, and (c) outcome mea- The only limit established was the language of the publica- sures, according to Kirkpatrick’s four-level framework (D. tion: English, French, Portuguese, Spanish, and Italian. No Kirkpatrick, 1996; D. Kirkpatrick & Kirkpatrick, 2006; see time limitations were applied to locate as many articles as Table 1). To present the effectiveness data, at each of the possible. The articles considered pertinent to achieve the Kirkpatrick’s levels, whenever possible, mean differences objective of this study were retrieved for a full-text review between groups were calculated, accompanied by their and were evaluated for inclusion. In the third and final phase, 95% confidence intervals. the “snowball” technique was used to locate relevant articles that were not identified in the previous phase. Results Methodological Quality Assessment Study Selection The methodological quality of the articles was evaluated using In the initial search, 2,112 studies were identified. After three standardized critical appraisal instruments from the removing duplicates (n = 99), the abstracts of 2,013 articles Joanna Briggs Institute–Meta-Analysis of Statistics were examined for their potential inclusion in the systematic Assessment and Review Instrument (JBI-MAStARI): (a) JBI literature review. Of these articles, 1,884 were considered Critical Appraisal Checklist for Randomized Controlled irrelevant for the purpose of this review. The remaining 129 Trials, (b) JBI Critical Appraisal Checklist for Quasi- articles were evaluated by two reviewers (T.G.-A. and N.E.) Experimental Studies (Tufanaru et al., 2017), and (c) JBI independently and in full text, after which 115 articles were Critical Appraisal Checklist for Analytical Cross-Sectional excluded for the following reasons: (a) the study design did Studies (Moola et al., 2017). This evaluation was performed not meet the inclusion criteria (n = 58), (b) no educational by two reviewers (T.G.-A. and C.A.-D.), independently, where intervention for developing competency in family nursing eight to 13 criteria were scored as “yes,” “no,” “unclear,” or had been implemented (n = 30) or was poorly described (n “not applicable.” A total score was calculated by summing the = 2), (c) no data on the effectiveness of the intervention for “yes” items, giving each study a score between 0 and the total developing competency in family nursing were reported (n number of items evaluated in each checklist (i.e., eight, nine, = 13) or they were poorly reported (n = 4), (d) the sample or 13). Studies with a score equal to or lower than half of the consisted of professionals from various fields (n = 12) or items evaluated were considered as having a high level of bias included only nursing students (n = 2), and (e) full-text and therefore poor methodological quality. Studies with a access was not available (n = 1). Some studies met more medium or high quality had higher scores. Any disagreement than one exclusion criterion (see Supplemental Material 2). between the two reviewers was resolved through discussion. Furthermore, no relevant article was found using the “snow- No study was excluded after evaluation; instead, the results ball” technique. Ultimately, 14 studies were included in this were used to make recommendations for improvement. review (see Figure 1). 258 Journal of Family Nursing 27(4) Number of records identified Number of additional records Identification through a systematic search identified through other sources (N = 2,112) (N = 0) Number of records after duplicates removed (N = 2,013) Screening Number of records screened (title and abstract) Number of records (N = 2,013) excluded (N = 1,884) Number of full-text Number of articles articles assessed for excluded on reading eligibility full-text (N = 129) (N = 115) Eligibility Number of articles excluded on critical Number of articles appraisal assessed for quality (N = 0) (N = 14) Included Number of articles included (N = 14) Figure 1. PRISMA flow diagram of search and study selection