ISSUES IN FAMILY CARE

Family assessment tools: A review of the

literature from 1978-1997
Barbara Neabel, RN, MScN, Frances Fothergill-Bourbonnais, RN, PhD, and Jean Dunning, RN, PhD,
Ottawa, Ontario, Canada

Traditionally, nursing practice in critical care settings has been focused on recognizing and addressing
the needs of the patient with an acute and serious health problem and individual family members. Lit-
tle progress has been made in understanding how families manage this hospitalization experience; how-
ever, family health has been reported to be a significant factor in the patient’s recovery. The purpose of
this article is to review the literature from 1978 to 1997 that has examined family assessment tools in
a variety of clinical settings. The ultimate goal of the review is to determine their usefulness for critical
care environments and their congruence with family systems nursing, which is aimed at the cognitive,
behavioral, and affective domains of family functioning. The following characteristics are used to review
each of the selected instruments: theoretical framework; purpose; description; the unit of analysis; ease
of administration and scoring; reading level; psychometric evaluation; and utility to guide clinical prac-
tice and research. Although the instruments have a variety of strengths, none of them are congruent
with the philosophy of family systems nursing. Therefore instruments need to be developed that would
guide assessment and interventions for nurses in critical care settings. (Heart Lung® 2000;29:196-209.)

T raditionally, nursing practice in critical care

settings has been focused on recognizing and
addressing the needs of the acutely ill patient
and individual family members. However, little
progress has been made in understanding how
families manage this hospitalization experience.1
Admission to an intensive care unit (ICU) frequent-
ly is a result of an unexpected onset of illness or
injury and uncertain outcomes. Often the family has
little experience with critical illnesses, but they are
required to make rapid decisions regarding the
care of their family member. It is difficult to be
adequately prepared for such an experience. The
cumulative impact of the critical illness results in
disruptions in home routines in the family2 and
may have detrimental effects on the family unit.
Health care professionals working with family mem-
From the School of Nursing, University of Ottawa.
Reprint requests: Barbara Neabel, RN, MScN, 225 Davisville Ave,
Apt. 2515, Toronto, Ontario, M4S 1G9 Canada.
Copyright © 2000 by Mosby, Inc.
0147-9563/2000/$12.00 + 0 2/1/106938
doi:10.1067/mhl.2000.106938
bers of critically ill patients need to expand their
practice to care for the patient and the family as a
unit. This focus may help nurses better understand
the family’s life situation and promote family
health.3
Recently, nursing scholars have legitimized fam-
ily nursing as a unique body of nursing knowledge.
The nursing literature stresses the importance of
understanding and intervening with a patient’s
family to create an environment supportive to the
health of the ill individual.4,5 Although there is
growing recognition in the nursing literature con-
cerning family-centered care, it remains an ideal
practice.5,6 Certain factors limit the extent to which
a family focus in critical care can be provided. For
example, budget cuts have resulted in fewer nurs-
es and therefore less time is available for attention
to other than immediate physical care needs of the
patients. In addition, nursing education, until the
last decade, has had a limited focus on family nurs-
ing.7 Consequently, the lack of educational prepa-
ration may be a barrier to family nursing.8-10 In
spite of these hindering factors, the purpose of
family nursing as part of routine care in critical care

