The purpose of this paper is to incorporate one family’s experience of living with multiple chronic illnesses into the Calgary Family Assessment Model (CFAM) and Rolland’s Chronic Health Challenge Framework. CFAM was developed by Dr. Lorraine M. Wright, a professor Emeritus of nursing and by Dr. Maureen Leahey, a manager of a mental health outpatient program both have over 25 years experience while still managing to supervise, teach, consult, write, and maintain a part-time clinical practice in individual, couple, and family therapy (Moxie, 2007).
CFAM allows nurses to assess families during interviews. CFAM is a multidimensional framework consisting of three major categories: structural, dimensional and functional. (Wright & Leahey, 2005)
Each category has its own subcategories, with the ability to pull out family strengths, weaknesses and roles of possible resources the family has or may need. These topics help the nurse assess the family’s perspectives at that particular moment in their lives and allows the nurse to help with any problems or challenges the family may face.
The family interviewed was a gentleman living with cystic fibrosis, diabetes, life threatening asthma and metabolic myopathies. For confidentiality, each family members name has been changed. The gentleman living with the chronic illness will be named Bob Jones, Bobs mother will be named Sue Jones, Bobs girlfriend will go by Jane, and the 2 year old daughter will be named Anna.
The structural category of CFAM is broken down into three subcategories: Internal, external and context. Developing questions according the family allows the nurse to develop an idea of who is considered family, what is the connection among family members and those outside the family, and what is the family’s context (Wright & Leahey, 2005).
Internal consists of family composition, gender, sexual orientation, rank order, subsystems and boundaries. Assessing family composition allows the nurse to discover who is considered family according to the patient, whether they are actual biological members or individuals who have influences the family’s life (Perry & Potter, 2006).
The Jones consist of Sue who is 47 years old, her son Bob who is 22 years old and has the chronic illnesses, Bobs girlfriend Jane who is 21 years old, and their daughter Anna who is 2 and a half years old. It was noted not to forget their loyal companion Sasha, the family dog or “second child”, as Bob puts it. (Personal) Due to the fact that Bob is not Anna’s Father, Bob’s family would be classified as a step family (Potter & Perry, 2006). Bob, Jane and Anna live at home with Bob’s mom Sue. According to Bob, Jane is works long hours throughout the week and being at home with his mother allows him to receive the care he needs socially, mentally and physically; while, acting as another pair of eyes on the very active Anna.
Bob’s family does not believe in the gender roles about wives staying home to cook and clean while the men are at work. Sue and Jane take on the responsibility of making sure Bob meets his nutritional requirements as well as their growing daughter Anna’s. Being a heterosexual couple, Bob and Jane were open to questions based on sexual orientation in their lives. Bob has done most of the teaching with Anna and due to his illness, he has been teaching her to treat everyone equally even if they are different. Although it is hard to understand such concepts at 2 years old “she is very smart and picks up on things very quickly” (Personal). Bob’s mother influenced him to be very open-minded in life, due to his illnesses it was sometime hard to cope with their effects. This open-minded characteristic about Bob allowed him to avoid putting people into genres and creating ideas of what they are meant to do.
There is no specific ranking order, as Bob’s illness plays a huge factor in what goes on within the family’s decisions and priorities. Anna is the only child present in the family and because of her age, she is given simple tasks to complete around the house to help out, such as putting away her toys and helping Sue and Jane with their chores. Most of the maintenance that is done around the house is Bob’s job. With the assistance of someone to be his arms and legs, things eventually get done, but at his own pace. Everyone in the family has equal tasks and say in what happens within the home.
