The impact of family nursing conversations targeting patients and their family members in the multidisciplinary outpatient treatment of chronic non-cancer pain

Introduction and background. This Ph.D. project investigated an intervention with family nursing conversations (FNCs) targeting patients with chronic non-cancer pain (CNCP) and their selected family members. The intervention was based on the Family Systems Nursing framework by Wright and Leahey and carried out at an outpatient Multidisciplinary Pain Center (MPC) by the employed nurses. CNCP is a complex, disabling illness with vast implications for patients, family members, and society. Simple treatment solutions do not exist, and available treatment seldom succeeds in healing the pain. Therefore, treatment should target its management. Though sparse, existing research has indicated that family involvement can support the management of CNCP. However, family involvement is often arbitrary and sporadically delivered, leaving families’ needs unmet. A gap in the research concerning the benefit of specific family involvement approaches called for a close investigation of interventions with the potential to comply with the family’s need for caring. Wright and Leahey’s Family Systems Nursing framework has proved beneficial in other populations but has never been investigated for CNCP. The benefit of an FNC intervention is also related to the intervening nurses’ performance. Thus, supporting their perceived self-efficacy concerning the conduction of FNCs is vital. The main objective of the Ph.D. project was to investigate the impact of family involvement through an FNC intervention targeting patients and their selected family members in the multidisciplinary outpatient treatment of CNCP.
Methods. Three studies contributed to answering the main objective: 1) A prospective non-blinded quasi-experimental trial investigated if adding FNCs to the usual treatment would affect patients’ and family members’ self-efficacy compared to the usual treatment. Moreover, to investigate any effect on family function, health-related quality of life, anxiety, and depression. 2) A phenomenological-hermeneutical study explored patients’ and family members’ experiences of participating in FNCs, including the perceived impact of the intervention, using individual interviews. 3) A longitudinal qualitative descriptive study used repeated focus group interviews to uncover barriers and facilitators influencing the intervening nurses’ perceived self-efficacy while incorporating FNCs in their practice.
Results. In paper 1B, the quasi-experimental trial demonstrated no effect on the primary outcome, self-efficacy, for either patients or family members. A significant effect was found on patients’ behavioral family function and anxiety. No effect was found on family members’ secondary outcomes. In paper 2, the FNC intervention was perceived as a mainly positive experience integrating CNCP and family life. Patients and family members developed a vocabulary to talk about CNCP and experienced increased mutual understanding and acceptance. Patients and family members, however, appeared as a heterogenous entity with diverse experiences of the impact of the intervention. Mechanisms contributing to experiencing the FNC intervention as beneficial comprised the nurses’ enactment and the perception of their role, timing, and readiness. Paper 3 found that the intervening nurses perceived the process as overwhelming. Heavy barriers characterized the initial phase. Learning to conduct FNCs and manage the required communication skills was akin to learning a new language and was marked by a fear of crossing the border into psychologists’ work areas and harming the families. Strong collective self-efficacy and ongoing project management were vital facilitators that eventually balanced the barriers. Being responsible for the FNCs strengthened the nurses’ professional identity beyond the scope of the intervention. However, subtle resistance from the multidisciplinary collaborators constituted a continuous barrier.
Discussion. The results were likely influenced by the fact that the intervening nurses were still learning while the data were being collected. The Ph.D. project was massively disturbed by the COVID-19 pandemic, the Danish nursing strike, and a reduced patient flow at the MPC, all decreasing the quasi-experimental trial’s internal validity. The results should be interpreted cautiously, and ideally, the trial should be repeated. Considering this, the patients and family members nonetheless believed that the intervention should become a permanent service. However, the study sample was selected and did not include the most vulnerable patients.
Conclusion and implications. The evaluated impact of the FNC intervention depended on the applied methodological approach. If implemented, the intervention should be carefully adjusted to the specific family’s needs. The FNC intervention was resilient in a changeable real-life setting and ready to be implemented in the study setting as it is now. Transfer to other settings would require a renewed translation process. Further research should be initiated with a mixed methods synthesis to comprehensively understand the impact of the intervention. Studies could also develop outcomes that are better able to capture change from an FNC intervention. Moreover, research on vulnerable patients with CNCP and on determinants of nurses’ roles and latitudes could contribute to improving the broader care of families.