196 MAY/JUNE 2000 HEART & LUNG

Neabel, Fothergill-Bourbonnais, and Dunning
settings is to enhance the promotion of family
strengths and coping skills, which may help to
maintain the family’s health. Family health has
been reported to be a significant factor in the
patient’s recovery.6
Increased consumer awareness and current limi-
tations of the health care system have created a cli-
mate for change. Now is the time for family nursing
to be embraced in tertiary settings.6 Shorter hospi-
tal stays, advances in technologically dependent
supportive health care, and a decrease in profes-
sionally provided home health care services have
created a situation where many families must
assume care-taking activities.11 Health care profes-
sionals recognize that families must assume more
responsibility for care once their family member is
discharged from the hospital. However, many fami-
lies are not prepared to assume the role of caregiv-
er because of (1) the complexity of care that is
required, (2) the added stress of taking on another
role, particularly for women who are already jug-
gling many responsibilities, and (3) diminished
extended families.6 Early interventions strengthen
the family and minimize real and potential family
problems that can develop as a result of the critical
illness.4,12 For example, interventions that are
planned and systematic may help to save nursing
time and improve family outcomes.12
For nurses to have a pivotal role in helping fam-
ilies adjust to the hospitalization experience and
subsequent discharge, they first need to under-
stand the family unit, what the critical illness means
to the family members, how they have been affect-
ed by the illness, and the support they require.
Therefore it is important for nurses to conduct com-
prehensive family assessments to gain a better
understanding of the family’s construction of the ill-
ness event.
Four intrinsic elements in family nursing assess-
ments include (1) having a human caring presence,
(2) acknowledging multiple perceptions, (3)
respecting diversity, and (4) valuing each person in
the context of the family.3 These elements are con-
sistent with family systems nursing in that all mem-
bers of the family are involved in the assessment
process. It would be beneficial for critical care nurs-
es to have an assessment tool that would not only
allow them to perform family assessments but also
provide appropriate nursing interventions to help
the patient’s family. Such a tool would target fami-
lies to help them deal with the critical illness of
their family member and subsequently improve
the patient’s outcome.
HEART & LUNG VOL. 29, NO. 3
Family assessment tools
The purpose of this article is to review the liter-
ature that has examined family assessment tools in
a variety of clinical settings. The ultimate goal of
the review is to determine the usefulness of avail-
able assessment tools for use in critical care set-
tings and whether these tools are congruent with
family systems nursing, which is aimed at the cog-
nitive, behavioral, and affective domains of family
functioning as noted in the Calgary Family Inter-
vention Model.13 By being cognizant of family
assessments tools, critical care nurses will be able
to select the most appropriate one to implement in
their practice.
BACKGROUND
Over the past 20 years, the focus of research on
family assessments in critical care settings has pri-
marily been on identifying the educational and
psychosocial needs of spouses or parents,
although other family members have been includ-
ed. For example, the Critical Care Family Needs
Inventory (CCFNI) has been used almost exclusive-
ly to assess the informational and psychosocial
needs of families. However, few studies have
focused on identifying how families manage during
critical illnesses. More studies are needed to
enhance nursing knowledge of this population. Lit-
tle research exists that has been directed toward
understanding the needs of the family as a unit or
to the development of nursing interventions to
assist families in the management of an acute or
critical illness.14-21 The emphasis of those nursing
strategies that do exist has been on the provision
of information to meet the cognitive needs of indi-
vidual family members. Addressing the informa-
tional needs reflects only part of the process of a
family’s adjustment to critical illness. Interventions
must also consider the behavioral and affective
needs of families. Interventions that target the 3
domains of family functioning (cognitive, affective,
and behavioral) may assist the family in finding
new solutions to their problems.13 A paucity of
instruments exists to direct nurses toward assess-
ment of and interventions for more than the cogni-
tive needs of families. However, a number of instru-
ments are available to assist nurses with complet-
ing family assessments. It should be noted that few
of these instruments have been used in research
studies, and few have been used with families of
patients who are critically ill.
Ideally, assessment instruments should develop
from a theoretical framework, which can help orga-
