Journal of Family Nursing 2014 Svavarsdottir 13 50

520345
research-article2014
JFNXXX10.1177/1074840713520345Journal of Family NursingSvavarsdottir et al.
Article
Strengths-Oriented
Therapeutic
Conversations for
Families of Children
With Chronic Illnesses:
Findings From the
Landspitali University
Hospital Family Nursing
Implementation Project
Journal of Family Nursing

2014, Vol. 20(1) 1350
The Author(s) 2014
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DOI: 10.1177/1074840713520345
jfn.sagepub.com
Erla Kolbrun Svavarsdottir, RN, PhD1,2, Anna

Olafia Sigurdardottir, RN, MSc2, and Gudny
Bergthora Tryggvadottir, MSc1
Abstract
Psychosocial services have been recommended for families of children
with chronic illnesses to assist them in adjusting to the illness experience.
However, little is known about the benefit of psychosocial interventions
in clinical practice. This study aimed at evaluating the benefits of a twosession family therapeutic conversation intervention (FAM-TCIs) for families
of children diagnosed with asthma, cancer, or diabetes. A secondary data
analysis was conducted on intervention data from 37 families of children with
chronic illnesses. Mothers of the children/teenagers perceived significantly
1University
2Landspitali
of Iceland, Reykjavik, Iceland

University Hospital, Reykjavik, Iceland
Corresponding Author:
Erla Kolbrun Svavarsdottir, Professor and Academic Chair of Family Nursing, Faculty of
University of Iceland and Landspitali University Hospital, Eirberg, Eiriksgata 34, IS-101
Reykjavik, Iceland.
Email: eks@hi.is
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14
Journal of Family Nursing 20(1)
higher family support after the FAM-TCI compared with before; mothers
reported significantly higher collaboration and problem-solving abilities on
the expressive family functioning scale after the FAM-TCI. However, no
significant differences were found on the fathers perceived family support
nor on their expressive family functioning after the FAM-TCI compared with
that before the intervention. It is promising that mothers of children with
chronic illness perceived the two-session FAM-TCI to be beneficial to them.
More attention should be paid to psychosocial interventions for families of
children with chronic illnesses.
Keywords
family nursing intervention, quasi-experimental, therapeutic conversation,
Family Systems Nursing, chronic illness, children, adolescents, parents,
Landspitali University Hospital Family Nursing Implementation Project
Globally, current economic constrains in health care have the potential to

threaten psychosocial services such as offering therapeutic conversation
interventions (TCIs) to families of children and adolescents diagnosed with
chronic illnesses, because such services may be viewed as expensive and
labor-intensive. Yet, the family intervention literature points to several factors that can help patients and family members better manage an illness experience such as by using active coping strategies, by practicing optimistic
thinking, and by finding meaning in the illness situation (Kamban &
Svavarsdottir, 2013; Kendall & Tabacco, 2011; Konradsdottir & Svavarsdottir,
2011, 2013; Moules, Laing, Morck, & Toner, 2011; Northouse, 2005;
Sigurdardottir, Svavarsdottir, Rayens, & Adkins; 2013; Svavarsdottir &
Sigurdardottir, 2013; Svavarsdottir, Tryggvadottir, & Sigurdardottir, 2012;
Sveinbjarnardottir, Svavarsdottir, & Wright, 2013). Furthermore, familylevel interventions have been found to significantly reduce patient outcomes
such as patient depression and patient mortality and also to significantly
decrease family members outcomes such as caregiver depression and caregiver burden (Armour, Norris, Jack, Zhang, & Fisher, 2004; Chesla, 2010;
Ducharme, 2011; Hartmann, Bazner, Wild, Eisler, & Herzog, 2010; Martire,
Lustig, Schulz, Miller, & Helgeson, 2004).
Offering families of children with chronic illnesses a family nursing health
care service creates the possibility to care for children and adolescents in ways
that support and promote their physical and psychological health. Such family-level health care services also contribute to healthy development between
family members and support health outcomes of other members of the family.
15
Svavarsdottir et al.
Therefore, to offer quality and effective health care to families of children

with chronic illnesses, educational and psychosocial family nursing interventions need to be developed and delivered in clinical settings, within a reasonable time. These interventions also need to capture the depth that is needed in
relational practices when offering psychosocial support. Effective nursing
interventions will therefore need to balance theoretically and clinically
grounded approaches with empirical evidence. In addition, these interventions
will need to be delivered in a brief format and designed so creatively that they
will be able to be woven into pediatric practices and health care economics.
Few studies have, however, been conducted within clinical settings to evaluate
the effectiveness of a brief family-level therapeutic conversation intervention
(FAM-TCI) on families of children with chronic illnesses.
The purpose of this quasi-experimental, family-level intervention study
was to assist advanced nurse practitioners at a University Hospital who were
working in outpatient clinics for children and adolescents with diabetes and
asthma and at an inpatient pediatric cancer unit and a day care cancer unit to
better support families and facilitate family functioning, well-being, and
quality of life (QOL).
Background
International research on families of children and adolescents diagnosed with
chronic illness(es) such as cancer or diabetes have recommended psychosocial support to assist families with both short- and long-term adjustment to
the changes that are activated by the illness situation. Furthermore, it is recognized that the progress of the cancer and the diabetes diseases are influenced by physical, psychological, and social factors. Psychosocial
interventions for families have therefore been developed over the last few
decades and have mainly focused on reducing stress symptoms among parents of children newly diagnosed with cancer (Fisher & Weihs, 2000; Kazak
etal., 2005; Stehl etal., 2009), coping with ongoing stress among parents of
children with cancer and enhancing their adaptation and well-being
(Svavarsdottir & Sigurdardottir, 2005, 2006), improving psychological and
physical states associated with the pediatric cancer experience (Beale, 2006;
Kazak, 2005), and focusing on the importance of social relationships
(Konradsdottir & Svavarsdottir, 2011, 2013; Svavarsdottir & Sigurdardottir,
2011; Sveinbjarnardottir etal., 2013).
Even though international organizations such as the International Council
of Nursing (ICN) and National and University Hospitals have recommended
that psychosocial services will be provided to families when a child member
is diagnosed with chronic illness such as cancer (Schober & Affara, 2001;
16
Landspitali University Hospital, 2011), few studies have been published

regarding the benefit of psychosocial interventions at the time of diagnoses.
Kazak and colleagues (2005) conducted a pilot study regarding the feasibility
of a three-session intervention for caregivers of children newly diagnosed
with cancer where the intervention was distributed over 1 month. Nineteen
families were randomly assigned to the intervention or the control group
(treatment as usual) to learning of their childs illness. The main focus of the
intervention was on identifying beliefs about cancer, the treatment, and the
impact on the family. The intervention also focused on changing beliefs to
enhance family functioning, as well as focusing on growth and future expectation. The results indicated a decrease in state anxiety for the primary caregivers in the intervention group; however, primary caregivers in the control
group showed no change in state anxiety across time. Similarly, both primary
and partner caregivers in the intervention group showed decline in post-traumatic stress symptoms over time, whereas primary and partner caregivers in
the control group showed an increase in symptoms over these time periods.
Similarly, Svavarsdottir and Sigurdardottir (2013), in a study of 19 parent
caregivers (10 primary and 9 partners) of children in active cancer medical
treatment, found the primary caregivers to perceive significantly higher family support after a two- to three-session brief TCI. Those caregivers also
reported significantly higher expressive family functioning and significantly
higher emotional communication after the intervention.
Nevertheless, conflicting results have been reported in the literature
regarding the benefits of a psychosocial intervention for families of children
newly diagnosed with cancer. In a randomized control trial (RCT) study
(Stehl etal., 2009) of 46 families of children newly diagnosed with cancer
(23 in the intervention group and 23 in the control group), families in the
intervention group received a three 45-min-session intervention and three
booster sessions; those who were in the control group received treatment as
usual. The intervention was offered to the families 4 to 6 weeks after diagnosis and focused on (a) identifying the caregivers beliefs about the difficulties
associated with cancer, (b) reframing these beliefs to alter unwanted consequences such as distress and relationships troubles, and (c) on drawing forward the family growth. The findings indicated that both the intervention and
the control groups showed significant decrease on state of anxiety over time
for primary and secondary caregivers. Similarly, there were no significant
differences found in traumatic stress scores after the intervention between the
intervention group and the control group, neither for primary caregivers nor
for secondary caregivers. However, evidence-based interventions for families dealing with childhood cancer following the first 6 weeks after diagnosis
are rare and need therefore to be tested further.
17
It is well known that family caregivers constitute the core of long-term