process. Source. Moher et al. (2009). Methodological Quality of the Studies study design, one was RCT design (Fisher et al., 2014); one was a cross-sectional study design (Svavarsdottir et al., Table 2 details the methodological quality of the studies. In 2018); one was a quasi-experimental two-group time series general, the studies presented medium quality (n = 11) and, design (Yamazaki et al., 2017); eight were quasi-experimen- to a lesser extent, low (n = 2) or high (n = 1) quality. The tal one-group pretest–posttest design (Lam et al., 1993; Ma most commonly found deficiencies, based on the criteria et al., 2018; Milic et al., 2015; Montgomery et al., 2016; analyzed for each type of study design, were related to the Petursdottir et al., 2019; Svavarsdottir et al., 2015; Svein- validity and reliability of outcome measures (n = 14); lack bjarnardottir et al., 2011; Zaider et al., 2016); one was a of follow-up, description, and analysis of differences between quasi-experimental, nonequivalent group before and after groups in the follow-up (n = 7); lack of a control group (n = design (Blöndal et al., 2014); and two were pretest–posttest 11); and insufficient description of the statistical analysis mixed-methods design (Broekema et al., 2018; Eggenberger used (n = 12), among other factors. & Sanders, 2016). Furthermore, three of the included studies were pilot studies (Eggenberger & Sanders, 2016; Lam et al., 1993; Montgomery et al., 2016). In 13 studies, the target Findings of the Review population were generalist nurses, whereas only one study General study characteristics. Table 3 outlines the main char- included advanced practice nurses in their sample (Ma et al., acteristics of the studies. These studies, published from 1993 2018). Most studies were conducted in a hospital setting, and to 2018, represent a total of seven countries, most frequently the most frequently included specialties were psychiatry, Iceland (n = 5) and the United States (n = 4). In terms of pediatrics, and intensive care. Gutiérrez-Alemán et al. 259 Table 2. Critical Appraisal. Study Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 TS JBI Critical Appraisal Checklist for Randomized Controlled Trials Fisher et al. (2014) Y Y U U N NA Y Y NA Y N Y Y 7/13 JBI Critical Appraisal Checklist for Quasi-Experimental Studies (non-randomized experimental studies) Blöndal et al. (2014) Y U U N Y U Y N U 3/9 Broekema et al. (2018) Y Y Y N Y Y Y N U 6/9 Eggenberger and Sanders (2016) Y Y Y N Y Y Y N U 6/9 Lam et al. (1993) Y Y Y N Y Y Y N U 6/9 Ma et al. (2018) Y Y Y N Y Y Y N U 6/9 Milic et al. (2015) Y Y Y N Y N Y N U 5/9 Montgomery et al. (2016) Y Y Y N Y Y Y N U 6/9 Petursdottir et al. (2019) Y Y Y N Y Y Y N U 6/9 Svavarsdottir et al. (2015) Y Y Y N Y N Y N U 5/9 Sveinbjarnardottir et al. (2011) Y Y Y N Y U Y N U 5/9 Yamazaki et al. (2017) Y Y Y Y Y N Y N U 6/9 Zaider et al. (2016) U Y Y N N N Y N U 3/9 JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies Svavarsdottir et al. (2018) Y Y U Y Y Y N Y 6/8 Note. The JBI critical appraisal checklist used in each case has been placed in the rows of the table. TS = total score; JBI = Joanna Briggs Institute; Y = yes; U = unclear; N = no; NA = not applicable. In JBI Critical Appraisal Checklist for Randomized Controlled Trials, Q1 = Was true randomization used for assignment of participants to treatment groups? Q2 = Was allocation to treatment groups concealed? Q3 = Were treatment groups similar at the baseline? Q4 = Were participants blind to treatment assignment? Q5 = Were those delivering treatment blind to treatment assignment? Q6 = Were outcomes assessors blind to treatment assignment? Q7 = Were treatment groups treated identically other than the intervention of interest? Q8 = Was follow-up complete, and if not, were differences between groups in terms of their follow-up adequately described and analyzed? Q9 = Were participants analyzed in the groups to which they were randomized? Q10 = Were outcomes measured in the same way for treatment