District nursing and family/whanau assessment practices: A New Zealand study

Abstract Aim District Nurses apply specialized nursing knowledge and assessment skills to provide care in New Zealand communities. This study aimed to identify whether District Nurse's (both Registered and supervised Enrolled Nurse's) had knowledge of, and used the 15‐Minute Interview tool, including Ecomaps/Genograms, and if not, what they saw as enablers or barriers to doing so. Design Participatory action research was used, following the phases of look, think and act. Methods Two pre‐intervention focus groups occurred, two education sessions which introduced the 15‐Minute Interview and four postintervention interviews which explored the use of the tools and their potential use in the future. Results District Nurses demonstrated working with families, and the selection of when and where to apply the 15‐Minute Interview.


| INTRODUC TI ON
Core to DN is the engagement of the nurse with the individual and the family unit. This requires the capacity to gather and share information, and effective documentation and communication within the DN team. Integral to DN documentation and care planning is an effective assessment process. One such process is the Calgary Family Assessment Model (CFAM), developed by Wright and Leahey (2013) reflecting the "ever changing and evolving relationship" between families and the nurses they work with (p. xiv). This model encourages a relational approach to family nursing, enabling nurses to connect across differences, highlighting issues of meaning, experience, race, history, culture and health, with socio-political systems often emphasized (Doane & Varcoe, 2015;Robinson, 2019). This model enables nurses to attend to the lived experience of the family in their context, recognizing that relationships between patients, families and healthcare providers are central to patient and family care (Bell, 2013).
The CFAM provides a framework that captures the psychosocial context; creating linkages between the cause of the health problem, family members' beliefs, family dynamics and relationships with health professionals (Duhamel et al., 2015). In an increasingly pressured work environment, nurses are often time poor. Wright and Leahey stated that "family nursing can be effectively, skilfully and meaningfully practiced in just 15 min or less" (Shajani & Snell, 2019, p. 255).
The DN study presented here replicates earlier research undertaken with Public Health Nurses; both centred on introduction of the 15-Minute Interview, part of the CFAM (Yarwood et al., 2016).
The current study population was drawn from nurses working for a DN agency. Potential participants were 36 registered nurses (RNs) undertaking general DN duties, and 13 enrolled nurses (EN, a second-level registration, under the supervision of RNs). Within this article, when the term DN is used in relation to study participants, this refers to both the registered and supervised enrolled nurses providing health care in the community.

| BACKG ROU N D
DNs utilize a restorative model of care, which aims to maximize self-care ability, improving quality of life and self-esteem with the intent of maintaining optimal functional ability (Senior et al., 2014;Walker et al., 2013). They typically incorporate a socio-ecological approach to nursing care, based on a holistic, social, and environmental perspective of health, recognizing that social determinants of health may have more impact than medical care on overall health outcomes (McMurray & Clendon, 2015). As part of this approach, DNs acknowledge family members as an integral part of the healthcare team, emphasizing therapeutic conversations as part of this approach (Beierwaltes et al., 2020).

| Family and family nursing
The concept of family nursing has developed over the past 20 years, yet research suggests there are still issues in nursing care provision (Bell, 2018;Østergaard et al., 2020). This is due to a variety of factors, including the individual nurse's capacity and knowledge, and structural arrangements in the health system (Eggenberger & Regan, 2010). The definition of family is commonly acknowledged as being "who they [the patient] say they are" (Shajani & Snell, 2019, p. 55). Effective nursing care requires inclusion of the wider family, not only the individual receiving care (Arabiat et al., 2018). Use of a clear conceptual framework encourages the synthesis of data so that family strengths and problems can be identified, and an appropriate nursing plan devised (Shajani & Snell, 2019, p. xiii).