care providers and that the economic value of unpaid caregiving to society by
family caregivers is huge (Harrison, 2010; Northouse, 2005). Providing family-centered care honors that a clinician incorporates into caregiving the
knowledge and conviction that the family is the constant in childrens lives
and by including families in care processes, children will receive higher quality care (Harrison, 2010). Furthermore, Harrison argues that pediatric nurses
still struggle with providing family-centered care, and that the gap between
what is perceived as important and what is actually practiced marks an area
of frustration and dissatisfaction for both families and clinicians. Over the
last decade, researchers have focused more on what effects, if any, interventions conducted with families managing a chronic illness had on patient outcomes, as well as on family caregiver outcomes. They have concluded that
there is consistent evidence in the literature that family-oriented interventions
are more beneficial than patient-oriented interventions (Berry etal., 2004;
Carr, 2009; Chesla, 2010; Martire, 2005; McBroom & Enriquez, 2009;
Rosland & Piette, 2010).
McBroom and Enriquez (2009) conducted a systematic literature review
to examine family-centered interventions that enhance the health outcome of
children with type 1 diabetes. Findings from nine RCT studies indicated that
family-centered interventions significantly improved A1Ca, enhanced family
dynamics, and decreased family conflict. Similarly, in a structured review of
meta-analyses, Chesla (2010) concluded that in eight RCT that tested family
intervention with childhood diabetes, a moderate significant positive effect
was found on glucose control when children and their families who received
the family-level intervention were compared with the control condition, indicating the benefits of the family-level interventions on childrens health.
Well-functioning families are important resources in times of stress.
Family functioning represents a family members subjective perception of
the family qualities and comprises dimensions such as (a) instrumental and
(b) expressive functioning (Wright & Leahey, 2013). According to Wright
and Leahey, the instrumental aspect of family functioning refers to routine
activities of daily living, and the expressive functioning component refers to
functions such as expressing emotions, beliefs, collaboration and problem
solving, and communication and behaviors. When a nurse and a family have
a conversation about family functioning, both the instrumental and the
expressive functioning need to be explored. Vollrath, Neyer, Ystrom, and
Landolt (2010) conducted a study on the dyadic personality effect on family
functioning in parents of newly hospitalized children. A sample of 183 couples whose child sought treatment for type 1 diabetes, cancer, or an unintentional injury were assessed at 1 and 6 months post-hospitalization. The results
18
indicated that influence on the parents own family functioning was twofold:
for the mothers, their own involvement and agreeableness; for the fathers,
their own openness and conscientiousness. However, the fathers conscientiousness was found to influence the mothers family functioning, indicating
the need to study the parents together.
QOL is another component that is of great importance to nursing researchers
when developing interventions for families dealing with chronic illnesses.
Measures of QOL have been used worldwide among researchers studying families of children and adolescents dealing with chronic illnesses. The QOL construct involves ones perception of how health status affects different domains
of daily functioning (Greenley, Josie, & Drotar, 2008; Varni, Burwinkle,
Rapoff, Kamps, & Olson, 2004). Rayens, Svavarsdottir, Burkart, and Zhang
(2011) studied health-related quality of life (HRQOL) among 30 families of
adolescents aged 13 to 17 years with asthma (adolescentparent dyads) in the
United States (n = 15) and in Iceland (n = 15) who were receiving health care
services from university clinics. The main finding indicated that the parents in
both cultures (United States and Iceland) rated their childrens QOL as poorer
than did the adolescents themselves. Furthermore, the findings suggested that
while parents and adolescents generally agreed on the degree to which asthma
symptoms affected QOL, they did not perceive in the same way the impact that
asthma treatments, worry, and communication had on asthma-related QOL.
The results also indicated that the Icelandic parents tended to overestimate their
childrens QOL compared with the adolescent scores and that the U.S. parents
tended to underestimate their childrens QOL compared with the U.S. adolescents own scores. It was concluded that family-centered interventions for adolescents with asthma may benefit by improving parents understanding of how
this chronic condition affects QOL and such interventions may have to be tailored for cultural differences. Furthermore, Sigurdardottir etal. (2013) conducted an intervention study on 31 families of children with asthma (31 mother,
15 fathers, and 31 children), and found the mothers in the experimental group
of the children/teenagers with asthma scored significantly higher on perceived
family support after the TCI compared with the mothers in the control group
who received treatment as usual. Interestingly in this study, the pre-teenagers
and teenagers with asthma, were also found to benefit from their parents intervention; that is, the teenagers whose parents received the two-session intervention, reported significantly fewer problems with asthma treatment
post-intervention compared with before intervention.
Nevertheless, the strength of an intervention, the competence of the interventionist, and the models used when delivering the intervention always need
to be considered carefully when developing and testing the effectiveness of a
theory-based intervention within clinical settings. Researchers who design an
19
intervention are interested in whether the content of the intervention is delivered as planned and whether all of the participants received the same dosage.
According to Brandt, Kirsch, Lewis, and Casey (2004) and Northouse (2005),
it is therefore crucial to systematically analyze the strength and integrity of a
pilot intervention so that the designers become more fully informed of what
works and what does not work and to be able to decide whether to continue
the intervention as originally designed or to make changes as needed. In an
era of cost constraints, it is necessary to consider what dose of an intervention
is essential and under what conditions (Lauver etal., 2002) the desired intervention effects are to be obtained.
The theoretical framework that guided the research was the Calgary
Family Assessment Model and Calgary Family Intervention Model (CFAM/
CFIM; Wright & Leahey, 2013). The focus in the intervention model is on
changing cognitive, affective, and/or behavioral domains of family functioning. As family members perceptions of one another and the illness in their
family change, so too do their behaviors change. In the model, where change
and healing are made possible, interventions are activated within the context
of a relationship between the nurse and the family. In this way, the family
nurse relationship is highlighted by focusing on the intersection between
family member functioning and interventions offered by nurses. It is at this
intersection that healing can occur (Wright & Leahey, 2013).
Hypotheses and Research Questions

Based on the literature review and the conceptual frameworks that guided our
research, it was hypothesized that (a) parents of children with chronic illness
(cancer, diabetes, and asthma) who received the two-session FAM-TCI would
perceive significantly higher family support after the intervention compared
with before and would report similar or significantly higher expressive family functioning after the FAM-TCI. Furthermore, it was hypothesized that (b)
parents of children with cancer, parents of children with diabetes, and parents
of children with asthma would perceive significantly higher family support
after the FAM-TCI compared with that before the intervention, and would
report similar or significantly higher expressive family functioning and report
similar or significantly higher disease-related QOL after the intervention
compared with before. The following research questions were asked:
Research Question 1: What are the differences from the childrens perspective, in HRQOL, based on the childs health condition (cancer, diabetes, or asthma), after the intervention compared with that before the
intervention?
20
Research Question 2: Are there significant gender differences between

the parents (the mothers and the fathers) regarding their perception on
their perceived family support and on their expressive family functioning
when evaluating the mothers and the fathers difference score between
pre-and post-intervention scoring?
Method
Sample
Data for this secondary data analysis study were obtained from 37 families of
children with chronic illnesses out of the original studies of 10 families of
children with cancer (19 parents; Svavarsdottir & Sigurdardottir, 2013); 31
families of children with asthma (Sigurdardottir etal., 2013); and 15 families
of children with diabetes (Konradsdottir & Svavarsdottir, 2013). These families were receiving health care services in 2010 at an inpatient cancer unit, a
day care cancer unit, or at an outpatient asthma and diabetic clinics at the
Childrens Hospital at LUH in Reykjavik, Iceland. In the original studies,
potential parent participants were introduced to the study by the clinical staff
on the cancer unit about 8 weeks after the child had been diagnosed with
cancer. In the Asthma and Diabetic clinics, the parents were introduced to the
study by the clinical staff when attending a clinical visit, and invited to participate if they met the studys eligibility criteria. The eligibility criteria for
the parents were being able to read or write Icelandic at a minimum fourthgrade level and the willingness of at least one parent to participate in the
study. Exclusion criteria for parents included being participants in any other
study regarding their childrens health condition at the time of the data collection, being participants in any study regarding their own health, and being
treated for any major physical or mental health problems. Approval to conduct the study was received from the Scientific Committee at the LUH
(Number 68/2008). The study was reported to the Data Protection Committee
in Iceland (Number S4118, November 13, 2008). Data were collected in 2010
using the Outcome electronic program.
Description of the FAM-TCI