While assessing the subsystems that are present in the Jones family, the significant bond that exists between Bob and his daughter Anna became very noticeable. Bob is at home with Anna 24 hours a day and is one of her main caregivers. “To take my mind off my illnesses, I try to place my attention on Anna” (Personal), Bob takes pride in teaching Anna how to tell time and pick up on the French language. “She is life a sponge that keeps on absorbing” (Personal). When she is not working, Jane spends her time bonding with Bob and Anna. Sue has been the guardian of Bob throughout his entire life living with his diseases. The attachment that they have developed for one another only gets stronger as they grow together. These subsystems all contribute in some way to the health and well being of this family (Wright & Leahey, 2005).
Living at home with Sue has given Anna the opportunity to bond with her step-grandmother and allowing her to develop a close relationship and security within the home. The boundaries within the family have been set at a group decision. One of the main boundaries that have been laid down is Anna’s interaction with Bob’s medication. Bob does not take pharmaceuticals as they have only decreased his health, depending on medicinal marijuana to fight off his attacks has been successful but as Anna grows up, it has been ruled that she has no interaction with it. Anna understands what a pipe and marijuana is, but has never seen it being used. Bob states “If I asked Anna what it was, she immediately replies by saying, it is papa’s medicine” (Personal). Another boundary that has been established is Anna’s interaction with television and the computer. Anna is allowed to have thirty minutes of television each day when Dora the Explorer is on. This boundary is respected by everyone in the house hold and extended family and friends so Anna can keep physically active.
The external subcategory of structural assessment consists of extended family and larger systems. Bob and his mother do not have much interaction with many family members and attend reunions and get-togethers due to his illnesses and inability to leave the house on bad days. Bob’s cousins Michael is not only his best friend and closest relative, but always takes time to visit and call on a regular basis. Michael and Bob’s close friends have always been there when his illness has decreased his health and for that, he considers all of his best friends to be a part of him extended family. Many friends that he grew up with in high school disappeared, but for the few that remained, they have become family (Personal).
Larger systems that have become a part of Bob’s life include the cystic fibrosis foundation, volunteer testing research projects, the government and the medical marijuana access regulations (MMAR). Bob has become a part of volunteer testing projects because he hopes that with his help they can in turn help others in the future who develop chronic illnesses. Bob doesn’t agree with the systems definition of the problem, he believes that “The system doesn’t get to live this life with such severe chronic illnesses, everyone’s case/illness is different and the system can only take info from the data they obtain” (Personal).
The final stage in structural assessment is context and consists of ethnicity, race, social class, religion and environment. The Jones are a Caucasian family who are from a Scottish and Irish background. Bob expressed that his family has no religious or spiritual beliefs, but “just hope the big guy is taking care of us” (Personal). When we asked Bob’s personal perspective on health, he stated “Health is overrated, if I was to describe it in one word, it would have to be underappreciated. I will never be as healthy as many people in the world but I can try to be as healthy as I am capable of” (Personal).
Having a low income brought in by only his mother and girlfriend and such high expenses to pay for medication and care, Bob perceived his family as being in a lower socioeconomic class. Bob dropped out of high school due to the severity of his illness and the stress that was associated with school, founding it a challenge to return, he doesn’t see himself returning anytime soon. In the past 5 years, the Jones have moved 4 times due to the progression of his illnesses and need for wheelchair accessibility. Each move has been a positive experience and bettered my environment as he now lives in a well built up area with access to medical, financial and educational facilities.
The Developmental Category of CFAM allows the nurse to focus on the developmental life cycle stages of the family including the emotional process and changes within family roles.
(Wright & Leahey, 2005). There are six stages in this developmental framework. These include leaving home, marriage, and families with young children, families with adolescents, entries and exits from family system and families in later life. The introduction of Anna into Bob life when he met Jane placed him in stage three of the family life cycle, which focuses on families with young children (Wright & Leahey, 2005). Within each stage there are changes the family is required to do in order to develop within the family home. At stage three these changes include, adjusting life to include children, joining in financial and household tasks and developing relationships with extended family members to include parenting and grand parenting roles (Wright & Leahey, 2005).
