Efficacy of the Use of the Calgary Family Intervention Model in Bedside Nursing Education: A Systematic Review

Figures & data

Table 1 CFIM Framework

Domain	Interventions offered by the nurse: “Fit” or effectiveness
Cognitive	Teaching new activities with rationales
Behavioral	Encouraging behavioral changes through structured actions
Affective	Protocol’s positive patient and family outcomes

Notes: This table is adapted to illustrate the domains of family function and intervention fit. Adapted from McClay R. Implementation of the Family HELP Protocol: A Feasibility Project for a West Texas ICU. Healthcare (Basel). 2021;9(2):146. © 2021 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).² Data from Wright et al.³

Figure 1 Study selection process.

Table 2 PICOS (Participants, Intervention, Results, Outcome, and Study Design) Characteristics of the Included Studies

P-I-C-O-S
No.	Authors	Participants	Intervention	Results (Compared to Control Group)	Medical Outcomes Reported	Study Design
9	Misto	60 family members, majority above the age of 56 and female.	CFIM	High levels of social support	None reported	Pilot study, convenience sample, questionnaire, qualitative study, survey.
15	Eggenberger and Sanders	Nurses of varying educational preparations and ages	Results of pre-intervention data collection from families and nurses	Increased confidence, knowledge, and skills	None reported	Pre and post mixed method design
16	Sveinbjarnardottir et al	Patients and family members from acute inpatient psychiatric units and other acute units	Short therapeutic conversation	Higher perception of cognitive and emotional support from the nurses than family members who received standard care	None reported	Pre-post
17	Misto	Registered nurses from medical-surgical units	Family Nursing Practice Scale	No control, comparison of responses based on demographics of registered nurses	None reported	Non-experimental, descriptive
18	Gisladottir and Svavarsdottir	Family members, parents, siblings, partners	Educational and support intervention, group sessions	Various results based on questionnaires used in study	None reported	Pre-post design
19	Menard and Saucier	Subject and family only	CFIM models	Family communication and enlightenment with support	None reported	Opinion
20	Arief and Rachmawati	Families and children	Parent empowerment program	Increase in positive family attitudes and family actions	None reported	Pre-post/pre-experimental research
21	Rempel	Various audiences	Applied CFIM interventions	Positive results overall	None reported	Non-experimental, descriptive recommendations
22	Clausson and Berg	School children, parents, nurses	Sessions held with families, using genograms, ecomaps, interventive questions	Triggered healing process, affective, cognitive, and behavioral changes, patient and family included	None reported	Pre-post design
23	Brumfield	High risk patients, patients who under/over use healthcare resources	Questions posed to the patient and family	Decreased readmission rates and ED visits. Positive rapport between the case management staff and patients	Decreased participants readmission rates and ED visits	Qualitative interviews, non experimental
24	Holtslander et al	Undergraduate nursing students	15-minute family interview	No control group for comparison	None reported	Non-experimental
25	Sigurdardottir et al	Families of children with asthma	Family therapeutic conversation intervention	Higher levels and perception of family support, cognitive and emotional support, better outcomes	Fewer reported problems with asthma treatment	Quasi-experimental intervention study, pre-post
26	Broekema et al	Female nurses (home health care and hospital)	6-day educational program utilizing FINC-NA (pre-post test)	Positive changes in attitude, knowledge, skills, and competence	None reported	Pre-post
27	Martinez et al	Nurses and families	In depth teaching sessions, hands-on coaching, 15-minute family interview	Perceptions of positive impact on ability to conduct family assessment and family interventions	None reported	Quasi-experimental, pre-test, post-test.
28	Simpson et al	Nurses (either psychiatric registered nurses or nursing officers)	Calgary Family Assessment Model (CFAM) and the Calgary Family Intervention Model	Significant changes in nurse confidence, satisfaction, knowledge and skill in family systems, as well as increased comfort working with families	None reported	Pilot study, pre-post design, qualitative
29	John and Flowers	Undergraduate and postgraduate nursing students	Workshops in family nursing	Family nursing more likely to be implemented where patients experience serious or life-threatening illnesses, staff are educationally prepared, there is ongoing mentorship, and management support for family nursing	None reported	Non-experimental, survey design
30	Choi et al	Parents and families of young children	FamilyAdapt-DS	Improvement in five family measures between pre and post test scores	None reported	Pre-post
31	Dorell and Sundin	Family members of those staying in residential homes	FamHC (Swedish version of the Calgary models)	Discovery of family members’problems and suffering, identification of family’s resources and strengths	None reported	Qualitative design, with semi-structured group interviews, qualitative content analysis.
32	Rosenbloom and Fick	Patients, caregivers, staff nurses	Nurse/Family Caregiver Partnership for Delirium Prevention program	Significant improvements in Knowledge of Delirium Questionnaire score and Attitudes towards aging	None reported	Quasi-experimental, pre-post
33	Binding et al	Nurses, family member, patients	Calgary Family Assessment Model and Calgary Family Intervention Model	Opinion based in research findings	None reported	Opinion
34	Lee et al	BSN level nursing students	Questionnaire and either Family in Health and Illness or Women’s Health course	Higher interest in family assessment reported	None reported	Quasi-experimental, pre-post
35	Sveinbjarnardottir et al	Family members	New Iceland-Family Percieved Support Questionnaire	Increased cognitive support and emotional support	None reported	Non-experimental
36	Silva et al	Registered nurses	15-Minute Family Interview	Benefits for the nurse–family relationship	None reported	Non-experimental, qualitative
37	de Jesus Silva Figueiredo et al	Family nurses	Calgary Family Assessment Model and Calgary Family Intervention Model	Family representations generated two perspectives in the nurses’ thought system: sociological and psychological	None reported	Qualitative interviews, non-experimental