| The 15-Minute Interview
Wright and Leahey, authors of the CFAM, state the experience of health and illness is a family affair (2013). The 15-Minute Interview was developed as a practical family-centred approach to determine appropriate health care in a time constrained environment. The five components of the 15-Minute Interview are outlined in Table 1.
The 15-Minute Interview provides a flexible guide for the nurse, embedded in family nursing and relational practice principles, to conduct a family health assessment. The first element is the therapeutic conversation, where all conversations between the nurse, patient and family are identified as having the potential for healing.
They enable the inclusion of family understanding of the experience of illness alongside the nurse's expertize in identifying problems.
Therapeutic conversations enable co-designing of health-promoting solutions, to jointly manage health issues and alleviate illness suffering (Doane & Varcoe, 2015). The second ingredient is manners; those simple acts of courtesy, politeness, respect and kindness are demonstrated in a society (Shajani & Snell,p. 264). A core demonstration of manners is the nurse introducing themselves to patients and families.
The third ingredient includes the tools of the Ecomap, a diagram of the family's social networks, and the Genogram, a format to capture the history of family behaviour patterns and illustrate the family tree over three generations (Crisp et al., 2017). The ecomap depicts contact with others outside the immediate family which can include sources of support or conflict (Shajani & Snell, 2019, p. 72). Relationships with education, health care, occupation, environment and other systems are acknowledged. The nurse and family can identify social, cultural and economic resources (or their absence) and can be co-created by the nurse and family. Genograms can illustrate generations of families and highlight repeated patterns and potential for illness, acting as a trigger for the nurse to "think family" (Wright & Leahey, 2013, p. 77

| Methodology and methods
Participatory action research (PAR) was utilized in this study, with the researchers working together with participants in cycles to explore the issues of interest (Koch & Kralik, 2006). Collaborative research with the DNs, acknowledging their clinical expertise and knowledge, enabled the researchers to deepen the shared understanding of DNs work with families. Stringer (1999) outlines three phases of PAR; Look, Think and Act, which was used to structure the research process, and designed to take place in three phases.
Phase one corresponded to the PAR stage of "Look: Building a picture and gathering information"-this involved the establishment of pre-intervention focus groups, exploring existing DN knowledge of family nursing models and any existing understanding of the 15-Minute Interview. Phase two corresponded to "Think: Interpreting and explaining"-this allowed for feedback to the DN group of the initial findings generated from the focus groups. Two education sessions were offered, each lasting 30 min, and covering the same core material. This included the formal introduction of the CFAM and the 15-Minute Interview. The first session was part of an agency education day, with 40 in attendance. The second session was run as a follow-up opportunity for anyone unable to be present at the first session, with eight participants.
Both of the education sessions began with feedback on the preliminary themes emerging from the focus groups, for confirmation from participants that these were relevant to practice. The CFAM was then introduced, and the 15-Minute Interview was explained, with an opportunity to practice drawing the ecomap and genogram with a colleague. At this point, the DNs were invited to introduce the model into their practice for a trial period (the intervention).
The third phase of the study corresponds to the PAR stage of "Act: Resolving issues"-following the trial period, the DNs were invited to take part in postintervention individual interviews to explore experiences of using the tools and discuss their potential use in the future.
This process is illustrated in Figure 1.

| Participants
A convenience sample of nurses were recruited from a single DN agency, from a potential 36 RNs and 13 enrolled nurses. Eight participants took part in phase one (pre-intervention): three ENs and five RNs whose ages ranged from 25 to over 55 years, with DN experience ranging from one to more than 15 years. Forty-eight attended the education sessions in phase two and four RN participants completed phase three (postintervention).

| Ethical considerations
Ethical approval was obtained from the Ara Research Knowledge sessions and discussion as part of regularly occurring group meetings was given. Informed consent was gained prior to data collection. Anonymity and participant confidentiality were maintained using pseudonyms in transcribing, and the transcriber was required to complete a confidentiality agreement.