groups? Q11 = Were outcomes measured in a reliable way? Q12 = Was appropriate statistical analysis used? Q13 = Was the trial design appropriate, and any deviations from the standard RCT design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial? In JBI Critical Appraisal Checklist for Quasi-Experimental Studies (non-randomized experimental studies), Q1 = Is it clear in the study what is the “cause” and what is the “effect”? Q2 = Were the participants included in any similar comparisons? Q3 = Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest? Q4 = Was there a control group? Q5 = Were there multiple measurements of the outcome, both pre- and postintervention/exposure? Q6 = Was follow-up complete, and if not, were differences between groups in terms of their follow-up adequately described and analyzed? Q7 = Were the outcomes of participants included in any comparisons measured in the same way? Q8 = Were outcomes measured in a reliable way? Q9 = Was appropriate statistical analysis used? In JBI Critical Appraisal Checklist for Analytical Cross- Sectional Studies, Q1 = Were the criteria for inclusion in the sample clearly defined? Q2 = Were the study subjects and the setting described in detail? Q3 = Was the exposure measured in a valid and reliable way? Q4 = Were objective, standard criteria used for measurement of the condition? Q5 = Were confounding factors identified? Q6 = Were strategies to deal with confounding factors stated? Q7 = Were the outcomes measured in a valid and reliable way? Q8 = Was appropriate statistical analysis used? Educational program components. Table 4 summarizes educa- of the educational programs were the Calgary Family tional program components. All programs were conducted Assessment Model (CFAM), the Calgary Family Intervention “face to face.” Regarding the teaching staff, except for two Model (CFIM; n = 7; Wright & Leahey, 2013), and the studies (Lam et al., 1993; Ma et al., 2018), all programs Illness Beliefs Model (n = 3; Wright & Bell, 2009). included at least one nurse in the team, and six had profes- The content of the programs was heterogeneous and, to a sionals from other fields (psychologists, social workers, and large extent, depended on the frameworks used. The most physicians) (Broekema et al., 2018; Fisher et al., 2014; Lam frequent topics, among others, addressed communication et al., 1993; Milic et al., 2015; Montgomery et al., 2016; skills, meaning of the illness experience for the family, fam- Zaider et al., 2016). Only five programs had at least one edu- ily nursing theory, nursing roles, family nursing practice cator with education in family nursing (Broekema et al., skills, family assessment and intervention tools (genogram 2018; Eggenberger & Sanders, 2016; Petursdottir et al., 2019; and eco-map, among others), and the theoretical background Svavarsdottir et al., 2018; Sveinbjarnardottir et al., 2011), and of the research findings. in four of these programs, the teaching team consisted of both Most studies used several teaching-learning methods, clinical and academic nurses (Eggenberger & Sanders, 2016; especially lectures (n = 14), combined with the following: Petursdottir et al., 2019; Svavarsdottir et al., 2015, 2018). role-play (simulation) with supervisor or peer-led feedback Of the 14 studies included in this review, four did not (n = 9), clinical case group discussion (n = 6), reflective report having used a specific conceptual framework. The approach/inquiry (n = 5), expert demonstration (n = 3), and most commonly used conceptual frameworks for the content direct clinical practice (n = 6). The programs that included 260 Table 3. General Study Characteristics. Study, location Study design Sample, setting Study purpose Blöndal et al. (2014); Reykjavik, Quasi-experimental, T1 N = 179: n = 103 RN, n = 76 LPN; T2 N = 131: n = To examine nurses’ attitudes about the importance of the family in surgical hospital Iceland nonequivalent group before 86 RN, n = 43 LPN; surgical services, university hospital