Table 3 Summary of Strength and Quality of Evidence Identified with the JHNEBP

Strength of Evidence	Frequency	Quality of Evidence	Frequency
I	0	A	0
II	5	B	21
III	18	C	3
IV	0
V	1
A		B

Table 4 Summary of Analysis, in Order of Use in Paper

No.	Authors	Facilitators	Themes	Barriers	Themes
9	Misto	Nurses evaluated their family nursing practice at high levels indicating their confidence working with families in areas of knowledge, skill, and comfort	Education increasing awareness of nurses	Nurses found notice of illness to family members negatively impacted family functioning	Patients with preexisting health concerns lack motivation to take part
		Frequent interaction and reciprocity were common in the nurse–family relationship supporting that nurses positively perceive family presence and nurse–family interactions	Clear two-way communications necessary	Nurses are not communicating concrete aids effectively such as type of exercise and diet restrictions	Communications concerns
		Nurses found that patient care was enhanced and nurse–family relationships were improved as a result of involved families in patient care plans	Families as a unit of care or collaboration
		Stronger nurse–family relationships and coordination of care plans benefits nurses as it increases their understanding of the patient	Families as a unit of care or collaboration
		Patient outcomes were improved by incorporating family involvement and increasing their ability to care for the patient after discharge	Families as a unit of care or collaboration
		Nurses promote the nurse–family relationship by encouraging the family to help them get to know the patient. This is done utilizing interviews and questioning techniques	Clear two-way communications necessary
15	Eggenberger and Sanders	Patient outcomes improved with additional support from nurses during their critical illness	Improved patient/family outcomes	Nurses report lack of confidence in communicating	Inadequate education
		Patient outcomes improved significantly when nurses managed their shared critical illness experiences and related it to the patient.	Improved patient/family outcomes	Nurses have trouble working with families which report troubling relationships with nurses that magnify their suffering and uncertainties.	Unrealistic expectations from family
		In comparison to the pre and post Family Nurse Practice scale, nurses felt after the program their skills in family systems increased tremendously	Education increasing awareness of nurses
		Educational intervention has potential to increase nurses understandings of family illness experiences	Education for nurses/families
16	Sveinbjarnardottir et al	Family reported high levels of cognitive and emotional support after short therapeutic conversation with nurses	Therapeutic conversations with families	Difficult for nurses to incorporate therapeutic conversations in routine nursing practice given time constraints and traditional practices	Nursing staff burden increased/stress concerns
		Collaborative relationship between nurses and families was improved by short education and training on family therapeutic conversations	Therapeutic conversations with families	Lack of inclusion of family members in patient care	Lack of nursing or family commitment
		Family’s perceived support is influenced by the success of a clinicians engagement with the family and can lead to therapeutic change	Improved patient/family outcomes	Psychological and emotional demand of families experiencing a psychiatric event	Unrealistic expectations from family
		The quality of nursing care is improved by the involvement of families in nursing practice	Improved patient/family outcomes
		Emotional support provided by nurses helps families and patients with the emotional difficulties associated with caring for a psychiatric patient	Improved patient/family outcomes
17	Misto	Nurses focused on FSN model which helped relationship building, communication, and improved patient outcomes	Use of reflection and other tools	Time constraints, interruption of nurse routines, and poor nurse perception of family nursing care negatively impact and interfere with family nursing care	Nursing staff burden increased/stress concerns
		CFIM gave tools necessary for nurses to generate the change for the family managing exacerbations that can occur during the course of a chronic illness such as diabetes	Education increasing awareness of nurses	Nurses reported that diminished functioning within the family created a disadvantage in the nurse–family relationship	Family dynamics concerns
		Family members reported high levels of social support from nurses	Improved patient/family outcomes	Family members may be passive and fail to initiate engaging with nursing staff	Family dynamics concerns
		Nurses noticed positive outcomes when they included of family members in decision making	Improved patient/family outcomes	Lack of knowledge, unrealistic expectations, and cultural/language barriers made it more difficult for families to understand the plan of care as explained by nurses	Unrealistic expectations from family
		Nurses greatly improve the care and support families receive by sharing information regarding the patients illness and lifestyle adjustments they need to make	Resources to families
18	Gisladottir and Svavarsdottir	Nurses communicated information clearly and concisely for patients to understand intervention	Clear two-way communications necessary	Patients had a hard time understanding how to deal with a family member with a eating disorder	Family dynamics concerns
		Patients found the support intervention by nurses useful and helpful.	Improved patient/family outcomes
		Nurses conducting intervention found great success in allowing the patient to write about the experience being a relative of an individual with an eating disorder	Therapeutic conversations with families