The FAM-TCI consisted of two interview sections where the main focus of
the intervention was based on the key elements of the brief family interview
framework identified by Wright and Leahey (2013; for example, drawing
family genogram and an ecomap, in collaboration with the families, using
therapeutic questions, and offering recommendations and commendations).
21
The therapeutic conversations were introduced to the parents as an opportunity for them to engage in a therapeutic relationship. Each family received
two therapeutic conversation interviews. The therapeutic conversations
ranged from 45 to 90 min, each conversation averaging 60 min. After the
parents had signed the consent form, the study nurse in the Asthma and
Diabetic clinics accompanied the parents to the intervention room where the
setting was arranged in such a way that the nurse was seated across from the
parents at a round table. For parents of children with cancer, a nurse from the
cancer day care unit followed the parents to the Faculty of Nursing, which is
a building next to the Childrens Hospital, where they met the study nurse
who conducted the interviews in an interview room.
First therapeutic conversation. In the first therapeutic conversation, the nurse
began by introducing herself to the parents, stating the purpose of the study,
and giving her estimate of how long she expected the interview to take (e.g.,
about 60 min). Then the nurse drew a genogram of the family with the help
and input of the parents. She also drew an ecomap, with a specific focus on
identifying the quality of the parents relationships with other family members, friends, work environment, and institutions in the society. In the first
therapeutic conversation, the nurse offered the parents some informative
information regarding their childs health condition and asked therapeutic
questions such as the following: Could you tell me about the day when your
child was diagnosed with the cancer/asthma/diabetes? What was your reaction/response to learning about the diagnosis? What is your illness story/
narrative? Who in the family do you think the illness has the most impact on?
Who is suffering the most? What is the greatest challenge facing your family
now? The parents described the size of their families, the relationships within
them, and the duration of their marital relationships. All of the parents also
described their experiences of having their children diagnosed with the
chronic illness, their social support systems such as friends and extended
family, their employment status, their relationships with coworkers, and their
financial situations. Communication and relationships with other families in
the same situation were also discussed. Responses from friends, extended
family members, coworkers, health care professionals, teachers, schools, and
society in general were mentioned frequently by the parents
Second therapeutic conversation.In the second therapeutic conversation, the
nurse started by asking if the family had any specific questions from the last
therapeutic conversation and how the children themselves and other members
of their families had been doing since the first therapeutic conversation (both
parents were invited to speak). The parents were also asked whether anything
22
specific was on their minds and how the following weeks and even months
looked to them. Then the nurse put the genogram and the ecomap on the table
in front of the family and herself to have a visual image of the family in front
of them while they were having the therapeutic conversation. The nurse asked
specific interventive questions such as the following: What has been most and
least helpful to you in similar situations? If there were one question you could
have answered now, what would it be? How do other members of your family
handle the situation? How do the siblings handle the situation that the family
is dealing with now? What beliefs do you have toward the disease? What
beliefs do other members of the family have toward the disease? Does anyone
in your family have constraining beliefs toward the illness or the situation the
family is now in? What core beliefs have you and your family found helpful to
rely on when dealing with the illness on a daily basis? What do you believe the
future holds for your family and your child with asthma/diabetes/cancer?
Some specifically tailored questions were also asked based on the childs
health condition. Mothers and fathers were given time to reflect on their own
experiences, discuss worries and concerns, and express how they were dealing
with the situation. In this section, the parents were also given a chance to discuss how, if at all, the experience of having a child diagnosed with cancer,
diabetes, or asthma had changed them or their beliefs. At the end of the interview the nurse thanked the parents for their participation and emphasized that
they were welcome to contact the research team if they had any questions or
concerns regarding the interview. They were also told that they could approach
the nursing staff at the unit with questions or concerns.
Treatment integrity. Treatment integrity was addressed by intensive training of
the advanced study nurses, through lectures, seminars, role-playing, and
observations. The study nurses met with the intervention team once a week for
3 to 4 hr each time over a period of 4 weeks to go over the intervention protocol and to practice how the intervention would be delivered. In addition, the
intervention team met weekly over the 1 month of the training time period, as
well as over the time of the data collection, to discuss issues regarding the
intervention protocol, documentation, and family issues that arose during the
therapeutic conversations. The principal investigator, who was also a family
nurse, attended those meetings to support the advanced study nurses and to
ensure that no care needs of the families were being overlooked.
Role of the nurse in the intervention. The role of the advanced practice nurse
who delivered the FAM-TCI was, in both therapeutic conversations, to reflect
on the parents experiences by asking relevant circular therapeutic questions,
and encouraging, empowering, and pointing out in what way the families
23
were handling their situations well (i.e., offering commendations). The nurse
also listened to the parents stories of their experiences, pointed out differences between the parents, and answered specific questions asked by the parents. In general, the nurse had to create a context in the interview where
families could make small or significant changes by recognizing their problem-solving abilities and by realizing that interventions are focused on cognitive, emotional, and/or behavioral domains of family functioning.
Furthermore, the nurse encouraged family members to explore alternative
solutions to problems, invited them to think differently, encouraged different
affective expressions, and asked families to perform new tasks. The nurse
used questions as interventions, empowered and supported the families, and
expressed confidence in their problem-solving abilities when appropriate.
Procedure for Data Collection

The parents who participated in the study were introduced to the study by a
staff nurse working on the units or by a doctoral student nurse research assistant working at the Childrens Hospital. If the parents agreed to participate,
they signed the consent form and then they went to a private room in the clinic
or to an interview room at the Institute of Nursing Research at the Faculty of
Nursing to complete the questionnaires on a computer (the questions involved
background information and childs health, the IcelandExpressive Family
Functioning Questionnaire (ICE-EFFQ); the IcelandFamily Perceived
Support Questionnaire (ICE-FPSQ); and the disease-specific QOL questionnaires; Time 1). After the parents had completed the questionnaires at time
one, the parents received the first section of the intervention from the nurses
(two of the nurses who conducted the therapeutic conversation had an MSc
degree in nursing and special training in Family Systems Nursing [FSN], and
one of the nurses had a PhD in family nursing). After the first section was over,
the families were scheduled for the second interview (Section 2), which took
place 1 to 6 weeks later at the same location. When the parents had finished
the second section of the intervention, they were then given a code to use on
their computer at home to answer the same set of questions again as they did
before the intervention (Time 2). If parents had not responded at Time 2 on the
5 to 7 day after they finished section 2 of the intervention, they were sent an
email reminder and asked to respond within the next 2 or 3 days.
Participants
In this secondary data analysis, all of the families were assigned to the experimental group (one-group prepost-test design). Of the families, 40 were
24
introduced to the study (10 families of children with cancer, 15 families of

children with asthma, and 15 families of children with diabetes), but 37 families (60 parents, 35 mothers, and 25 fathers) were recruited and completed
participation in the study at both time periods (92.50% participation rate; see
Table 1).
Data Collection Tools

To evaluate the effectiveness of the intervention, three questionnaires were
used: the ICE-EFFQ, the ICE-FPSQ, and disease-specific QOL Questionnaire.
In addition, information on the demographical status of the family, as well as
on the health conditions of the children from the parents perspective, were
collected.
Information on sociodemographics and child-health variables. The sociodemographic questionnaire included questions about the parents age, the category
of relationship to the child (e.g., parent vs. guardian), marital status, education, and family income. This instrument also included questions for the parents regarding the gender of the child, the reason for the child being admitted
to the hospital at the time of the study, and the age of the child when admitted
to the hospital.
ICE-PFSQ.The ICE-PFSQ is a 14-item instrument that includes two subscales: (a) Cognitive Support and (b) Emotional Support ( = .953; Sveinbjarnardottir, Svavarsdottir, & Hrafnkelsson, 2012b). This questionnaire is
based on the CFIM (Wright & Leahey, 2013). The questionnaire has a Likert-type scoring procedure (1-5). On this questionnaire a higher score reflects
a perception of better family support. The questionnaire was constructed and
developed in Iceland and has been found to be both valid and reliable (Leahey & Svavarsdottir, 2009). The instrument has been psychometrically
tested (Sveinbjarnardottir etal., 2012b). According to these authors, Cronbachs alpha has been reported to be .953 for the total scale; for the subscale
of (a) Cognitive Support = .874; and for the subscale of (b) Emotional
Support = .937. In this sample of Icelandic families, alpha for the total
scale was .913 to .973 at Time 1 and Time 2. For the subscales in this sample: (a) Cognitive Support, = .889 to .949; (b) Emotional Support, = .877
to .973 across time.
ICE-EFFQ. The ICE-EFFQ is a 17-item instrument which includes four subscales: (a) Emotional Communication, (b) Collaboration and Problem Solving, (c) Verbal Communication, and (d) Behavior ( = .895; Sveinbjarnardottir,
25
Table 1. Demographic Characteristic of Families of Children and Adolescents
With Asthma, Cancer, and Diabetes Who Received the TCI (N = 37 Families; 35
Mothers and 25 Fathers).
Intervention group
Mothers (n = 35)
n
Childs gender
18
Female
Male
18
Childs age (years)
0-5
5
6-10
6
24
11-18
Type of childs chronic illness
7
Cancer
Diabetes
13
Asthma
15
Age of children with cancer
0-5
5
2
13-16
Age of children with diabetes
8-12
4
9
13-18
Age of children with asthma
6 years
1
8-12
5
13-18
9
Time from diagnoses
Cancer
Diabetes
Asthma
Parents age
1
19-30
31-40
13
41-50
18
51-60
3
Marital status
Married/cohabiting
29
Single parent
6
Education completed
Middle school
1
High school
16
University
18
Income
<400
7
401-600
8
19
>601
(%)
Fathers (n = 25)
M (range)
(%)
(51.4)
(48.6)
12
13
(48.0)
(52.0)
(14.3)
(17.1)
(68.6)
5
3
17
(20.0)
(12.0)
(68.0)
(20.0)
(37.1)
(42.9)
8
11
6
(32.0)
(44.0)
(24.0)
(71.4)
(28.6)
5
3
(62.5)
(37.5)
(30.8)
(69.2)
3
8
(27.2)
(72.8)
(6.7)
(33.3)
(60.0)
0
3
3
(0.0)
(50.0)
(50.0)
7.6 months (3-17 months)