units before and after implementation of an FSN educational intervention and after Broekema et al. (2018); Pretest–posttest mixed- T1 and T2 N = 18: n = 10 home health care nurses, n = To explore nurses’ perspectives about their competencies in FN following a 6-day Groningen, The Netherlands methods, pilot study 8 hospital nurses educational program in FN conversations Eggenberger and Sanders Pretest–posttest mixed- T1 N = 30 RN, T2 N = 14 attended educational To examine the influence of an educational intervention on nurses’ attitudes toward (2016); Mankato, United methods, pilot study intervention; critical care unit, suburban hospital and confidence in providing family care States Fisher et al. (2014); Oklahoma Randomized controlled trial T1 and T2 N = 35 pediatric nurses: EG = 21, CG = 14; To evaluate the effectiveness of a validated brief communication training (Four Habits City, United States urban adult and pediatric tertiary care hospital Model) session using simulation Lam et al. (1993); London, Quasi-experimental: One- Pilot 1: N = 10: n = 6 charge or community psychiatric To report the impact on nurses’ knowledge, attitudes, and beliefs of two pilot studies England group, pretest–posttest, nurses, n = 4 staff nurses conducted to develop a training package for schizophrenia family work pilot study Pilot 2: N = 12: n = 10 charge or community psychiatric nurses, n = 2 staff nurses Ma et al. (2018); Hong Kong, Quasi-experimental: One- T1 and T2 N = 24 psychiatric nurses: n = 15 RN, n = 8 To assess the nurses’ degree of satisfaction toward the training and the learning China group, pretest–posttest advanced nurses, n = 1 ward manager; T3 N = 17: n = outcomes of family therapy training, and the perceived helpfulness of the course for 12 RN, n = 4 advanced nurses, n = 1 ward manager; enhancing their professional competence in FN care mental hospitals/clinics (group size: 4–5) Milic et al. (2015); San Quasi-experimental: One- T1 N = 82 nurses, To improve critical care nurses’ skills and confidence to engage in discussions with Francisco, CA United States group, pretest–posttest T2 N = 80, patients’ families and physicians about prognosis and goals of care by using a focused T3 N = 43; critical care, university medical center (group educational intervention size: 12–15) Montgomery et al. (2016); Quasi-experimental: One- T1 and T2 N = 36 RN: n = 29 BSc, n = 4 diploma, n = 3 To evaluate the effects of an educational workshop on nurses’ intention to practice Calgary, AB Canada group, pretest–posttest, LPN; 2 pediatric inpatient units, academic tertiary care FBR using the TPB constructs pilot study center Petursdottir et al. (2019); Quasi-experimental: One- T1 and T2 N = 11 nurses; specialized palliative home care To evaluate the impact of an advanced educational and coaching program in an FSN Reykjavik, Iceland group, pretest–posttest unit, university hospital approach Svavarsdottir et al. (2015); Quasi-experimental: One- T1 N = 457 nurses, To report on approaches that were used to assist with implementation of FSN at a Reykjavik, Iceland (Phase 1) group, pretest–posttest T2 N = 411; women and children, mental health, surgical, university hospital level and internal medicine services, university hospital Svavarsdottir et al. (2018); Cross-sectional N = 436: n = 266 BSc, n = 170 graduate; emergency, To evaluate the level of nursing education, having taken a continuing hospital Reykjavik, Iceland mental health, women and children, internal medicine educational course in FSN, and the impact of job characteristics on nurses’ and surgical services, university hospital perceptions of their FN practice skills Sveinbjarnardottir et al. (2011); Quasi-experimental: One- T1 N = 81 RN, To assess the change in nurses’ attitudes toward families in psychiatric care after Reykjavik, Iceland group, pretest–posttest T2 N = 52; psychiatric division, university hospital having received an education and training intervention program in FSN Yamazaki et al. (2017); Osaka, Quasi-experimental