19	Menard and Saucier	Families benefit from professional support of nurses in coping with the death of a relative.	Improved patient/family outcomes
		Nurses found support from patient participation when the family is in tune	Improved patient/family outcomes
		Redefined and enhanced family–nurse relationships	Clear two-way communications necessary
		Nurses had high encouragement to interact with families due to administrative support	Education changing perceptions of nurses towards CFIM
20	Arief and Rachmawati	Parent empowerment can be utilized by nurses to improve the family’s ability to care for their child’s condition	Improved patient/family outcomes
		Helping families through the empowerment process improves the relationship between family and health professionals through an increase in trust and decision-making	Improved patient/family outcomes
		Increasing knowledge of the patient’s condition enables families and patients to manage the condition and symptoms	Improved patient/family outcomes
		A positive attitude regarding treatment and patient condition is impacted positively by the sharing of experiences and an increase in knowledge	Improved patient/family outcomes
21	Rempel	Promotion of parent resilience is supported by nurses modeling care and empowering them to care for their child	Families as a unit of care or collaboration	A cost-focused healthcare culture may result in disempowering attitudes and behaviors of health professionals	Increased time required to develop nursing skills
		A family’s perception of treatment and intervention is influenced by their relationship with nurses	Clear two-way communications necessary	High pressure, clinical environments impact healthcare professionals’ perception of available time and ability to interact with families beyond the traditional care model	Nursing staff burden increased/stress concerns
		Trusting relationships are built through genuine and positive interactions between nurses and families	Clear two-way communications necessary	Lack of collaboration and failure to share information between health professionals and families	Problems surrounding family sharing of patient information
		Empowerment-based approaches can be utilized by nurses to aid in parental decision-making	Improved patient/family outcomes	Difficulty for parents of overcoming the loss of a healthy child, complex choices and decisions, and emotional strain of illness and uncertainty	Family dynamics concerns
		Circular questioning by nurses allows parents to reflect on their beliefs and their family relationship. Circular questions also enable nurses to determine areas where parents lack understanding and address them accordingly	Resources to families	Parents differed in perception of greatest stressors and demands in caring for their child	Family dynamics concerns
		Nurses are influential in offering pertinent information and recommendations/opinions for parents to base their decisions	Improved patient/family outcomes	Healthcare professionals may doubt whether a family can make appropriate decisions for their child	Family dynamics concerns
		Nurses can help a family by validating their emotions and concerns regarding their child’s condition and/or treatment	Therapeutic conversations with families	Families must learn complex, medical information that can be perceived as overwhelming in an effort to care for their child	Communications concerns
		A collaborative approach to care increases trust, facilitates joint decision-making, and aids parents in making decisions	Therapeutic conversations with families
		Commendation of family strengths helps to empower families and provide a context for change in problem-solving	Resources to families
22	Clausson and Berg	Nurses felt the tools were time saving and easy to use	Use of reflection and other tools	School nurses lacked experience and knowledge with including families in intervention	Inadequate education
		Families reported relief and described positive affective, behavioral, and cognitive changes as a consequence of the interventions	Improved patient/family outcomes	Parents differed in perception of greatest stressors and demands in caring for their child	Family dynamics concerns
		Nurses reported that the family was the most important factor for schoolchildren’s mental health	Therapeutic conversations with families
		Nurses encouraged the Illness Beliefs Model to uncover constraining illness experience beliefs which improved relationships which ultimately brought a feeling of support and collaboration between family members when illness arises	Families as a unit of care or collaboration
23	Brumfield	Patients expected to benefit from the CMP program are those who underuse health care resources	Improved patient/family outcomes	Patients experience financial disparities	Family dynamics concerns
		Nurses effectively communicate with “noncompliant” family members to influence adherence to treatment plans	Therapeutic conversations with families	Patients lack of health conditions provokes lack of motivation to follow treatment plans and denial of care assistance	Patients with preexisting health concerns lack motivation to take part
		Patients positive comments after nurse sessions were found innovative compared to other actions offered	Clear two-way communications necessary
24	Holtslander et al	15-minute family interviews allowed students to increase their perspective regarding their patient and patient’s family, identify their needs, and improved their ability to work in a therapeutic relationship	Use of reflection and other tools	Nurses may not know how to cope with the suffering of family members	Inadequate education