nize the nurse’s thoughts, observations, and inter-
197
Family assessment tools
pretation of the data gathered and provide a ratio-
nale for interventions.12,22 To date, little attention
has been paid to the congruence between the the-
oretical philosophy of family nursing, the definition
of the family unit, and subsequent inferences and
conclusions about family function when selecting
an assessment tool.1,22 Consequently, potential
problems may develop, such as family needs being
overlooked and interventions being initiated that
are not meaningful or beneficial to the family. The
next section focuses on the process of reviewing
the family assessment tools for their potential use-
fulness in critical care environments.
METHODS
The nursing literature related to family assess-
ments from 1978 to 1997 was reviewed through a
computerized search of the Cumulative Index to
Nursing and Allied Health Literature (CINAHL),
Medline, and PsycINFO. The key words used for
the search strategy included acute care, critical
care, tertiary care, family needs, family assessment,
family interventions, and research instruments.
Additional sources were obtained from the refer-
ence lists of pertinent articles. Seventeen assess-
ment instruments used in a variety of clinical set-
tings were found in the literature. Eight of these
instruments were not appropriate because (1) four
were modified versions of the CCFNI (Family
Needs Questionnaire,23 Family Inventory of
Needs,24 Daley’s questionnaire,25 and Norris and
Grove’s questionnaire26) and therefore used simi-
lar questions; and (2) four were used to measure
the needs of parents of young children who had
disabilities in a home or community-based setting
(Family Needs Survey,27 Support Functions Scale,28
Family Needs Scale,29 and Parents Need Survey30).
The remaining 9 instruments were subsequently
examined because (1) they offered a global per-
spective on family assessment; (2) they could be
easily implemented in critical care settings; and (3)
they have established reliability and validity for
use in research and clinical practice.
Each of the selected instruments was reviewed
on the basis of the following characteristics: theo-
retical framework, purpose, description, the unit of
analysis, ease of administration and scoring, read-
ing level, psychometric evaluation, and utility to
guide clinical practice and research.31-33 The fol-
lowing tools were selected and are summarized in
the Table: Family Adaptability and Cohesion Eval-
uation Scales III (FACES III)34; Feetham Family
Functioning Survey (FFFS)35; Family APGAR36;
198
Neabel, Fothergill-Bourbonnais, and Dunning
Family Assessment Device (FAD)37; Family Envi-
ronment Scale (FES)38; Family Crisis Oriented Per-
sonal Evaluation Scales (F-COPES)39; Family Needs
Assessment Tool (FNAT)40; Family Functioning
Index (FFI)41; and Critical Care Family Needs Inven-
tory (CCFNI).42
CRITIQUE OF NINE FAMILY
ASSESSMENT TOOLS
Theoretical basis
The selected instruments originate from a vari-
ety of theories, such as family social science theo-
ries, general systems theory and structural-func-
tional theories in particular. General systems theo-
ry is appropriate for studying the family because it
is concerned with viewing the family as a whole
rather than each member separately. The underly-
ing premise is that individuals are best understood
in the context of their family.12 In addition, systems
theory allows for viewing families as part of a larger
suprasystem, such as their community or family
subsystem (eg, parent-child relationship).5,12,13,43,44
General systems theory is the underlying frame-
work of the Circumplex Model of Marital and Fami-
ly Systems.45,46 This model offers a dynamic view of
families adapting to the developmental changes
that occur during the life cycle.44 The model is also
the foundation for FACES III.47
The theoretical foundation for the FFFS is an
ecologic framework35 supported by general sys-
tems theory5 and developmental theories.48,49
Although this framework views the family from a
systems perspective, the focus is directed toward
the examination of the interdependence of family
members with one another and their environ-
ment.50 Individual and family development occurs
as a result of these interactions.49 This framework
acknowledges that the family system is dynamic
and in a state of constant change and adaptation.
Structural-functional theory is the underlying
framework for both the Family APGAR51 and FAD.37
The structural-functional theory views the family as
a social system but focuses more on family func-
tions. Examples of family functions include meet-
ing the family members’ psychological needs, pro-
viding physical necessities such as food and cloth-
ing, and socializing children.5 This theory also
emphasizes the relationships between the family
and its individual members and the family struc-
ture and its ability to perform family functions.43
The McMaster Model of Family Functioning37
stems from the structural-functional theory and is
MAY/JUNE 2000 HEART & LUNG
Neabel, Fothergill-Bourbonnais, and Dunning Family assessment tools