4.6 years (6 months-7 years)
8.5 years (6 months-17 years)
(2.9)
(37.1)
(51.4)
(8.6)
1
11
12
1
(4.0)
(44.0)
(48.0)
(4.0)
(82.9)
(17.1)
22
3
(88.0)
(12.0)
(2.9)
(45.7)
(51.4)
4
13
8
(16.0)
(52.0)
(32.0)
(20.6)
(23.5)
(55.9)
2
8
14
(8.3)
(33.3)
(58.4)
26
Svavarsdottir, & Hrafnkelsson, 2012a). This questionnaire is based on the

CFAM (Wright & Leahey, 2013). The instrument has a 1 to 5 Likert-type
scoring procedure. On this instrument a higher score reflects better expressive family functioning. The instrument was constructed and developed in
Iceland and has been found to be both valid and reliable (Leahey & Svavarsdottir, 2009). The instrument has been psychometrically tested (Sveinbjarnardottir etal., 2012a), where the Cronbachs alpha of the total scale has been
reported to be .895; for the subscale of (a) Emotional Communication, =
.617; (b) Collaboration and Problem Solving, = .735; (c) Verbal Communication, = .796; and (d) Behavior, = .808. In this sample of Icelandic
families, alpha for the total scale was .851 to .965 at Time 1 and Time 2. For
the subscales in this sample (a) Emotional Communication, = .758 to .909;
(b) Collaboration and Problem Solving, = .717 to .904; (c) Verbal Communication, = .784 to .821; and (d) Behavior, = .824 to .933 at Time 1 and
Time 2.
Disease-Specific QOL Questionnaire. Disease-specific QOL was measured for
parents of children aged 13 to 18, 8 to 12 years, 5 to 7 years, and 2 to 4 years
by the Pediatric QOL (PedsQL) Inventories (25-28 items instruments); the
PedsQL TM 3.0 Asthma Module (28-items); the PedsQL TM 3.0 Diabetic
Module (28-items); and the PedsQL TM 3.0 Cancer Module (27 items; Varni,
1998). The children responded to the original version and parents completed
the adolescents proxy report of this same instrument to rate their perception
of their childs disease-related QOL. In this study, both the parents responses
and the childrens responses will be reported. The items assess a potential
problem with the disease; the 5-point Likert-type responses range from never
a problem to almost always a problem. Items are reverse-scored and rescaled
to range from 0 to 100, with higher scores indicating better QOL. Subscales
for the asthma module include Asthma Problems Within The Last Month (11
items); Treatment Problems Within The Past Month (11 items); Problems
With Worry During The Last Month (3 items); and Problems With Communication During The Last Month (3 items). Subscales for the diabetes module
include: Diabetes Symptoms (11 items); Treatment I Problems (4 items);
Treatment II Problems (7 items); Worry (3 items); and Communication (3
items). Subscales for the cancer module include: Problems With Pain and
Hurt (2 items); Problems With Nausea (5 items); Procedural Anxiety (3
items); Treatment Anxiety (3 items); Worry (3 items); Cognitive Problems (5
items); Perceived Physical Appearance (3 items); and Communication (3
items). The PedsQL TM asthma module has been found to be both reliable
and valid (Varni etal., 2004). Varni and colleagues (2004) found that the
average Cronbachs alpha across the four subscales was .86 for parents of
27
children with asthma. In this Icelandic study, the Cronbachs alpha for the
total scale for parents of children with cancer was .848 to .940; for parents of
children with diabetes the alpha was .830 to .917; and for parents of children
and adolescents with asthma alpha ranged from .883 to .908 over time. For
the children with asthma, diabetes, and cancer, the alpha for the total scales
ranged from .864 to .963 across time.
Analyses
Data were summarized using descriptive analyses, including means, standard
deviations, and frequency distributions. When the data met the assumption
for normal distribution, comparisons of demographic characteristics and
main study variables of family perceived support and expressive family functioning between the two time periods were made using the paired-samples t
test. However, Wilcoxons test was used when the data did not meet the
assumption for normal distribution.
A post hoc power analysis was calculated for paired-samples t test. Based
on the number of participants in the experimental group (n = 35 mothers; 25
fathers; N = 60 parents), with the alpha level set at .05 and the effect size of
0.674 (indicating medium to large effects, signifying that the test is catching
medium to large effect). The power was 0.971, which is high, indicating a
small probability of Type II errors, or a 3% chance of not catching a difference when there is a true difference between the two data collection time
points. Data analyses were conducted using SPSS for Windows version 18.0;
p < .05 was used throughout.
Results
Participants
The children who were admitted or received health care services from the
outpatient clinics at the Childrens Hospital or from the Cancer unit at the
Childrens Hospital at the time of the study were admitted because of the
chronic illness of the children (N = 37; asthma n = 15; diabetes n = 14; cancer
n = 8). Most of the children/adolescents who received the health care service
at the Hospital were pre-teenagers or teenagers between 11 and 18 years of
age (n = 24; 68%); the gender of the children were equally distributed, with
18 girls (51%) and 17 boys (49%). Of the children with cancer, they had been
diagnosed with the illness on average for 7.6 months (range = 3-17 months).
The mean length of time since diagnoses for the children with diabetes was
4.6 years (range = 6 months-7 years), and the average length of time since
28
diagnosis for the children with asthma was 8.5 years (range = 6 months-17
years). All of the children were receiving treatment for the cancer, asthma, or
the diabetes at the time of the study (see Table 1).
Of the parents (N = 60), 35 were females and 25 were males. These parents
belonged to the 37 families who participated in the study. The majority of the
parents ranged in age from 31 to 50 years old (n = 31; 88.0%). Most of the
parents were married or cohabiting with their partner (n = 29; 82.9%). The
majority of the parents had completed either a high school or a university
education (n = 34; 97.1%). Family income ranged in most cases between
US$3,300 to more than US$5,000 a month (401,000 to more than 601,000
Icelandic kronur; n = 27; 79.4; see Table 1).
Effects of the TCI on Parents Perception of Perceived Family

Support and Expressive Family Functioning
Based on the paired-samples t tests for mothers (n = 35) of children with
cancer, diabetes, and asthma, a significant difference was found on perceived
family support after the intervention (T2 M = 45.94, SD = 16.75) compared
with that before the intervention (T1 M = 37.49, SD = 17.55, t value = 3.99,
p value = .000), as well as on the two subscales of cognitive (T2 M = 18.46,
SD = 5.87, T1 M = 15.66, SD = 7.23, t value = 3.49, p value = .001) and
emotional support (T2 M = 27.49, SD = 11.49, T1 M = 21.83, SD = 11.43, t
value = 3.65, p value = .001). Mothers of children with chronic illnesses
perceived significantly higher family support and significantly higher cognitive and emotional support after the intervention (at Time 2) compared with
that before the intervention (at Time 1; see Table 2). Furthermore, when the
mothers expressive family functioning was evaluated, a significant difference was found on the subscale of collaboration and problem solving of the
expressive family functioning scale (T2 M = 21.03, SD = 2.43, T1 M = 20.20,
SD = 3.25, t value = 2.05, p value = .048) after the intervention compared
with that before the intervention. Mothers of children with chronic illnesses
reported significantly higher collaboration and problem-solving abilities
after the intervention compared with that before the intervention. Nevertheless,
there was no significant difference found on the mothers subscales of emotional communication, verbal communication, and behavior, or on the total
scale of expressive family functioning, after the intervention compared with
that before the intervention (see Table 2).
For the fathers of children with chronic illnesses (n = 25), no significant
differences were found on their perceived family support or on their expressive family functioning after the intervention compared with that before the
intervention. Fathers of children with chronic illnesses did not perceive
29
*p < .05. **p < .01. ***p < .001.
Mothers (n = 35)
Family support
Cognitive support
Emotional support
Expressive family functioning
Emotional communication
Collaboration and problem solving
Verbal communication
Behavior
Fathers (n = 25)
Family support
Cognitive support
Emotional support
Behavior
Variables
17.55
7.23
11.43
8.58
1.99
3.25
2.79
2.82
13.15
5.55
8.89
7.55
2.48
3.55
2.44
2.13
44.00
18.20
25.80
64.88
15.76
18.72
15.12
15.28
SD
37.49
15.66
21.83
69.11
17.00
20.20
15.71
16.20
Pre-intervention
44.60
17.52
27.08
66.36
15.64
19.68
14.80
16.24
45.94
18.46
27.49
70.94
17.06
21.03
16.14
16.71
17.87
5.88
12.58
11.47
3.20
3.45
2.53
3.13
16.75
5.87
11.49
7.16
1.73
2.43
2.61
2.27
SD
Post-intervention
0.22
0.64
0.64
0.86
0.23
1.30
0.72
1.88
3.99
3.49
3.65
1.85
0.16
2.05
1.09
1.41
t tests
Table 2.Paired-Samples t Tests For Mothers (n = 35) and Fathers (n = 25), Pre- and Post-Intervention, of Children and
Adolescents With Chronic Illnesses (Cancer, Diabetes, and Asthma).
.827
.529
.527
.398
.824
.204
.480
.073
.000
.001
.001
.074
.874
.048
.282
.168
p value
30
significantly higher family support or significantly higher expressive family