		Conversations between nursing students and families increase capacity for healing by improving education and skill development	Improved patient/family outcomes	The nursing profession, along with other fields, is experiencing a decline in the prevalence of appropriate manners and civility	Nursing staff burden increased/stress concerns
		Personal growth was seen in student nurses as they practiced skills, abilities, and improved their attitudes towards working with families and reflecting on their experiences	Education changing perceptions of nurses towards CFIM	Lack of time in the clinical setting to talk with families	Nursing staff burden increased/stress concerns
		Understanding the theory behind therapeutic conversations increases the willingness to listen to families and affirm their thoughts and perspectives	Therapeutic conversations with families	Families afraid to accurately fill out the genogram for fear of being judged for their differences	Problems surrounding family sharing of patient information
		Appropriate manners can prevent nurses from interrupting families, enable them to properly introduce themselves, and increase the trust in the family–nurse relationship by using the family names	Education for nurses/families	Family frustration with the lack of communication about patient condition and treatment plan	Lack of nursing or family commitment
		The genogram and ecomaps served as a framework for collecting information and helped facilitate the family interview	Use of reflection and other tools	Lack of inclusion of the family as partners in the patient’s care	Lack of nursing or family commitment
		Utilization of circular questions and therapeutic questions increase interaction between family members and increased nurse understanding of relationships, intercommunication, and personality	Use of reflection and other tools
		Commending families allows nurses to identify specific strengths within a family and help to create a context for change in future challenges	Resources to families
		Completing the interview earlier on in a nursing shift would deepen the therapeutic relationship in increasing nurse understanding of the family needs and priorities	Education for nurses/families
25	Sigurdardottir et al	Mothers reported increased emotional and cognitive family support after the conversation intervention	Improved patient/family outcomes	Limited time of providers	Nursing staff burden increased/stress concerns
		Mothers found the professional opinions, caregiver support, and additional information on the child’s condition to be beneficial	Therapeutic conversations with families	Gender and familial roles may influence relative satisfaction with parental knowledge of the child’s condition	Problems surrounding family sharing of patient information
		Parents who participated in the therapeutic conversation group experienced fewer difficulties with treatment of their child’s condition	Therapeutic conversations with families	Nurses and midwives felt their job was high strain	Nursing staff burden increased/stress concerns
		Nurses and midwives who took the family nursing training program felt as if they received more support from administrators and coworkers	Education changing perceptions of nurses towards CFIM	Nurses expressed doubts regarding the effectiveness and utility of the family interview	Nursing staff burden increased/stress concerns
		Increased autonomy for nurses and midwives to control their own work	Education increasing awareness of nurses
		Family’s perceived support is influenced by the success of a clinicians engagement with the family and can lead to therapeutic change	Education changing perceptions of nurses towards CFIM
26	Broekema et al	Nurses received a 6-day education on family nursing	Education for nurses/families	Some nurses experienced difficulties in utilizing the genogram and ecomaps and did not feel adequately capable of using these tools	Inadequate education
		Nurses taught to conduct a family nursing conversation	Education for nurses/families	Nurses felt that the education provided them with knowledge, but they needed time to actual develop the skills associated with family nursing conversations	Increased time required to develop nursing skills
		Nurses taught to utilize reflection as a technique for connecting with families	Use of reflection and other tools	Six days of education on family nursing increases pressure on nurses and organizational budgets	Nursing staff burden increased/stress concerns
		Nurses instructed on genograms and ecomaps and assessed on their utilization of these tools	Use of reflection and other tools	Nurses family nursing competency was self-assessed by the nurses and could be inaccurately reported	Self-assessment of nursing skills can be inadequately reported
		Educational intervention increased awareness among nurses of the importance of families and their contributions	Education increasing awareness of nurses
		Nurses gained a more positive perception of the importance of family nursing conversations	Education changing perceptions of nurses towards CFIM
		The educational intervention incorporated a systemic view leading nurses to view the family as a unit of care for their patients	Families as a unit of care or collaboration
		A collaborative focus in nursing education on family nursing created the perception among nurses that caring for the patient is a collaborative effort between the nurse and the patients’ family	Families as a unit of care or collaboration
		The educational intervention included practical and theoretical knowledge in addition to knowledge on nursing roles and boundaries	Education for nurses/families
		Nurses who received instruction on the development on family nursing skills found they became more aware of their communication and more cognizant in their interactions with families	Education increasing awareness of nurses