Table
Summary of 9 family assessment tools

FACES III FFFS Family APGAR

Authors Olson et al (1985) (as Roberts & Feetham Smilkstein (1978)

cited in Olson, 1986) (1982)
Theoretical Circumplex Model of Ecological framework Common themes in
framework Marital & Family Sys- (general systems social science literature.
tems (general systems theory) The framework is
theory) reported to be struc-
tural-functional.51
Purpose To provide an assessment To provide information To be used as a utili-
on how individuals on parent’s perception tarian screening tool
perceive their family of family relationships to provide information
and the description of and functioning. on the satisfaction of
their ideal family. family functioning.
Description A self-report question- 21-item self-report 5-item self-report ques-
naire with 20 items questionnaire measur- tionnaire measuring 5
that measures 2 dimen- ing 3 areas of family areas of family func-
sions of family func- functioning on the basis tioning: adaptation,
tioning: cohesion and of relationships between partnership, growth,
adaptability.34 It pro- the family and social affection, and resolve.
vides a linear measure.66 unit, subsystems, and
Linear measures are individual members.
reported to have a
straight–line cause-and-
effect, or A leads to B.5
Unit of Whole family Whole family Whole family
analysis
Ease of The tool is taken twice Takes 10 min to com- Very quick to complete.
adminis- to measure their per- plete. The Porter format Five questions with 3
tration and ception and their ideal is used to allow for 3 possible responses
scoring description. The discrep- direct measures and 1 (2, 1, 0). The total
ancy between the 2 indirect measure. Each score range is from 0
measures provides a item is rated on a to 10. The larger the
measure on family 7-point scale.35 Scoring score the greater
satisfaction. The larger format is slightly com- amount of satisfaction
the discrepancy the less plicated.47 with family functioning.
satisfied the person is Similar tool with 5 res-
with his or her family. ponses for each item is
It takes 10 min to com- used for research.60
plete the tool and each
item response is on a
5-point Likert scale.47
Reading level For people 9 y and May be difficult for Can be used for people
older47 those who do not have over 10 y old.60
a high school educa-
tion.47

Continued.

HEART & LUNG VOL. 29, NO. 3 199

Family assessment tools
Table (Cont’d)
FACES III
Reliability Homogeneity: internal
consistency for the
tool, r = 0.68; for cohe-
sion, r = 0.77; for
adaptability, r = 0.62.
Stability: The 4- to 5-wk
test-retest for FACES III
is r = 0.83 for cohesion
and r = 0.80 for adapt-
ability.
Validity Content: The authors of
the tool state there is
good evidence for con-
tent validity; however,
no information is pro-
vided.
Construct: Correlation
between scales: cohe-
sion and adaptability,
r = 0.03; cohesion and
social desirability,
r = 0.39; and adaptabil-
ity and social desirability,
r = 0.00. The correlation
between family mem-
bers (n = 370) for cohe-
sion is r = 0.41 and
adaptability is r = 0.25.
Criterion: There is good
evidence that FACES III
can discriminate
between groups; how-
ever, this is not expand-
ed upon by Olson.34
Utility to It is helpful for assessing
guide clini- change over time.34 It
cal practice measures relevant fac-
and tors for nursing.33 Cutoff
research scores are available that
will increase its useful-
ness.47
200
Neabel, Fothergill-Bourbonnais, and Dunning
FFFS
Homogeneity: Cronbach’s
alpha reliability coeffi-
cient for the 4 scores
obtained from 103
mothers ranges from
0.66 to 0.84. The inter-
nal consistency for the
tool is r = 0.81.
Stability: The 2-wk test-
retest is r = 0.85 for 22
mothers.35
Content: 5 sources were
used: literature, previ-
ous research, clinical
observations, experts,
and parents who dis-
cussed the instrument
with the developers.
Concurrent: The corre-
lation coefficient
between the FFFS and
FFI for 103 mothers is
r = –0.54 (P < .001).
Construct: Factor analysis
supports the 3 areas of
family functioning as
relationships.35
The FFFS measures 3
areas of family function-
ing that are important in
health assessments. The
preliminary reliability
and validity test supports
the FFFS’s potential as a
clinical assessment tool.
However, additional test-
ing is required for other
patient populations be-
sides families of children
with myelodysplasia.
MAY/JUNE 2000
Family APGAR
Homogeneity: Interitem
correlation ranges from
r = 0.46-0.64. Split-half
reliability index is
r = 0.93.64 The internal
consistency for the tool
is r = 0.86.
Stability: 2-wk test-retest
is r = 0.83 for 100
students.60
Construct: Correlation
of Family APGAR with
FFI is r = 0.80 with 33
nonclinical respondents.
In this same group, the
interspouse correlation
is 0.67 for the Family
APGAR and 0.65 for
the FFI. The correlation
of Family APGAR with
family therapist in the
clinic group is 0.64.64
Criterion: Family
APGAR score can dif-
ferentiate between test
and control groups,
adopted and biological
children, and students
separated from parents
and those living with
parents. The test group,
adopted children, and
students separated from
parents have signifi-
cantly lower Family
APGAR scores.60
It serves as a screening
test36 and guides inter-
ventions because there
is some normative
data.64 The tool mea-
sures relevant factors.33
The tool allows a quick
assessment of family
function as a resource
for social support for
the patient.47
HEART & LUNG
Neabel, Fothergill-Bourbonnais, and Dunning Family assessment tools