Both Bob and Jane, contribute to Anna’s development as a person. Having Sue present in the home allows her to provide additional support financially, emotionally, mentally and physically. Both Jane and Sue work and provide financial support, while keeping the home in working order. Daily activities around the house are completed by all, included Bob when he is feeling up to the challenge. Anna’s father is not longer present in the picture and Anna has turned to Bob as her father figure in life. Spending most of her days at home with Bob whom she now calls pap, they have developed a strong and caring relationship.
The final Stage of CFAM is the functional assessment. The nurse can focus on how each individual in the family actually behaves in relation to one another and also, how the chronic illness influences the function of the family (Wright & Leahey, 2005). This section has two subcategories, instrumental functioning and expressive functioning. Instrumental assessment involves each individuals active daily living routines. Due to the severity of his metabolic myopathy and Cystic Fibrosis, Bob’s muscles are constantly having contractions. Diabetes is common in people with cystic fibrosis, making nutritional requirements challenging for individuals like Bob who need to obtain roughly 20 000 calories a day (Ruder, 2007). Sue takes the time to prepare meals each day for the family, her task is to meet Bobs nutritional requirements and at the same time keep Jane, Anna and her own nutritional health in mind.
Bob will find himself drinking meal replacement shakes every few hours as needed. Cystic Fibrosis is a genetic disease that causes mucous to build up and clog organs of the body such as the respiratory system (Ruder, 2007). Bob sleeps with Jane in the basement with Sue and Anna upstairs so that Bobs coughing fits during the dead of night remain unheard. Bobs Medicine is kept in every place that he may happen to go (car, bathroom, bedroom, and kitchen) to allow immediate access when he has an attack. The bathroom is located at the top floor of the house; therefore, it is a challenge for Bob to reach the bathroom on days that his muscles are having severe spasms. He must also be well aware of when he has to go because it tends to take him over 5 minutes to get up each set of stairs (Personal). The expressive functioning assessment of CFAM allows the nurse to focus on patterns of interaction among family members through various means of communication.
Expressive functioning is divided into nine categories; Emotional, verbal, nonverbal, and circular communication, problem solving, roles, influence and power, beliefs, alliances and coalitions (Wright & Leahey, 2005). The Jones family have many ways of communicating with one another in the household. Due to Bob’s chronic illness, there are many days when his emotions are expressed in sadness and disappointment because he is unable to physically get involved with Anna’s active life. Stress is a factor that if it progresses will send Bob’s body into attacks that are challenging to control. Bob must keep constant verbal communication with Sue and Jane so they can help him if he is having a bad day. (Sorrell, 2007)Bob states that “sometimes it is hard to tell when I need help because I do not ask for it” (Personal).
Jane and Sue must pay attention to Bob’s nonverbal communication to know when he needs intervention. As Bob’s condition progresses, the family comes together and using their problem-solving skills to find solutions to problems such as finding a wheelchair accessible house or places to contact if help is needed. Living in the middle of a well developed city allows the Jones access to health clinics and hospitals to attend to Bob’s health needs and that of the families. A variety of shopping centres, social and physical facilities and learning opportunities are essential. All of these support systems contribute to the health and well being of the Jones family.
J.S. Rolland is the author of the article “Chronic Health Challenge Framework”, a framework that offers a conceptual base for theory building, clinical practice and research investigation in the area of chronic and life threatening illnesses. The framework is based around four categories that include onset, course, outcome and degree of incapacitation of the chronic illness (Rolland, 1987). Rolland’s conceptual model of chronic illness is useful in family assessments because such illnesses do not just affect the individual, but those around them as well.
The onset of a chronic illness of an illness can be acute and gradual; this allows the individuals family more time to adjust to permanent changes that have to be made in the home environment (Rolland, 1987). The Jones are a prime example of a family that fits into Rolland’s framework due to Bob’s struggle with cystic fibrosis. Cystic fibrosis is a genetic disease that has been progressively getting worse for Bob within the past few years. Sue has been by Bobs side throughout the entire course of his illness and thus giving her time to adjust to the anxiety, stress and changes that had to be made to suit Bob’s needs. Jane and Anna have been introduced into the family only within the past year and have had to adjust to the Bob’s lifestyle and having to adjust to the stress and anxiety present.