27	Martinez et al	Nurses believed that they had developed their ability to intervene and effectively resolve problems	Education increasing awareness of nurses	The 15 minute family interview is virtually unknown by staff nurses who work directly with patients	Inadequate education
		Nurses reported use of circular questions helped clarify expectations in relationship between themselves and patients and their families	Education increasing awareness of nurses	Nurses found difficulty in pre-intervention based on different beliefs within family members	Problems surrounding family sharing of patient information
		Increased nurse confidence and competence after learning the proper steps to conduct the assessment	Education for nurses/families	Few nurses perceived the family as a unit of intervention	Family dynamics concerns
		High percentage of nurse participants expressed an interest in including more family interventions into their practice	Education increasing awareness of nurses	Some families had lack of cooperation	Family dynamics concerns
		Nurses found using the 15-minute family interview model is beneficial to conduct family assessments	Education changing perceptions of nurses towards CFIM
28	Simpson et al	Nurses reported that by involving families they were able to obtain a more complete picture of the situation with more comprehensive assessment and treatment planning	Families as a unit of care or collaboration	Lack of systematic training to for nurses to involve families in care planning	Inadequate education
		Nurses found it helpful to explore beliefs and family strengths	Families as a unit of care or collaboration	Nurses do not want to trouble family members on top of their existing workload	Nursing staff burden increased/stress concerns
		Nurses found that they were thinking about their practice in a different way after assessment	Education increasing awareness of nurses	Nurses and family members were subject to time constraints	Nursing staff burden increased/stress concerns
		Majority of nurses stated they were more confident in their knowledge and some reported a new pride in their profession	Education increasing awareness of nurses	Nurses explained family members are sometimes reluctant to disclose their problems	Problems surrounding family sharing of patient information
				In Hong Kong it is very unusual to involve the family in the assessment of family nursing	Family dynamics concerns
				Some nurses were afraid of the negative responses or of making the patient angry	Communications concerns
29	John and Flowers	Educational preparation in family nursing resulted in a willingness to step into leadership positions for staff practice and development	Education for nurses/families	Nurse perception that ecomaps do not add useful information in a family assessment	Increased time required to develop nursing skills
		The recognition of the importance of family nursing practice resulted in agencies allocating time for family meetings and discussions	Education increasing awareness of nurses	General patient wards may be less supportive of family nursing given high turnover rates and acute conditions	Nursing staff burden increased/stress concerns
		Family nursing practice is particularly encouraged in areas where the patient is experiencing a chronic or terminal illness	Education for nurses/families	Nurses did not utilize the formal assessment tools due to the intuitive and need-focused structure of the assessment	Nursing staff burden increased/stress concerns
		Nurses identified the processes and strategies for interaction facilitation as being the most useful	Education increasing awareness of nurses	Additional documentation limited by the amount of time allocated for documentation in the traditional clinical setting	Nursing staff burden increased/stress concerns
		Family nursing skills and interaction processes aided nurses in exploring the family’s perspective on their priorities	Families as a unit of care or collaboration	The development of family-centered nursing models is hindered by a lack of time, a lack of family nursing being perceived as beneficial, and a lack of knowledge and skills throughout healthcare organizations on family nursing	Nursing staff burden increased/stress concerns
		Staff development may benefit organizations in changing and implementing family-centered care	Education for nurses/families
		Administrative support of family nursing and emphasizing the importance of working with families is integral to the success of family centered care implementation	Education changing perceptions of nurses towards CFIM
		Nurses reported that family nursing improved their job satisfaction and improved nursing unit morale	Education increasing awareness of nurses
30	Choi et al	No drop-out rate for the intervention given an effort by the researchers to ensure the family therapeutic conversations were held when both parents were available	Families as a unit of care or collaboration	Difficult for parents to share their experiences regarding their child’s condition due to traditional familial roles	Problems surrounding family sharing of patient information
		Families were able to access the website contents (educational website designed for the intervention) using multiple devices at their convenience	Resources to families	Study was performed in Korea where Confucian values impact the family culture	Problems surrounding family sharing of patient information
		Family therapeutic conversations were found to be helpful in allowing parents to discuss their partner’s experience, learn problem-solving communication, and manage their child’s condition	Therapeutic conversations with families
		Family support conversations created opportunities for families to recognize their strengths	Therapeutic conversations with families