| Data collection
Data collection occurred across the look, think and act stages of the PAR process. The "look" component began with data collection from two pre-intervention focus groups. These began with semi-

| Data analysis
Three researchers were involved in the data collection, education sessions and analysis. All audio recordings from the focus groups and interviews were transcribed verbatim. Handwritten notes were taken during the education sessions, and additional recall /reflection entries were collected post these sessions to maintain a data trail.
Transcripts were reviewed both individually and collectively using an inductive approach to analyse qualitative data (Thomas, 2006).
This approach acknowledges that although the findings are influenced by the research question and the evaluation objectives, they still emerge directly from analysis of the raw data, not from preexisting expectations or imposed models. In line with the method of analysis, the researchers read and re-read the transcripts, at times also referring to handwritten journal notes taken at the time of the focus groups and interviews. Following this, each researcher went through a process of identifying text segments within the data, labelling these to create categories, then comparing these against each other and identifying opportunities for clarification, collapsing and joining of categories, recognizing overlap and redundancies. By this process, the number of categories was gradually reduced, forming summary categories (sub-themes) and finally synthesized into overarching, simplified themes. Clarity of category coding was confirmed by checking between coders following initial coding of the raw data. Member checking occurred in the form of feedback of the preliminary themes derived from the focus groups at the education sessions, with recognition and acknowledgment of these provided by participants verbally.

| Rigour
Trustworthiness was achieved through five criteria: credibility, dependability, confirmability, transferability and authenticity (Cope, 2014). Credibility was enhanced by the participant verification of transcripts, evaluation and summary of the two education sessions through utilization of the same education resources and note taking and recognition of the emerging themes. Confirmability was demonstrated by the utilization of focus group and interview participation, where quotes from the data are utilized to depict emerging themes. The explanation of research processes, such as data collection, with researcher process logs and analysis has promoted dependability (Plummer, 2017). Transferability is determined by the readers of research and their judgement of the ability to apply the findings to their family nursing practice (Connelly, 2016).
Authenticity refers to the ability and extent to which the researcher expresses the feelings and emotions of the participants' experiences in a faithful manner (Polit & Beck, 2012). In the pre-intervention education sessions, the researchers took the opportunity to present the preliminary findings from the focus groups to check for authenticity. These initial findings were received with interest and discussion about the possibility of utilizing a 15-Minute Interview in practice.

| FINDING S
The data generated from the focus groups and the interviews were Further analysis of the complete data set, combining the follow-up interviews with the initial focus group transcripts generated the following set of synthesized themes: "Family is who they say they are"; "Navigating complex families and family issues"; The scope of the DN role: "It's the best job in the world." Each of these overarching themes was informed by several categories/sub-themes, with these illustrated in Table 2.
Theme One: "Family is who they say they are" Theme One included two categories: "Each family's quite individual" and "They don't get on, they don't talk." These illustrated the breadth of family representation identified, with the DNs accepting of (and expected) very fluid outlines of family construction, inclusions and relationships. Illustrations of "Each family's quite individual" identified that definitions of family were not limited to close blood relations or traditional definitions.
"But he had a niece, but she wasn't the niece…I found out. She was his best friend's daughter." "Family are who the client says they are as well.
You've got to be quite mindful of that, and it may not be blood-related, but if they say that they're family then you have to respect that too." In some circumstances there can be an absence or distancing of family, which was recognized in the category "They don't get on, they don't talk." "Some clients, there's always someone there with them; others you might never see anyone else." "…for a lot of people, we're the only person they might see for a week or two on end." Theme Two: Navigating complex families and family issues The second overall theme also included two categories-"Families are really important" and "Some scenarios can be a little bit scarring." This theme encompassed the concepts of working with families and involving them in assessments, while also recognizing the challenges associated with complex family situations. District Nursing was explained as a family affair, where DNs had the opportunity to get to know families well over time. Navigating family issues highlighted a diverse range of concerns, including loneliness, family "interfering," abuse, fears of patients being "put in a home" and the continuity of care all intertwined in the patient and family stories. An overall sense of complexity in the situations these nurses dealt with was expressed, and the need to interpret, to analyse, to make sense of the myriad chaotic pieces of information and to draw out an understanding and plan.
Under the category "Families are really important," the DNs expressed their relationship with families, and how they say the opportunities to work together through assessment, information gathering or communication activities. Other distressing situations included recognition of limited resources, inability to provide all the services or time that the nurse felt was needed or concern when a client disclosed issues of possible abuse. Others noted that individuals, at point of assessment, would indicate that their only "goal" now was "to die." "-you didn't see the daughter, but the husband and wife would complain of abuse from the daughter, but they didn't feel that they could actually…" Theme Three: "The scope of the DN role: 'It's the best job in the world'" This theme had five categories associated with it, "I really want it to be a true partnership"; "We can't judge people"; "I'm present and it's with purpose"; "It's just a whole different" and "It's not always easy." The category "I really want it to be a true partnership" included the DN perceptions of their interactions and relationships with clients, and the roles they identified within the DN position. These included case manager, coordinator, enabler, "empowerer," facilitator of restorative care and health promoter.
"I really want it to be a true partnership where they're gonna trust me enough to convey their concerns…" One DN summarized the essence of the DN role, identifying the significance and depth of the relationship that can develop: "You've had this relationship for three years, and all of a sudden they're semi-conscious and …no recognition apart from family members…and it's that total feeling this person in front of me absolutely trusts me, and that is enormously special." One DN described making assessment through family, suspending judgement: You know they are hiding something. Sometimes it's just visiting again, and again, and just building that trust. Then once they feel comfortable with you, they'll share.
once they're comfortable, you walk in the door and all of a sudden everything just