Rolland’s framework addresses three stages of a chronic disease; progressive, constant and relapsing. Bob’s illness was developed from birth and places him in the constant stage due to the loss of muscle control and constant spasms. Cystic Fibrosis is a fatal illness, but survival has increased from late teens to mid-30’s because of the many advances in diagnosis and treatment (Grossman, 2005). Bob’s illness has been progressively becoming more severe and being unable to adapt to his illness, he instead focuses on everything he is thankful for having, such as Anna, Jane and his mother Sue. Although there has been advances in diagnosis and treatments for cystic fibrosis (Grossman, 2005), there is still no cure for cystic fibrosis. Those who live with this genetic disorder unfortunately only have a fatal outcome in their future. As Bob’s cystic fibrosis progresses, so does his degree of incapacitation. Over a three year period, Bob has experienced difficulty controlling his body spasms that send him into attacks that have caused contractions of his muscles to break his rib cage.
Rolland’s framework for individuals with chronic illnesses consists of three time phases, crisis, chronic and terminal (Rolland, 1987). The crisis phase is when an individual is diagnosed with the illness. With cystic fibrosis, it is a genetic disease that is present at birth. The early diagnosis of Bob’s illness allowed his family to adapt to the changes needed to be made to his diet, level of activity and addition of medications. Moving into the chronic period is the long haul of any chronic illness. Bob is currently in the chronic phase as he lives through each day without knowing what to expect.
Most days, Bob’s illness causes his muscles to become so weak that he cannot find the strength to move. Days such as these have placed Bob in the position to use his assistive devices for mobility around the home. The family has come together with each decision to move to homes that are wheelchair accessible and convenient for Bob. Bob will stay in the chronic phase of Rolland`s time phases until he passes from cystic fibrosis (Rolland, 1987).
In conclusion, the use of the Calgary Family Assessment model and Rolland’s Chronic Health Challenge Framework has allowed me to assess the different components of the Jones family. Assessing means of communication between family members, changes made in active daily living routines and each individual’s views on dealing with the stress that walks hand in hand when living with a chronic illness has allowed me to develop a new outlook on life with an illness. This experience has left me enlightened on the effects that one individual may have on his system as a whole.
Grossman, L. & Grossman, S., (2005). Pathophysiology of Cystic Fibrosis: Implications for Critical Care Nurses. Critical Care Nurse, 25(4), 46-51. Retrieved February 11, 2008, from ProQuest Nursing & Allied Heath Science database. (Document ID: 878095951).
Moxie, 2007. Maureen Leahey & Lorraine Wright. Family Nursing Resources. Retrieved February 3, 2008 from http://www.familynursingresources.com/aboutus.htmPerry, A & Potter, P. ( 2006) Canadian fundamentals of nursing. (J.Ross-Kerr & M. Wood, Eds.) (3rd ed.) Toronto, ON: Elsevier Mosby.
Ruder, K., (2007, November). Cystic Fibrosis and Diabetes. Diabetes Forecast, 60(12), 28,31. Retrieved February 11, 2008, from ProQuest Nursing & Allied
Health Source database. (Document ID: 1380669491).
Rolland, J.S., Chronic illness and the family: An overview. (1987). PA: Springhouse.
Sorrell, J.M.,(2007). Caring for the Caregivers. Journal of Psychosocial Nursing & Mental Health Services, 45(11), 17-20. Retrieved February 12, 2008, from ProQuest Nursing & Allied Health Source database. (Document ID: 1380091541).
Wright, L.M., & Leahy, M. (2005). Nurses and families (4th ed.) Philadelphia: F.A. Davis.