31	Dorell and Sundin	Nurses communication with family members turned into a trusting relationship	Clear two-way communications necessary	Family members did not want to interfere with nurses activities because they did not want to be perceived as demanding which could have a negative effect on family members care	Family dynamics concerns
		Nurses understood families members concerns and added structure to the conversations which ended in collaboration	Families as a unit of care or collaboration	Family members persisted in biases until nurses showed sufficient care	Family dynamics concerns
		Emotional support, listening to the patient and family, and engaging with the family to form a sense of trust are found to be the predominant effective intervention	Clear two-way communications necessary
32	Rosenbloom and Fick	Participation positively impacted by an increased knowledge of delirium and attitudes toward collaboration with families	Families as a unit of care or collaboration	Staff burden inhibits successful implementation	Nursing staff burden increased/stress concerns
		Reciprocal, clear, and honest communication between staff and family caregivers is vital for effective caregiving and prevention	Clear two-way communications necessary	An inability to commit to daily visits was cited as the reason for lack of participation	Lack of nursing or family commitment
		Simultaneous education of nurses and families on the patient’s condition, prevention of symptoms, and partnerships is both achievable and desired	Education for nurses/families	Prior nursing experience dealing with challenging family dynamics impacted their level of stress during conflict with family	Family dynamics concerns
33	Binding et al	Nurses found increased opportunity to make a positive difference in the illness and health experiences of families	Improved patient/family outcomes	Nurse educators found difficulty in assisting students to see diversity and differences	Inadequate education
		Stronger nurse–family relationships and coordination of care plans benefits nurses as it increases their understanding of the patient	Families as a unit of care or collaboration	Students had little to no experience in family nursing	Increased time required to develop nursing skills
		Reflective writing practices of nurses increased educational understanding	Use of reflection and other tools
34	Lee et al	Confidence in practicing family nursing was positively impacted by increased education in a family nursing course	Education for nurses/families	Lack of skill among nursing students to utilize family assessments in clinical practice	Inadequate education
		Nursing student interest in a family nursing course positively impacted the nurse–family relationship	Education for nurses/families	No formal education or standardized framework for family nursing to improve skills, knowledge, and attitudes regarding working with families	Inadequate education
				Perception of family nursing may be impacted by prior painful experiences with their own families and an unwillingness to confront their own family issues	Increased time required to develop nursing skills
				Lack of recognition/support for family nursing in healthcare	Lack of administrative support
35	Sveinbjarnardottir et al	Emotional support, listening to the patient and family, and engaging with the family to form a sense of trust are found to be the predominant effective intervention	Clear two-way communications necessary
		The proposed measurement tool includes consideration of family perception of family nursing interventions regarding cognitive and emotional functioning	Use of reflection and other tools
36	Silva et al	Therapeutic conversations allowed the opportunity for families to share their needs and experiences with the patients health and illness	Therapeutic conversations with families	A lack of theoretical references and tools hinders the incorporation of family in patient care	Inadequate education
		Nurses experienced positive emotions when offering commendations to families	Resources to families	Nurses lacked confidence in introducing a new procedure into their traditional routine of care	Increased time required to develop nursing skills
		Perception among nurses that the time utilized for the 15 minute family interview is beneficial	Education changing perceptions of nurses towards CFIM	Fear among healthcare professionals that the introduction of the 15-minute family interview will overwhelm them with responsibilities	Nursing staff burden increased/stress concerns
		Family appreciation for the interview and time spent, compassion, and recognition made the experience rewarding for nurses	Resources to families	Perception of the interview as a burden or obligation made the nurses uncomfortable	Nursing staff burden increased/stress concerns
		Providing a space for families to discuss their experiences and acknowledgements increased the amount of information for the family assessment	Resources to families	Nurses expressed doubts regarding the effectiveness and utility of the family interview	Communications concerns
		Trust and support are important factors for nurses and families during home visits	Clear two-way communications necessary
37	de Jesus Silva Figueiredo et al	Nurses gained a more positive perception of the importance of family nursing conversations	Education changing perceptions of nurses towards CFIM	Nurses were not prepared for a differentiated intervention	Inadequate education
				Nurses lacked education in the family nursing area	Inadequate education
				Nurses and administration lack of guiding models	Inadequate education
				Fragmentation by the institution was considered as a problematic element for full understanding	Lack of administrative support