Quote (examples) Category (Sub-theme) Synthesised theme
"Family is who they say their family is. Families come in all different forms. It could be your neighbour or a friend. It doesn't necessarily have to be a relation, does it?" (FG P.1) "It's who the actual client refers to as family really, isn't it? As you say, it might not necessarily be blood-related" (FG P.3) "I think each family's quite individual" (FG P 1) "Each family's quite individual" "Family is who they say they are" "Some clients there's always someone there with them; others you might never see anyone else" (FG P 2) "The only people involved socially … or have interaction with this client … are health services or social services" (Int 4 K) "Or they can be family living in the house -they don't get on, they don't talk." (FG P 4) "They don't get on, they don't talk." "Families are really important, because particularly with the difficult clients or the clients that have cognitive decline and they are continuing to live in their own homes by themselves, we need the supports of the family to know exactly what is going [on] behind the scenes" (Int 2 R) "if one member of the whānau's [family] sick, everyone is affected. So that unwellness cannot in my view be limited to the one person, because this particular person who's the client, his behaviours and attitudesnon-adherence to some of the regimes, medication and dressings really disrupted the whole family unit." (Int 4 K) "Families are really important" "Navigating complex families and family issues" "…when it's the end of the day and I've run out of time and I know I'm already an hour and a half late or whatever. Then when I come into the home, the complications for a couple of my clients are just endless," "-you didn't see the daughter, but the husband and wife would complain of abuse from the daughter, but they didn't feel that they could actually…" "…when you go to somebody and they say, 'I just want to die, -that's my goal.'" "Some scenarios can be a little bit scarring" "…to honour and acknowledge the person, their efforts, what they're doing, what their family's doing. Because it's their resources, it's their emotional health, it's the drain on them as a family." "…it's a trust thing as well, because we are strangers walking into someone's house, they are letting us into their house, and they've got to take us on trust really" "I really want it to be a true partnership" "The scope of the DN role: 'It's the best job in the world'" "We can't judge people. We have to be very non-judgemental" "Some places you go into, horrible states of things" "We can't judge people" "Sometimes it's just visiting again, and again, and just building that trust. Then once they feel comfortable with you, they'll share".) "Once they're comfortable, you walk in the door and all of a sudden everything just comes out…" "I'm present and it's with purpose" "…it's so different having a patient in their home environment, in their environment, it's just a whole different -than being in the hospital" "…when you see them at home, you see so much more…" "it's just a whole different" "…because sometimes you feel like you've promised, but you're never sure whether you can deliver" "Then if you get told, 'well sorry, we can't, that's too much', you have to go back and say, 'well look I can't.'" "I feel really pushed for time with each house that I go into. Some days I have up to 20 visits or 20 appointments…" "it's not always easy." comes out, and they tell you exactly what you know has been going on.
Under the category "We can't judge people," the DNs acknowledged the power they hold, and the responsibility that goes with this; also the challenging situations and clients they had to deal with. They recognized that they may not identify with or approve of people's lifestyle choices, but saw the need to support them to improve their health outcomes.
"…some clients live in a hoarder status but who are we to judge them that that's not the right way to live? You have to be accepting…" The third category, "I'm present and it's with purpose," relates to the DNs communication skills and therapeutic use of self. The nurses were able to describe many examples of establishing effective relationships, not only with clients and families but also with colleagues.
"I can honestly say I'm present and it's with purpose and I really want to hear what the person is saying. My key thing when I go into the home is that introduction of self and role identifying, 'cause I haven't met them before. I want to find out what their concern is and how they want me to work with them'" The fourth category, "It's just a whole different" refers to the concept of working in the home environment, and the difference this makes in terms of assessment, care provision and relationship building.
The nurses described this as a privilege, which was linked to trust, and offered greater opportunities.
"Yet it's so different having a patient in their home environment, in their environment, it's just a whole different -than being in the hospital" "Because you're looking after people in their own home -it's such a privilege, and an honour" The realities of DN were also acknowledged, in the final category: "It's not always easy." This included recognition of time and resource constraints, exhaustion, moral distress, and process issues.
"Because we're actually seeing it when we visit them in the home where management, they're seeing it [from] a statistical point of view."