FAD FES F-COPES

Authors Epstein et al (1983) Moos & Moos (1976) McCubbin et al (1987)
Theoretical McMaster Model of Family Systems Theory47 Double ABCX Model of
framework Family Functioning Family Adjustment
(structural-functional and Adaptation (family
theory) stress theory)
Purpose To screen family func- To measure perceived To identify problem-
tioning on 7 various family interactions56 solving and behavioral
dimensions. It is also by assessing the family strategies used by
used to distinguish social environments.38 families during a crisis.
between healthy and
unhealthy families.47
Description A 60-item self-report A self-report question- A 29-item self-report
questionnaire with 7 naire or with modifica- questionnaire with 5
subscales: problem tions it can be used by subscales: acquiring
solving, communica- an interviewer. It consists social support, refram-
tion, roles, affective of 90 true or false items ing, seeking spiritual
responsiveness, affective that measure 3 dimen- support, mobilizing
involvement, behavior sions: relationship, family to acquire and
control, and overall personal growth, and accept help, and passive
general functioning.67 system maintenance. appraisal.
There are 10 subscales.
Additional forms exist,
such as Real Form (Form
R to describe the current
environment); Ideal
Form (Form I to describe
the ideal family); and
Short Form (Form S to
be used in research be-
cause it has only 40
questions).63
Unit of Whole family Whole family Whole family
analysis
Ease of Takes 15-20 min to com- It is easy to administer The time to complete the
administra- plete. Family members and score, and there is questionnaire is not
tion and rate their agreement or no time limit.47 Scores reported. Each item is
scoring disagreement with each are totaled for each rated on a 5-point Lik-
item on the basis of subscale with higher ert-type scale ranging
how well it reflects scores representing a from 1-5.39 For each
their family. There are positive environment.58 subscale a summary
4 possible responses for A family profile is score can be obtained. A
each item, from strongly generated by averaging total score is obtained by
agree to strongly dis- the family members’ adding the items. Four of
agree.47 Scores for each scores and comparing the items require reverse
subscale are averaged the subscale averages scoring to weigh all items
and range from healthy with normative scores.58 in a positive direction.
(1.0) to unhealthy (4.0). The tool can be adminis-
tered to family members
12 y of age and older.57
Reading Approximately 6th Easily understandable56 It is appropriate for people
level grade47 12 y of age and older.

Continued.