functioning after the intervention compared with that before the intervention.
As a result, Hypothesis (a) was partly supported (see Table 2).
We further evaluated the impact of the TCI based on the type of disease
that the child or the adolescent was diagnosed with. For mothers of children
with cancer (n = 7), a significant difference was found on perceived family
support (T2 median = 54.00, T1 median = 38.00, z = 2.20, p value = .028),
as well as on both subscales of cognitive (T2 median = 18.00, T1 median =
12.00, z = 2.04, p value = .041) and emotional support (T2 median = 33.00,
T1 median = 23.00, z = 2.03, p value = .042) of the family support scale
after the intervention compared with that before the intervention. A significant difference was also reported by mothers of children with cancer on
expressive family functioning after the intervention (total score; T2 median =
68.00, T1 median = 59.00, z = 2.21, p value = .027). Mothers of children and
adolescents with cancer perceived significantly higher family support and
perceived significantly higher expressive family functioning after the intervention compared with that before the intervention (see Table 3). However,
for the fathers of children and adolescents with cancer (n = 8), there was no
significant difference on perceived family support found after the intervention compared with that before the intervention. Nevertheless, there was a
significant difference found after the intervention on the fathers collaboration and problem-solving subscale of the expressive family functioning scale
(T2 median = 20.00, T1 M = 17.00, z = 2. 04, p value = .042). Fathers of
children and adolescents with cancer reported significantly higher collaboration and problem-solving capabilities after the intervention compared with
that before the intervention. Furthermore, when the mothers and the fathers
perception of their childrens cancer-specific QOL (proxy rapport) was evaluated, as well as the childrens own perception on their QOL because of the
cancer situation, no significant differences were found on the parents perception or on the childrens own perception of their cancer-related QOL after
the intervention compared with that before the intervention. Hypothesis
(b) was therefore partly supported (see Table 3).
On the other hand, for the parents of children and adolescents with diabetes, no significant differences were found on the parents perception on their
family support or on their perception of expressive functioning after the intervention compared with that before the intervention. Both the mothers (n = 13)
and the fathers (n = 11) of children and adolescents with diabetes did not
report significant difference on their perception of family support or on their
perception of expressive family functioning after the therapeutic conversation intervention compared with that before the intervention. Nevertheless,
regarding the mothers perception on their childrens diabetes-related QOL, a
31
Median
38.00
12.00
23.00
59.00
14.00
18.00
16.00
14.00
60.60
50.00
50.00
29.17
62.50
100.00
54.17
54.17
54.17
Variables
Mothers
Family support (n = 7)
Cognitive support
Emotional support
Expressive family functioning (n = 7)
Behavior
Cancer quality of life (n = 6)
Problems with pain and hurt
Problems with nausea
Procedural anxiety
Treatment anxiety
Worry
Cognitive problems
Perceived physical appearance
Communication
19.00
9.00
15.00
36.00
8.00
13.00
8.00
12.00
32.00
75.00
75.00
100.00
66.67
66.67
56.67
100.00
66.67
Range
Pre-intervention
54.00
18.00
33.00
68.00
16.00
20.00
17.00
16.00
52.00
62.50
45.00
33.33
50.00
83.33
50.00
70.83
58.33
Median
27.00
15.00
19.00
23.00
5.00
10.00
6.00
6.00
49.00
50.00
80.00
100.00
100.0
66.67
58.33
83.33
66.67
Range
Post-intervention
2.20
2.04
2.03
2.21
1.89
1.78
1.76
1.47
0.11
0.32
0.27
1.07
1.34
0.18
0.55
0.32
0.00
Wilcoxons test (z)
.028
.041
.042
.027
.058
.075
.078
.141
.916
.761
.785
.285
.180
.854
.581
.748
1.000
p value
(continued)
Test-statistics
Table 3. Wilcoxons Tests for Mothers (n = 7) and Fathers (n = 8) of Children and Adolescents With Cancer and for the
Children (n = 3), Pre- and Post-Intervention.
32
Fathers
Family support (n = 8)
Cognitive support
Emotional support
Expressive family functioning (n = 8)
Behavior
Cancer quality of life (n = 7)
Procedural anxiety
Treatment anxiety
Worry
Cognitive problems
Communication
Variables
Table 3. (continued)
37.50
15.00
22.00
62.50
15.00
17.00
15.50
14.50
60.19
37.50
50.00
25.00
41.67
75.00
66.67
58.33
50.00
Median
31.00
12.00
21.00
15.00
6.00
14.00
6.00
5.00
44.81
75.00
80.00
75.00
58.33
83.33
60.00
100.00
100.00
Range
Pre-intervention
43.50
15.00
28.00
66.50
16.50
20.00
15.00
16.00
52.00
37.50
45.00
41.67
58.33
66.67
75.00
66.67
66.67
Median
41.00
15.00
31.00
26.00
8.00
10.00
5.00
5.00
61.00
87.50
80.00
100.0
91.67
100.00
50.00
83.33
100.00
Range
Post-intervention
0.51
0.42
1.19
1.68
0.53
2.04
1.56
1.62
0.41
0.51
0.81
0.74
0.27
0.31
0.14
0.73
0.68
Wilcoxons test (z)
.612
.673
.231
.093
.596
.042
.119
.105
.680
.611
.071
.458
.786
.753
.888
.465
.499
p value
(continued)
Test-statistics
33
*p < .05.
Children (n = 3)
Cancer quality of life
Procedural anxiety
Treatment anxiety
Worry
Cognitive problems
Communication
Variables
46.30
50.00
30.00
33.33
66.67
41.67
45.00
25.00
50.00
Median
28.70
25.00
25.00
100.00
8.33
50.00
15.00
83.33
91.76
Range
Pre-intervention
44.44
62.50
20.00
33.33
75.00
41.67
55.00
25.00
58.33
Median
50.93
50.00
70.00
100.00
66.67
50.00
30.00
83.33
75.00
Range
Post-intervention
0.54
0.27
0.54
0.00
0.00
0.00
0.27
0.00
0.58
Wilcoxons test (z)
Test-statistics
.593
.785
.593
1.000
1.000
1.000
.785
1.000
.564
p value
34
significant difference was found regarding the mothers perception on the

subscale of diabetes symptoms after the intervention compared with that
before the intervention (T2 median = 63.64, T1 median = 65.91, z = 2.73,
p value = .015), indicating that the mothers reported significantly higher diabetes symptoms after the intervention compared with that before the intervention. In contrast, no significant difference was found on the fathers
perception or on the childrens perception on their diabetes health-related
QOL after the intervention compared with that before the intervention.
Hence, Hypothesis (b) was partly supported (see Table 4).
For the mothers of children and adolescents with asthma (n = 15), a significant difference was found on their perceived family support (T2 median
= 31.00, T1 median = 18.00, z = 2.86, p value = .004), as well as on the
subscales of cognitive (T2 median = 15.00, T1 median = 9.00, z = 2. 45, p
value = .013) and emotional support (T2 median = 16.00, T1 median =
9.00, z = 2.50, p value = .012) after the TCI compared with that before the
intervention. Mothers of children and adolescents with asthma perceived
significantly higher family support after the intervention compared with
that before the intervention. However, there was no significant difference
found on the mothers expressive family functioning after the intervention
compared with that before the intervention (see Table 5). In spite of the
findings for the mothers, the fathers of children and adolescents with
asthma (n = 6) did not report significant difference on their perception of
family support or on their expressive family functioning. But a significant
difference was found on fathers perception of their childrens asthmarelated QOL after the intervention (T2 median = 77.23, T1 median = 84.82,
z = 1.997, p value = .046), indicating that the fathers reported significantly
lower asthma-related QOL after the intervention compared with that before
the intervention. Nevertheless, the children with asthma reported significantly lower asthma symptoms after the intervention compared with that
before the intervention (T2 median = 77.27, T1 median = 72.73, z = 2.014,
p value = .044), indicating that after the intervention children and adolescents with asthma perceived their asthma symptoms to be significantly better compared with that before the intervention. Thus, Hypothesis (b) was
partly supported (see Table 5).
Childrens Perspective of Their Disease-Related QOL After the