| The 15 Minute-Interview feedback
In addition to the analysis of the overall themes, participants who had trialled the Minute interview were specifically asked to feedback on their experience around this. Four DNs shared their perceptions around this.

| Determining relevance
Three of the four DNs found that overall, the structure and at least some elements within the 15-Minute Interview were useful in their practice. Comments related to the usefulness, potential benefit, or lack of applicability and what circumstances affected this. The holistic focus of the 15-Minute Interview assisted the development of rapport and it was noted that it "brings up other questions." Responses regarding its capacity to assist with time management were mixed, with some suggesting that in principle it sounded useful (but that they hadn't managed to try it in full), while all still noted that time constraints were an ongoing issue for them. One DN chose not to trial the system, identifying that it offered no additional benefits to the current agency forms.
The importance of including and working with families was high-

| Using the ecomap and genogram
The genogram was identified as being used most often. For one participant, this was in conjunction with an existing process, the InterRAI assessment. Both processes are ways of showing links and relationships between individuals, of illustrating family connections. The 15-Minute Interview was also seen to align to the Hui Process, a Māori framework to guide clinical interaction and engagement of Māori patients and whanau in the health services (Lacey et al., 2011, p. 72).

| DISCUSS ION
Overall, the findings from our research align with much that is identified in wider family research. The theme of "Family is who they DNs are being constantly challenged to take on new activities, higher workloads, and to incorporate new technologies into their practice. Within this study, the DNs were asked to trial the 15-Minute Interview as part of their assessment practice. Despite indicating a general willingness to do so, very few ultimately followed through and reported on the experience, most commonly citing time constraints. This has implications when considering the capacity for the workforce to continue to introduce or change aspects of practice.
When analysing the feedback of those who did trial the model, it was apparent that while there was potential for the family assessment tool to be incorporated alongside other processes routinely used by the DNs, this was seen as requiring time and resource that was not always available. Even where processes (such as the CFAM model) were identified as useful in principle, the opportunity to incorporate them into practice was not always present. This resulted in the DNs selectively choosing elements, typically parts of the ecomap or genogram, which they then adapted for use. This demonstrates the prioritization and adaptation skills used by DNs, but also the limitations and risks associated with informal and partial adoption of systems.
DNs described long lists of patients to care for each day and some preferred to use the brief agency-based record of contact with the patient, especially for brief DN/patient encounters. There was acknowledgement that repeated use of the model might make it easier to use. Leahey and Wright (2016) support the grounding of nurses in family conceptual practice models as the application of them assists the nurse to develop the skills and competencies to help families more efficiently and easily.