HEART & LUNG VOL. 29, NO. 3 201

Family assessment tools
Table (Cont’d)
FAD
Reliability Homogeneity: Cronbach’s
alpha for subscales ranges
from 0.72 to 0.92. The
internal consistency for
the tool is not reported.
Correlation among the
subscales ranges from
r = 0.37-0.76. When the
general functioning
subscale is held constant,
the correlation among the
remaining 6 scales ranges
from r = 0.01-0.23.
Validity Construct: To determine
construct validity, the
score obtained from the
instrument was correlated
with the scores obtained
from FACES II and Family
Unit Inventory. Correl-
tion between FAD and
Family Unit Inventory
closely approximated pre-
dictions. However, corre-
lations between FAD and
FACES II did not support
the hypothesis, indicating
the 2 instruments mea-
sure different constructs.65
Criterion: By use of regres
sion analysis, the FAD
predicted 28% variance
(r = 0.53) for husbands on
the Wallace Marital Satis-
faction Scale and 17%
variance (r = 0.41) for
wives.65 The FAD is able
to distinguish between
nonclinical and clinical
groups (66% nonclinical
and 64% clinical, P <
.001).37
Utility to The cutoff limits for healthy
guide clin- and unhealthy family
ical prac- functioning have accept-
tice and able sensitivity, specificity,
research and positive predictive
value.65 This would be
helpful for providing
nursing interventions.
The 7 subscales provide
a detailed picture of
families, which makes it
useful. It measures areas
that nurses could
change.33
202
Neabel, Fothergill-Bourbonnais, and Dunning
FFS
Homogeneity: Internal
consistency for the 10
subscales ranges from
0.64-0.79. The internal
consistency for the
tool is not reported. The
average subscale inter-
correlations are 0.20.
Stability: The 8-wk test-
retest ranges from
0.68-0.86.
Validity is seldom
reported on the FES.63
Researchers document-
ed that although empir-
ical studies have been
done, little of this infor-
mation is provided.
Most of this informa-
tion is documented in
unpublished manu-
scripts.
It is useful for measuring
change over time.33 It
is useful to change the
focus from the individ-
ual to the family.56 It is
also useful for clarify-
ing the nature and
extent of disagreement
in families when
using the Ideal Form
and Real Form.
MAY/JUNE 2000
F-COPES
Homogeneity: Cron-
bach’s alpha for the
subscales ranges from
0.63-0.83. Internal
consistency for the
tool is r = 0.86.
Stability: The 4-wk test-
retest for the subscales
ranges from 0.61-0.95,
and for the total tool
it is 0.81.
Construct: Factor
analysis revealed 5
factors.
Normative data are avail-
able for adolescents and
adults of both sexes. The
information will help
nurses to know which
families may need addi-
tional assistance with
managing the crisis. In
addition, the normative
data may help nurses
compare family cop-
ing and develop mod-
els of family coping in
clinical studies.57
HEART & LUNG
Neabel, Fothergill-Bourbonnais, and Dunning Family assessment tools

FAD FFS F-COPES

Authors Rawlins et al (1990) Pless & Satterwhite Molter & Leske (1983)
(1973) (as cited in Leske,
1986)
Theoretical King’s Theory of Goal Not reported by the Comprehensive litera-
framework Attainment authors except that the ture review in crisis and
choice of questions was human need theories
eclectic and came from
theoretical knowledge.
Purpose To provide information To assess the strength of To provide a practical
on the needs of families family relationships and useful instrument
with chronically ill and lifestyles and iden- to assess the degree of
children. tify families who require importance on a wide
additional assistance. variety of needs with
family members of
critically ill patients.
Description 54-item self-report ques- 15-item self-report A self-report question-
tionnaire consisting of questionnaire covering naire consisting of 45
9 subscales that cover 3 6 dimensions of family need statements and
general areas of needs: functioning: intrafami- an open-ended ques-
information, services, ly communications, tion. It measures 5
and obstacles to treat- cohesiveness, decision areas: support, comfort,
ment. making, marital satis- information, proximity,
faction, general level and assurance.
of happiness and close-
ness in the family unit.
Unit of Whole family Whole family Whole family
analysis
Ease of Not reported Easy to administer, scor- It is easy to administer
administra- ing is simple, a value and scoring is simple.
tion and of 0, 1, or 2 is assigned Each need statement
scoring depending on how is rated from 1-4, with
congruent the response 1 as “not important”
is to the family’s opti- and 4 as “very impor-
mal functioning, higher tant.” Length of time
scores represent more to complete the
desirable functioning. questionnaire is not
The scoring is slightly reported.
complicated.33
Reading Not reported It is appropriate; how Appears to be appro-
level ever, because the priate
response format
varies, it may be con-
fusing.47

Continued.