Intervention
Interestingly, when disease-specific QOL was evaluated among the children
and the adolescents after the TCI that their parents received, only the children
35
Mothers (n = 13)
Family support
Cognitive support
Emotional support
Behavior
Diabetes quality of life
Diabetes symptoms
Treatment I problems
Treatment II problems
Worry
Communication
Fathers (n = 11)
Family support
Cognitive support
Emotional support
Variables
45.00
14.00
34.00
16.00
5.00
9.00
11.00
7.00
46.30
47.73
66.67
42.86
66.67
75.00
25.00
10.00
11.00
52.00
24.00
31.00
Range
52.00
23.00
29.00
72.00
17.00
22.00
16.00
17.00
70.37
65.91
75.00
71.43
66.67
58.33
Median
Pre-intervention
58.00
24.00
34.00
57.00
23.00
32.00
74.00
17.00
22.00
15.00
16.00
63.89
63.64
75.00
71.43
66.67
66.67
Median
40.00
11.00
29.00
29.00
9.00
22.00
20.00
5.00
6.00
10.00
7.00
51.85
54.55
58.33
60.71
91.67
83.33
Range
Post-intervention
1.16
0.95
1.63
1.18
0.31
1.49
0.32
0.18
0.77
0.18
0.21
1.22
2.42
1.35
0.52
0.72
0.45
Wilcoxons test (z)
(continued)
.247
.344
.102
.239
.759
.136
.753
.857
.442
.857
.837
.223
.015
.176
.607
.472
.653
p value
Table 4. Wilcoxons Tests for Mothers (n = 13) and Fathers (n = 11) of Children and Adolescents With Diabetes and for the
36
*p < .05.

Behavior
Diabetes symptoms
Worry
Communication
Children (n = 13)
Diabetes symptoms
Worry
Communication
Variables
30.00
9.00
9.00
9.00
8.00
25.00
34.09
50.00
39.29
25.00
50.00
86.61
79.55
100.00
100.00
100.00
100.00
72.32
68.18
75.00
85.71
75.00
66.67
Range
61.00
15.00
19.00
15.00
15.00
73.15
68.18
83.33
82.14
66.67
66.67
Median
Pre-intervention
74.11
59.09
81.25
85.71
75.00
83.33
68.00
16.00
21.00
15.00
17.00
74.07
65.91
66.67
82.14
75.00
75.00
Median
93.75
90.91
100.00
100.00
100.00
100.00
56.0 0
14.00
16.00
13.00
13.00
30.56
31.82
66.67
42.86
50.00
41.67
Range
Post-intervention
0.55
0.13
0.27
0.26
0.28
1.75
0.71
0.00
0.88
0.66
1.27
0.31
0.72
0.49
0.09
1.10
1.56
Wilcoxons test (z)
.583
.893
.788
.796
.777
.080
.475
1.000
.383
.510
.205
.759
.474
.622
.931
.273
.119
p value
37
Mothers (n = 15)
Family support
Cognitive support
Emotional support
Behavior
Asthma quality of life
Asthma symptoms
Treatment problems
Worry
Communication
Fathers (n = 6)
Family support
Cognitive support
Emotional support
Variables
56.00
20.00
36.00
32.00
5.00
9.00
10.00
10.00
40.18
59.09
45.45
50.00
83.33
43.00
16.00
33.00
35.00
16.00
20.00
Range
18.00
9.00
9.00
71.00
17.00
21.00
17.00
16.00
75.00
68.18
81.82
91.67
75.00
Median
Pre-intervention
24.00
14.00
9.50
31.00
15.00
16.00
67.00
17.00
21.00
16.00
17.00
81.25
75.00
77.27
91.67
83.33
Median
46.00
14.00
32.00
56.00
20.00
36.00
29.00
5.00
9.00
9.00
8.00
40.18
56.82
45.45
75.00
75.00
Range
Post-intervention
0.31
1.17
0.68
2.86
2.45
2.50
0.04
1.56
0.86
0.42
0.85
0.66
1.79
0.59
0.26
1.53
Wilcoxons test (z)
(continued)
.753
.244
.500
.004
.013
.012
.969
.118
.389
.672
.396
.509
.074
.550
.796
.126
p value
Table 5. Wilcoxons Tests for Mothers (n = 15) and for Fathers (n = 6) of Children and Adolescents With Asthma and for the
38
43.75
47.73
36.36
58.33
75.00
79.46
72.73
88.64
91.67
83.33
*p < .05.
22.00
6.00
7.00
7.00
4.00
13.39
25.00
18.18
25.00
91.67
65.00
16.00
22.50
14.50
15.00
84.82
81.82
81.82
91.67
70.83

Behavior
Asthma symptoms
Treatment problems
Worry
Communication
Children (n = 15)
Asthma symptoms
Treatment problems
Worry
Communications
Range
Median
Pre-intervention
Variables
85.71
77.27
90.91
100.00
83.33
66.00
15.50
19.50
15.50
16.00
77.23
70.45
79.55
91.67
50.00
Median
47.32
54.55
40.91
66.67
83.33
26.00
8.00
9.00
5.00
7.00
21.43
34.09
29.55
25.00
100.00
Range
Post-intervention
1.48
2.01
0.78
0.24
0.58
1.27
1.34
1.51
0.14
0.71
1.99
1.89
1.17
0.00
0.14
Wilcoxons test (z)
.140
.044
.438
.809
.560
.206
.180
.131
.891
.480
.046
.058
.244
1.000
.892
p value
39
and adolescents with asthma were found to have reported significantly lower
asthma symptoms after the TCI with their parents compared with that before
the intervention (see Tables 3-5).
Gender Differences
To evaluate gender difference between the parents, a difference score was
created between pre- and post-scoring among the 23 pairs (couples) of parents of children or adolescents with chronic illnesses who belonged to the
same family. That is, a difference score was created for the 23 mothers and
another difference score was created for the 23 fathers who belonged to the
same family, based on their pre- and post-scores. In this way, a pairedsample t test (on the mean difference score) was used to test the significance
of difference between the genders on perceived family support and on the
parents expressive family functioning. Interestingly, a significant difference
was found between the mothers and the fathers mean difference scores on
their perceived family support (Mothers M difference score = 9.22, SD =
10.23; Fathers M difference score = 0.04, SD = 13.58, t value = 2.97,
p value = .007), as well as on the subscales of cognitive (Mothers M difference score = 3.09, SD = 3.94; Fathers M difference score = 1.09, SD =
4.94, t value = 3.71, p value = .001) and emotional support (Mothers
M difference score = 6.13, SD = 8.31; Fathers M difference score = 1.13,
SD = 10.28, t value = 2.10, p value = .047). Compared with the fathers in
these families, the mothers scored significantly higher on their perception of
family support and on the subscales of cognitive and emotional support.
Similarly, the mothers also scored significantly higher on their perception of
verbal communication, which is a subscale of the expressive family functioning scale, compared with the fathers in these families (Mothers M difference score = 1.17, SD = 1.83; Fathers M difference score = 0.44, SD =
2.29, t value = 2.76, p value = .011). The mothers perceived the verbal communication in their families to be significantly better than did the fathers
(see Table 6).
Discussion
Evidence-based TCI can support families in caring for their children or adolescents with chronic illnesses and may advance clinical practices and health
care services for the families. Developing a family strengths-oriented intervention that focuses mainly on assisting family members to discover new
solutions to help diminish and ease emotional, physical, and spiritual suffering can contribute to strengthening, promoting, and/or sustaining effective
40
9.22
3.09
6.13
3.00
0.22
1.00
1.17
0.61
Difference score (pre/post)