Table 5 Study Results Affinity Matrix for Facilitators

Themes/Observations	References	n	%
Improved patient/family outcomes	[^Citation15^–^Citation25]	21	18.58
Education increasing awareness of nurses	[^Citation9,Citation15,Citation17,Citation23,Citation26^–^Citation29]	14	12.39
Families as a unit of care or collaboration	[^Citation9,Citation21,Citation28^–^Citation33]	14	12.39
Education for nurses/families	[^Citation15,Citation24,Citation26,Citation27,Citation29,Citation32,Citation34]	13	11.50
Therapeutic conversations with families	[^Citation16,Citation18,Citation21^–^Citation25,Citation30,Citation36]	13	11.50
Clear two-way communications necessary	[^Citation9,Citation16,Citation18,Citation19,Citation21,Citation23,Citation31,Citation32,Citation36]	12	10.62
Use of reflection and other tools	[^Citation16,Citation17,Citation22,Citation24,Citation26,Citation33]	9	7.96
Education changing perceptions of nurses towards CFIM	[^Citation19,Citation24^–^Citation27,Citation29,Citation36,Citation37]	9	7.96
Resources to families	[^Citation17,Citation21,Citation24,Citation30,Citation36]	8	7.08

Table 6 Study Results Affinity Matrix for Barriers

Themes/Observations	References	n	%
Nursing staff burden increased/stress concerns	[^Citation9,Citation21,Citation24^–^Citation26,Citation28,Citation29,Citation32,Citation36]	18	24.32
Family dynamics concerns	[^Citation9,Citation18,Citation21^–^Citation23,Citation27,Citation28,Citation31,Citation32]	14	18.92
Inadequate education	[^Citation15,Citation22,Citation24,Citation26^–^Citation28,Citation33,Citation34,Citation36,Citation37]	13	17.57
Problems surrounding family sharing of patient information	[^Citation21,Citation24,Citation25,Citation27,Citation28,Citation30]	7	9.46
Increased time required to develop nursing skills	[^Citation21,Citation26,Citation29,Citation33,Citation34,Citation36]	6	8.11
Lack of nursing or family commitment	[^Citation16,Citation24,Citation32]	4	5.41
Communications concerns	[^Citation17,Citation21,Citation28,Citation37]	4	5.41
Unrealistic expectations from family	[^Citation9,Citation15,Citation16]	3	4.05
Patients with preexisting health concerns lack motivation to take part	[^Citation17,Citation23]	2	2.70
Lack of administrative support	[^Citation34,Citation37]	2	2.70
Self-assessment of nursing skills can be inadequately reported	[^Citation26]	1	1.35

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