HEART & LUNG VOL. 29, NO. 3 203

Family assessment tools
Table (Cont’d)
FNAT
Reliability Homogeneity: The inter-
nal consistency is not
reported. Primary
factor reliability ranges
from r = 0.773-0.944,
and secondary factors
range from r = 0.841-
0.884. Primary factor
correlations range from
0.05-0.6, and secondary
factors range from
–0.34 to 0.23.
Stability: 2-wk test-retest
on 20 parents is r = 0.77.
Validity Content: 2 doctorally
prepared nurses and 20
parents screened the
items for representa-
tiveness and coverage
of needs. Multiple
regression in the pilot
study indicated that
almost all items were
predictive of overall
needs.
Construct: Factor analysis
suggests 9 primary
factors and 3 secondary
factors.
Utility to It has potential as a use
guide clini- ful clinical tool. It is
cal practice restricted to identifying
and needs of families with
research chronically ill children in
the 3 general areas pre-
viously described. How-
ever, the tool would
assist nurses in planning
care once the needs are
identified.
204
Neabel, Fothergill-Bourbonnais, and Dunning
FFI
Homogeneity: The
internal consistency is
not reported. Correla-
tions between the
factors and the total
instrument for the
mothers is r = 0.21-
0.95, and for the fathers
it is r = 0.07-0.96.
Stability: 5-y test-retest
is reported to be 0.83
(P = .001).63
Construct: The correlat-
ed results of FFI scores
of parents of new
clients with social
workers are mothers,
r = 0.48 (P < .01) and
fathers, r = 0.35
(P < .013); correlation
of mother’s scores with
nonprofessionals is
r = 0.39 (P < .001);
correlation of Family
APGAR with FFI is
r = 0.80.63 The tool
can differentiate
between healthy and
clinic families.
Criterion: The authors
hypothesized that
families seeking assis-
tance would have
lower FFI scores. The
results were significant
with t = 7.7, df = 387
(P < .001).
It has potential for
screening families;
however, the strength
of this would be
increased if the psy-
chometric properties
were stronger.47 It is
not sensitive to short-
term changes.33
MAY/JUNE 2000
CCFNI
Homogeneity: Internal
consistency is reported
to be r = 0.92.
Stability: 24-h test-retest
ranges from 64.71%
to 96.08% exact
agreement for item by
item.68
Construct: Factor
analysis reveals 5
factors: support,
comfort, information,
proximity, and assur-
ance. Factor correla-
tions range from
r = 0.07-0.39. Factor
alpha coefficients
range from 0.61-0.88.
The item-total correla-
tions range from
0.25-0.60. Only 2 items
did not correlate higher
than 0.20: to know
the prognosis
(r = 0.15) and to have
questions answered
honestly (r = 0.17).61
The tool assists nurses
to identify family
needs on the basis of
the perceptions of the
individual completing
the questionnaire.
Researchers hope this
will help nurses pro-
vide the interventions
to meet the family’s
needs.
HEART & LUNG
Neabel, Fothergill-Bourbonnais, and Dunning
the foundation for the FAD. This model describes
the structural and organizational properties of the
family and transaction patterns among family mem-
bers.37
Family systems theory is the basis of the FES.47
Family systems theory is considered a practice the-
ory and was developed for use with troubled fami-
lies. Family systems theory is pathology oriented5;
however, it describes both functional and dysfunc-
tional families and suggests interventions thus
making it pertinent to family nursing. Family sys-
tems theory is psychologically based and is more
concerned with how to facilitate a change in fami-
lies who are having problems.52 To varying degrees,
this theory has been influenced by general systems
theory.5,44
Family stress theory was originally developed in
1949.53 According to family stress theory, the family
experiences a “roller-coaster” adjustment process
when it faces a crisis event.53 After experiencing the
crisis, the family goes through a downward period
of disorganization, an upward period of recovery,
and then a new level of organization.5,43 The ABCX
model of family stress identifies how the interpre-
tation of stressors and available resources can
result in a crisis or noncrisis situation.53 Family
stress theory is a middle-range theory and is the
basis of the Double ABCX Model of Family Adjust-
ment and Adaptation.5,12,43 This model expands
family stress theory by adding postcrisis factors to
explain family adaptation.5,12 The Double ABCX
Model of Family Adjustment and Adaptation was
used to develop the F-COPES.39 The model offers a
way to examine the family’s efforts of adapting to
multiple stressors on the basis of the members’
perception of an event and by use of a number of
resources and family strengths.5