Family support
Cognitive support
Emotional support
Behavior
*p < .05. **p < .01.
Variables
10.23
3.94
8.31
6.21
2.76
2.73
1.83
2.27
SD
Mothers (n = 23)
0.04
1.09
1.13
1.00
0.13
0.74
0.44
0.83
M
13.58
4.94
10.28
8.76
2.77
3.73
2.29
2.62
SD
Fathers (n = 23)
2.97
3.71
2.10
1.14
0.48
0.38
2.76
0.30
t tests
.007
.001
.047
.277
.638
.711
.011
.765
p value
Table 6.Paired-Samples t Tests Based on the Difference in Scoring Pre- and Post-Intervention (M Difference Score) by the
Parents Gender (n = 23).
41
family functioning. Interestingly, in this study, mothers of children with

chronic illness reported significantly higher family support as well as significantly higher cognitive and emotional support after the TCI compared with
that before the intervention. Knowing that the mothers experienced that the
study nurses offered them needed information and their professional opinion
regarding their childs disease, informed about available resources, offered
family meetings, helped family members recognize their emotional response,
encouraged family members to share their illness narratives/stories, and
looked for the family strength, is of great value in clinical practice, when
offering advanced health care services to families, dealing with long-term
and chronic health condition of a child family member. Furthermore, these
mothers were also found to report significant increase on the subscale of collaboration and problem solving of the expressive family functioning scale
after the intervention. Thus, the mothers of children with chronic illnesses
experienced their family to be better at dealing with problems after the intervention; they were more aware of how the relationships within the family
changed and developed after problems had been solved; and they were more
mindful of who would notice the impact on the family of working together as
a team instead of competing. These findings on the added benefit for the
mothers and of the two-session FAM-TCI are in harmony with findings
reported by Kazak etal. (2005), who found that working on identifying and
changing beliefs about the disease and focusing on family relations enhanced
family functioning and was of benefit to the primary caregivers of children
with cancer. Further, the findings on the benefit of the two session FAM-TC
intervention for the mothers in this study of children with chronic illnesses
are also in harmony with our earlier findings regarding the benefits of the
two-to-three session FAM-TC intervention for primary caregivers of children
newly diagnosed with cancer, as well as with the benefits for mothers in our
experimental group of children/teenagers with asthma, who were found to
score significantly higher on perceived family support after a two session
FAM-TC intervention, compared to the mothers of children with asthma in
the control group who received treatment as usual.
The findings regarding the benefit for the mothers in this study are however, in contrast with the findings reported by Stehl etal. (2009), who, in a
RCT study, did not find any benefit of a three-session intervention for caregivers of children newly diagnosed with cancer when the caregivers stress
level and their state of anxiety was evaluated and compared with the group of
caregivers who received treatment as usual. The findings by Stehl and colleagues are nevertheless in agreement with the findings reported by the
fathers of children with chronic illnesses in our study, but we did not find any
42
difference in the fathers perception on family support after the intervention

compared with that before the intervention.
The effectiveness of the FAM-TCI was evaluated further based on the
childrens type of disease. The mothers of children with cancer reported significantly higher family support and significantly higher cognitive and emotional support after the intervention compared with that before the intervention.
Furthermore, these mothers also reported significantly higher expressive
family functioning after the intervention compared with that before. However,
fathers of children with cancer only reported significantly better collaboration and problem solving on the expressive family functioning scale after the
intervention. These benefits of the two-session FAM-TCI for parents of children newly diagnosed with cancer are impressive. Being aware of when family members express their feelings and knowing the effect this expression
will have on other family members when family members say what they
really mean puts an emphasis on the importance of the core elements in the
FAM-TCI, which focuses on helping caregivers and families to cope with and
adapt to their childrens cancer situation by drawing on the families strengths.
Recognizing that both mothers and fathers of children with cancer may
benefit from the brief FAM-TCI, in such a way that both parents are experiencing better family functioning after the intervention and where the fathers
are specifically experiencing better collaboration and problem solving, is
important new knowledge for pediatric cancer nurses. Offering health care
services that are focused on maintaining and/or improving family functioning
is needed and gives nurses in advanced cancer practices the opportunity to
support and contribute to helping families to deal effectively with the oftentimes painful, vulnerable, and critical situation in family life. These findings
on the benefit of the FAM-TCI on family functioning for parents of children
with cancer are also in congruence with Wright and Leaheys (2013) emphasis on the evidence that well-functioning families are important resources
when dealing with chronic diseases. In addition, these findings are in agreement with Vollrath and colleagues (2010), who pointed out in a study on
newly hospitalized children with cancer or diabetes that being involved,
open, and alert influenced the parents family functioning.
However, there were no significant differences found among mothers and
fathers of children and adolescents with diabetes either on the parents perceived support or on the parents expressive family functioning after the
FAM-TCI compared with that before the intervention. One explanation for
the lack of significant difference after the FAM-TCI is the length of time
since diagnosis: These parents had been caring for their children or adolescents with diabetes on average for close to 5 years, and were already evaluating their family support to be very high before the intervention. Furthermore,
43
when the parents perception on their childrens QOL was evaluated, the
mothers of children or adolescents with diabetes were found to report their
childrens diabetes symptom on the QOL scale to be significantly worse after
the intervention compared with that before the intervention. Symptom management is oftentimes challenging in the teenage years, but most of the children with diabetes were in the pre-adolescent or adolescent age range at the
time of the study. As the mothers evaluated their adolescents to have significantly more diabetes symptoms post-intervention, the content of the intervention for this group of parents might have needed to focus more on diabetes
symptom management in the pre-adolescent or the adolescent years. Another
explanation for the lack of significant difference post-intervention is the fact
that the intervention might not have met these parents needs or that the duration and intensity of the intervention was not long enough. Also, the parents
might have needed a different type of intervention, or we might have needed
a bigger sample size to be able to capture a change. Nevertheless, there was a
near five-unit increase in the mothers score and a three-unit increase in the
fathers score on perceived family support post-intervention, indicating that
both parents perception on their perceived family support was in the direction of benefitting the parents. Furthermore, their expressive family functioning score was maintained after the intervention despite the fact that the
mothers reported significantly higher diabetes symptoms post-intervention
compared with that before the intervention. Sustaining the level of family
functioning despite increased diabetes symptoms in the child may be valuable to the families. Further studies are however needed with a follow-up
measures design, regarding testing the effectiveness of the FAM-TCI for
families of children or adolescents with diabetes.
On the other hand, for parents of children or adolescents with asthma,
mothers were found to report significantly higher perceived family support
and significantly higher cognitive and emotional support after the FAM-TCI
compared with that before the intervention. However, there were neither, differences on the mothers expressive family functioning scale nor on their
perception of their childrens asthma-related QOL post-intervention. For the
fathers of children with asthma, no difference was found on their perceived
family support or on their expressive family functioning post-intervention
compared with that pre-intervention. However, the fathers of children with
asthma reported significantly lower asthma-related QOL for their children
after the intervention compared with that before the intervention. When the
childrens perception on their own asthma-related QOL was evaluated, a significant decrease was found in their perception on their asthma symptoms
after their parents had received the FAM-TCI compared with that before
the intervention. These children perceived their asthma symptoms to be
44
significantly lower after their parents received the FAM-TCI compared with
that before the intervention. These findings are encouraging and need to be
explored further with a bigger sample size and where the impact of one family member measure can be evaluated in relation to the outcome measure by
another family member, such as by using the actorpartner interaction analyzes modeling. Nevertheless, if the two-sessions FAM-TCI is perceived by
the mothers of children with asthma to be supportive, even though they have
been dealing with the asthma situation in their child and their adolescent on
average for over 8 years; it may be concluded that the core elements of the
FAM-TCI such as establishing therapeutic relationships, using therapeutic
questions, and empowering families, are needed and perceived as helpful for
these mothers, when dealing with the asthma situation in their pre-teenagers
or teenagers on a daily basis.
One of the findings that is of special interest to advanced nurses practitioners and to health care professionals in general who are working with families of children and adolescents with cancer, diabetes, and asthma are the
gender differences that were found in this study. The pairs of parents of
children with chronic illnesses, who participated in this study, were found to
differ significantly based on the gender of the parent. The mothers of these
children were found to report significantly higher difference score on their
perceived family support and on their cognitive and emotional scores, compared with the fathers in these families. Furthermore, the mothers were also
found to report significantly higher difference score on the verbal communication subscale of the expressive family functioning scale compared with
the fathers in the families. This finding in our study on the gender difference
in families of children with chronic illnesses was unexpected. Kazak and
colleagues (2005) found in a three-session family-level intervention study
focusing on cancer treatment and its impact on the family, that the intervention benefited both the primary caregiver, who usually was the mother, as
well as her partner when post-traumatic stress symptoms and state anxiety,
over time, were evaluated. Nevertheless, no study was found that evaluated
the benefit of a therapeutic conversation intervention on the outcome of perceived family support or on expressive family functioning. One might however argue, that for families of children newly diagnosed with cancer and for
families of pre-adolescents and adolescents with diabetes and asthma, that
the mothers in the family, who oftentimes are the primary caregiver, might
benefit more from an intervention that is geared toward family support and
focuses on expressive emotional responses. Further studies are needed
regarding how the FAM-TCI might benefit fathers in the long run as they
may contribute over time, through having participated in the intervention, to
the functioning of their family.
45
Study Limitations
The sample size of the FAM-TCI study was small and the design of the study
was one-group pre post-test, with no control group, which limits the generalizability of the study. The findings may therefore not generalize to other
countries or to other health care situations. However, the content of the FAMTCI was theory driven (based on the Calgary Family Assessment and
Intervention Models) and can therefore provide a framework for future
research.
Conclusion
Relational practices are on its rise, especially within pediatrics, where
advanced practice nurses caring for children and adolescents with chronic
illnesses need to establish a collaborative relationship with parents or other
primary caregivers, to be able to offer quality and evidence-based health care
services. In that light, the main findings from the hypotheses testing in this
study are of great value to clinicians, who oftentimes need to justify for themselves well as to their administrators, the need and/or importance of offering
families in the clinic, structured family meetings. The findings are also of
great importance to the families of children with chronic illnesses, especially
to the mothers of children and adolescents with cancer and asthma. These
mothers need to be given an opportunity to reflect on how they are handling
their caregiving activities and benefit from support and professional opinions
regarding managing and coping with the illness situation on a daily basis. We
are optimistic about the added benefits of the two-session theory-driven
FAM-TCI for families of children and adolescents with chronic illnesses.
However, the intervention needs to be tested further with larger samples and
in different health care settings.
Acknowledgments
We would like to thank all the children and adolescents and their families who participated in this studywe learned so much from their experience and participation. We
would also like to thank the nurses at the Childrens Hospital at Landspitali University
Hospital (LUH), Iceland who participated in the data collection as well as in offering
the interviews to the families for their valid and important contribution. We would like
to especially thank Elisabeth Konradsdottir for participating in the data collection and
for offering the interviews to the families at the diabetes pediatric outpatient clinics.
We would also like to thank Maria Gudnadottir and Tonie G. Srensen, for participating by offering intervention to the families at the asthma outpatient pediatric clinic.
Thanks are also due to Sigrun Thoroddsdottir for offering intervention with one of our
team members to families from the day care cancer unit at the Childrens Hospital.
46
Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: The study received funds from the
Landspitali University Hospital (LUH) Scientific Fund.
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Author Biographies
Erla Kolbrun Svavarsdottir, RN, PhD, is a professor and academic chair of family
nursing at the Faculty of Nursing, University of Iceland (UI) and at Landspitali
University Hospital (LUH). During the past decade, she has collaborated on national
and international research focused on families of children with asthma. She has also
collaborated with Icelandic researchers on Family Systems Nursing (FSN) research
projects regarding families of children and adolescents with cancer, asthma, diabetes,
anorexia and bulimia, and attention-deficit hyperactive disorder (ADHD). Her current
research links quality of life with family experiences of violence, childhood chronic
illness, and adolescents with cancer. She served as the co-chairperson of the committee in charge of implementing FSN at all clinical units at the LUH during the years
2007 to 2011 in collaboration with Anna Sigurdardottir (co-chairperson) and other
members of the implementation team for the Landspitali University Hospital Family
Nursing Implementation Project (2007-2011). She was also in charge of developing
and designing research projects for clinical nurse specialists at LUH and for graduate
nursing students at the UI from the LUH Family Nursing Implementation Project
(2007-2011). She received an Innovative Contribution to Family Nursing Award from
the Journal of Family Nursing in 2005. Her recent publications include Benefits of a
Brief Therapeutic Conversation Intervention for Families of Children and Adolescents
50
in Active Cancer Treatment in Oncology Nursing Forum (2013, with E. K.