The usefulness of the 15-Minute Interview was summarized as assisting the DN to collaborate with the patient and family and explore the support systems the patient might have. As many of the patients were older adults, the 15-Minute Interview assisted identification of potential social isolation and provided an opportunity to understand the social dynamics in the family. Repeating the application of the framework over time assisted identification of health issues, such as memory loss. Participants found that the 15-Minute Interview was "more personal" than the structured InterRAI framework and family members appeared "totally comfortable" being interviewed utilizing the tool. The genogram was valued for the ability to highlight hereditary components of health and illness. Overall, while it took extra time to use the 15-Minute Interview, the participants found it was "putting in time, to save time," meaning more effective and efficient interviews with the patient and family subsequently. Nurses are increasingly urged to engage with families-to "think family" (Duhamel et al., 2015;Eggenberger et al., 2011). This is particularly important for indigenous peoples, and DNs working with Māori whānau (family) in New Zealand are expected to include whānau in the patient's care. Māori perceive themselves as a collective, with the inclusion of whānau considered essential to health assessment and culturally appropriate nursing care (Pitama et al., 2014). Taking a whānau approach enables the comprehensive assessment of a Māori patient in the community. The participants recognized that the 15-Minute Interview was compatible with the holistic Māori framework of Te Whare Tapa Wha (translated as the four cornerstones of the house, including spiritual, mental, physical, and extended family dimensions (Durie, 1994), and the Hui process. The Hui process was used with When considering future practice of the DN, it is likely that additional DN responsibilities will be added, or existing scopes expanded rather than reduced, alongside the ageing population and push towards community care. West (2014) West, 2014) suggest that DNs have a delicate balance of the provision of care to ensure the health needs of the patient and family are met. As Leahey and Wright (2016) have identified, illness is a "family affair" and the use of the 15-Minute Interview assists the DN to apply theory to practice. The purpose of the 15-Minute Interview is a rapid interview, which can assist the DN to develop an assessment efficiently and make a difference to the patient and family illness experience and indeed, the DNs nursing satisfaction.

| Strengths and limitations
The strength of this study is the contribution to the body of knowledge in terms of a "snapshot" of DN in New Zealand and the use of family nursing models. There is a dearth of current international literature related to the use of family models in district or community nursing or the application of Wright and Leahey's CFAM. However, the limitation is the small number of participants. The patient load was identified by participants as the key contributing factor for declining to participate in the research or to utilize the CFAM. However, the data from the study can be helpful in the context of family nursing and how nurses can involve family in district nursing. Further research in family nursing in the district and other community nursing practice is needed.

| CON CLUS ION
Our research has provided useful insights into DN family practice in New Zealand. DNs described a broad and inclusive definition of family structures, valuing family inclusion and engagement.
Collaboration, support, negotiation and shared decision-making were described by DNs working to engage each family.
The CFAM, particularly the 15-Minute Interview, were seen as potentially useful tools relevant to several areas of practice; This study highlighted the constraints to introducing new tools and approaches into already pressured workloads, even when these have potential to improve efficiency or engagement. The time needed to gain familiarity, and to apply new interventions needs to be balanced against future benefits; this has significance in terms of the range of additional tasks being asked of DNs. DNs described the challenge of balancing the provision of care to ensure the needs of the patient were met, with the time given and the patient allocation for the day. If the CFAM were to be introduced into district nursing, personal, organizational and professional barriers would need to be addressed.

ACK N OWLED G EM ENTS
We wish to thank the district nurse participants of the research project and the support from the District Nurse management.

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.