two- N = 41 nurses: EG = 21 (group size: 5–10), CG = 20; To evaluate the feasibility and short-term impact of case study training in FN care Japan group, time series NR Zaider et al. (2016); New York, Quasi-experimental: One- T1 and T2 N = 282 oncology nurses; comprehensive To report on the implementation and preliminary evaluation of a new training United States group, (retrospective) cancer center (group size: 10–12) curriculum for improving skills in RCIF during a patient’s hospitalization pretest–posttest Note. T1 = pretest; RN = registered nurse; LPN = licensed practical nurse; T2 = posttest; FSN = Family System Nursing; FN = family nursing; EG = experimental group; CG = control group; T3 = second posttest (follow-up); BSc = bachelor of science; FBR = family-centered bedside rounds; TPB = theory of planned behavior; NR = not reported; RCIF = responding to challenging interactions with families.  Table 4. Educational Program Components. Educator(s)/FN education Theoretical Study (Yes/No) foundations Content Teaching-learning methods Duration, time period Blöndal et al. (2014) 6 RNs/ NR CFAM, CFIM CFAM, CFIM; methods to increase interactions Lectures; 8 hr; 1 day with the family during patients’ admission and Workshops + clinical vignettes skills training; discharge; importance of a positive approach toward families and their presence Broekema et al. RNs/ Yes; CFAM, CFIM FN foundations; NANDA, NIC, NOC related to Lectures; NR, 6 days, + Clinical (2018) 1 Social Worker/ No FN; CFAM, CFIM; genogram, eco-map; Systems Role-play + supervisors’ feedback; practice: 3 months; (5 and Communication theory; FN conversations FN conversation expert demonstration + discussion; months) Clinical practice: FN conversations + group supervision and reflection with educator; Nurses’ presentations: FN practice experiences + group discussion Eggenberger and 5 nurses/NR; CFAM, CFIM; IBM Nurse and family experiences with critical illness, Digital storytelling; 4 hr; NR Sanders (2016) 1 nurse manager/NR; therapeutic conversation  Workshop: Nurses’ reflections and dialogue about family experiences and 1 nurse researcher/Yes interventions + manual provision; Role-play: Nurse–family interactions Fisher et al. (2014) NR Professional EG: Four habits communication model EG: Theory session, simulation, and debriefing 1 hr; 1 day development CG: Travel-documentary CG: Video framework; Information processing theory Lam et al. (1993) 1 psychologist/NR; NR Skill acquisition to practice Didactic teaching; 72 hr; 9 months 1 physician/NR Role-play: Discussion + experiential learning + weekly group supervision; Work in pairs with at least 2 families Ma et al. (2018) 2 NR/No; Family-centered Marriage and family therapy; systemic and Lectures + clinical vignettes discussion; 35 hr + Clinical 1 Social Worker/No approach strengths-based perspective; family assessment Sensitivity training + self-reflexivity; supervision: 14 hr; (3 and intervention skills; genogram Clinical observation or simulated role-plays + individualized learning goals; months) Clinical practice + videotape clinical supervision (2 days) Milic et al. (2015) 5 RN/ NR; NR Roles and responsibilities of bedside nurses to Workshop; 8 hr; 1 day 1 RN, PhD/ NR; patient and family; communication skills: Family Didactic session and discussion; 2 physicians/ NR; meeting, nurse–family and nurse–physician Facilitated role-plays; 1 psychologist/ NR conversations Reflection session; Narrative reflection practice. Montgomery et al. 1 RN, MN/NR TPB Importance of relational practice; value of patient Workshop: FCC video + nurses’ reactions; 2 hr; 1 day (2016) and FCC and FBR; nursing FBR role; skills FBR literature overview; during FBR FBR video demonstration; Small group discussion; Tip sheet provision for FCC communication (continued) 261 262 Table 4. (continued) Educator(s)/FN education Theoretical Study (Yes/No) foundations Content Teaching-learning methods Duration, time period Petursdottir et al. 1 RN/Yes CFAM, CFIM; IBM CFAM, CFIM; FN