Svavarsdottir & A. O. Sigurdardottir), Knowledge Translation in Family Nursing:
Does a Short-Term Therapeutic Conversation Intervention Benefit Families of
Children or Adolescents Within a Hospital Setting? Findings From the Landspitali
University Hospital Family Nursing Implementation Project in Journal of Family
Nursing (2012, with E. K. Svavarsdottir, G. B. Tryggvadottir, & A. O. Sigurdardottir),
and The International School Nurse Asthma Project: Barriers Related to Asthma
Management in Schools in Journal of Advanced Nursing (2012, with E. K.
Svavarsdottir, A. W. Garwick, L. S. Anderson, W. S. Looman, & B. Orlygsdottir).
Anna Olafia Sigurdardottir, RN, MSN, is a clinical nurse specialist at the LUH in
Iceland, and a PhD student at the Faculty of Nursing, UI. During the last decade, she
has been in nursing administration as a nurse manager and a nursing director of pediatrics at the LUH and a clinical assistant professor at the LUH and UI. She served as
a co-chairperson of the committee in charge of implementing FSN at all clinical units
at the LUH during the years 2007 to 2011 in collaboration with Dr. Svavarsdottir (cochairperson) and other members of the implementation team for the LUH Family
Nursing Implementation Project (2007-2011). She was in charge of the implementation committee located at the LUH. She received an Innovative Contribution to
Family Nursing Award from the Journal of Family Nursing in 2009. Her clinical and
research interests focus on FSN, pain intervention, and parental and job satisfaction.
She is collaborating with Icelandic researchers on intervention research projects
regarding families of children and adolescents with chronic illnesses. Her recent publications include, Benefits of a Brief Therapeutic Conversation Intervention for
Families of Children and Adolescents in Active Cancer Treatment in Oncology
Nursing Forum (2013, with E. K. Svavarsdottir & A. O. Sigurdardottir), Therapeutic
Conversations Intervention in Pediatrics: Are They of Benefit for Families of Children
With Asthma? in Nursing Clinics of North America (2013 with A. O. Sigurdardottir,
E. K. Svavarsdottir, M. K. Rayens, & S.Adkins), and Knowledge Translation in
Family Nursing: Does a Short-Term Therapeutic Conversation Intervention Benefit
Families of Children or Adolescents Within a Hospital Setting? Findings From the
Landspitali University Hospital Family Nursing Implementation Project in Journal
of Family Nursing (2012 with E. K. Svavarsdottir, G. B. Tryggvadottir, & A. O.
Sigurdardottir).
Gudny Bergthora Tryggvadottir, MSc, is the project manager at the Institute of
Nursing Research at UI. She holds an MSc in social research methods from The
London School of Economics with a focus on Health and Population. Prior to joining
the Institute of Nursing, she was a project manager in the Department of Statistics and
School Registry at the Education Body of Reykjavik Council. Her recent publications
include Knowledge Translation in Family Nursing: Does a Short-Term Therapeutic
Conversation Intervention Benefit Families of Children or Adolescents Within a
Hospital Setting? Findings From the Landspitali University Hospital Family Nursing
Implementation Project in Journal of Family Nursing (2012 with E. K. Svavarsdottir,
G. B. Tryggvadottir, & A. O. Sigurdardottir).

Journal of Family Nursing 2014 Svavarsdottir 13 50

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520345

JFNXXX10.1177/1074840713520345Journal of Family NursingSvavarsdottir et al.

Journal of Family Nursing

Erla Kolbrun Svavarsdottir, RN, PhD1,2, Anna

of Iceland, Reykjavik, Iceland

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Journal of Family Nursing 20(1)

Globally, current economic constrains in health care have the potential to

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Therefore, to offer quality and effective health care to families of children

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Journal of Family Nursing 20(1)

Landspitali University Hospital, 2011), few studies have been published

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It is well known that family caregivers constitute the core of long-term

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Journal of Family Nursing 20(1)

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Hypotheses and Research Questions

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Journal of Family Nursing 20(1)

Research Question 2: Are there significant gender differences between

Description of the FAM-TCI

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Journal of Family Nursing 20(1)

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Procedure for Data Collection

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Journal of Family Nursing 20(1)

introduced to the study (10 families of children with cancer, 15 families of

Data Collection Tools

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7.6 months (3-17 months)

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Journal of Family Nursing 20(1)

Svavarsdottir, & Hrafnkelsson, 2012a). This questionnaire is based on the

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Journal of Family Nursing 20(1)

Effects of the TCI on Parents Perception of Perceived Family

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*p < .05. **p < .01. ***p < .001.

Journal of Family Nursing 20(1)

significantly higher family support or significantly higher expressive family

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Wilcoxons test (z)

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Wilcoxons test (z)

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Wilcoxons test (z)

Journal of Family Nursing 20(1)

significant difference was found regarding the mothers perception on the

Childrens Perspective of Their Disease-Related QOL After the

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Wilcoxons test (z)

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Expressive family functioning

Wilcoxons test (z)

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Wilcoxons test (z)

p < .05. p < .01. p < .001.