approach and offering Customized educational session; 4–6 hr, + Clinical (2019) interventions; Theory and evidence base Face-to-face clinical mentoring; practice: Time NR; knowledge in FN, relational value of Clinical practice: FN intervention + live clinical supervision; (NR) implementing FN practice in palliative home Coaching; care, FN practical skills. Clinical meetings + nurses share FN practice experiences Svavarsdottir et al. NR CFAM, CFIM CFAM, CFIM; short-term FN interventions Seminar + lectures; 8 hr; 1 day + Clinical (2015; Phase 1) Family skills lab training + clinical case discussion; practice: 1–4 months Workshop; Clinical practice: Application of FSN + clinical supervision (3–5 sessions) Svavarsdottir et al. 1 nursing professor/yes; CFAM, CFIM CFAM, CFIM, FN interventions, therapeutic Lectures; NR; NR (2018) Advanced MSc nurses/NR; questioning, family strengths Seminar; CNSs/NR Family skills lab training + clinical cases discussion; Workshops Sveinbjarnardottir 3 RN, MSc/Yes CFAM, CFIM; IBM CFAM, CFIM; the 15-min family interview; Seminar + clinical vignettes; 8 hr, 1 day + et al. (2011) 2 RN, diploma/NR strengthening nurses’ clinical skills in family Clinical practice: FSN application; Clinical practice: 4 4 RN/NR nursing Supervision (3–5 sessions): Nurses’ experiences of applying FSN (cases presentation) months; (14-month) Yamazaki et al. EG: 2 CNSs MSN; 1CN; NR EG and CG: Definition of family; FN process; EG: Lectures, exercises, case study presentation and training sessions EG: 6 hr; 6 months (2017) 1RN/NR basic functions; developmental stages; life cycle; CG: Lectures CG: 3 hr; 1 day CG: 1 RN PhD/NR family profile; Family System, family structural functional and family stress theories EG: Case study Zaider et al. (2016) 1 Psychologist PhD/NR Collaborative, Family distress during hospitalization, collaborative Didactic presentation; 2 hr; 1 day (2-years 1 MPH/NR strength-based, care with families, responding effectively to Exemplary videos; program) 1 RN, PhD/NR family-centered challenging interactions Role-play + peer-led feedback; 1 RN, OCN/NR framework Reflection; 1 LCSW/NR Workbook provision Note. FN = family nursing; RN = registered nurse; NR = not reported; CFAM = Calgary Family Assessment Model; CFIM = Calgary Family Intervention Model; NANDA = North American Nursing Diagnosis Association; NIC = Nursing Interventions Classification; NOC = Nursing Outcomes Classification; IBM = Illness Beliefs Model; EG = experimental group; CG = control group; MN = master of nursing; TPB = theory of planned behavior; FCC = family-centered care; FBR = family bedside rounds; FSN = Family System Nursing; MSc = master of science; CNS = certified nurse specialist; MSN = master of science in nursing; CN = certified nurse; MPH = master of public health; OCN = oncology certified nurse; LCSW = licensed clinical social worker.  Table 5. Outcome Measures. Main results Learning Behavior Evaluation method(s) characteristics Knowledge Skills Attitudes (comparison groups) Study Data collection times Reaction MD 95% CI p MD 95% CI p MD 95% CI p MD 95% CI p Blöndal et al. FINC-NA: 26-item, 5-point Likert-type scale Total: (2014) (T1 vs. T2) 0.8 [–1.71, 3.31].640 T1: Before EI RNC: T2: 18 months after EI –0.3 [–1.35, 0.75].220 CP: –0.1 [–0.96, 0.76].900 B: 0.3 [–0.18, 0.78].290 OR: 0.1 [–0.42, 0.62].770 Broekema et al. FINC-NA: 26-item, 5-point Likert-type scale Total: (2018) (T1 vs. T2) –6.94 [–16.2, 2.14] <.001 T1: Before EI RNC: T2: 5 months after –3.77 [–6.40, –1.14].001 CP: –2.47 [–5.54, 0.60].012 B: –1.06 [–2.77, 0.65].019 OR: –1.83 [–3.33, –0.33].001 Eggenberger and 1. ASRQ: 3-item (T2) 1. Satisfaction: 2. FN, family illness experience: Sanders (2016) 2. ASRQ: 10-item, true–false (T1 vs. T2) EI: 92.9% extremely satisfied 0.4 [–0.25, 1.05].313 T1: Before EI Information and methods: 80.3% T2: After EI (NR) extremely valuable and effective Fisher et al. (2014) PERCS pre- and postquestionnaire (adapted version) Communication: Confidence: (CG vs. EG; T2) 1.02 [0.73, 1.31]