The only family instrument based on a nursing
theory is the FNAT. Its theoretical foundation is
from King’s theory of goal attainment.40 On the
basis of King’s theory, the assumption is that all
humans are in a constant interaction with their
environment. The family is viewed as an open sys-
tem composed of 3 interacting systems: personal,
interpersonal, and social.54 King reported that per-
ception is a key concept to her theory when work-
ing with families.55 Therefore obtaining the family’s
understanding of events is central to determining
appropriate interventions.
Little information is available on the theoretical
framework used to create the FFI and CCFNI. The
choice of questions asked on the FFI was reported
to be eclectic and came from theoretical knowl-
edge.41 However, the authors of the tool do not
HEART & LUNG VOL. 29, NO. 3
Family assessment tools
expand on the theory used to develop the FFI. The
CCFNI is based on a comprehensive literature
review in crisis and human need theories.42 No
additional information is provided on the theoreti-
cal background of the CCFNI.
In general, each theory examines concepts that
are applicable to critical care settings. For example,
general systems theory is concerned with the fami-
ly as a unit, whereas both the ecologic framework
and structural-functional theory emphasize the
interdependence or relationships between family
members. Family systems theory describes func-
tional and dysfunctional families, whereas family
stress theory examines the adaptive efforts fami-
lies make in response to stressors. Last, families
are viewed as an open system interacting with their
environment in King’s theory.54
General systems theory has also influenced the
development of all the theories reviewed except
family stress theory. Although a systems perspec-
tive is congruent with family systems nursing, the 3
domains of family functioning are not evident in
the review of the theories. For example, the behav-
ioral domain is not apparent in the theories except
for the Circumplex Model of Marital and Family
Systems (general systems theory), family systems
theory, and Double ABCX Model of Family Adjust-
ment and Adaptation (family stress theory). With-
out these data, an incomplete picture is provided
of the family members’ reaction to the illness and
their subsequent ability to manage over time. In
addition, a rationale for interventions is only pro-
vided by some of the theories, namely the family
systems theory, Double ABCX Model of Family
Adjustment and Adaptation, and King’s theory of
goal attainment. A theoretical framework that is
congruent with family systems nursing would guide
interventions on the basis of the assessment of the
3 domains of family functioning.
Essential components of an assessment and
intervention framework of family systems nursing
include (1) listening to the family, (2) engaging in
participatory dialogue between the nurse and fami-
ly members, (3) recognizing patterns, and (4) envi-
sioning action and positive change.3 These compo-
nents are not apparent in the theories reviewed. The
current focus of family theories when implemented
in tool development and in clinical practice tends to
be nurse driven identification of family problems
rather than reciprocal interactions with the family,
which could identify the family’s strengths. There-
fore a framework that includes the 4 elements would
help critical care nurses to work with the strengths of
the family and promote family health.3
205
Family assessment tools
Purpose
In general, each instrument provides a global
view of family assessments; however, 6 instruments
only obtain information from the individual’s per-
spective. Some instruments focus on the interac-
tions of family members and family functioning,
whereas others focus on family needs. The FACES
III focuses on how individuals perceive their family
and their description of the ideal family to provide
a measure of family satisfaction.34 Others assess
satisfaction with family functioning (FFFS35 and
Family APGAR36); measure perceived family inter-
actions56 by assessing the family’s social environ-
ments (FES38); identify the problem-solving and
behavioral strategies used by families who are fac-
ing difficulties or a crisis (F-COPES39); or identify
families who may require additional assistance
(FAD and FFI41,47).
The remaining 2 instruments, the FNAT40 and
CCFNI,42 focus on family needs. The FNAT provides
information on the needs of families of children
who are chronically ill,40 whereas the CCFNI is used
to assess the needs of family members of critically
ill adult patients.42
Description
Each instrument is a self-report questionnaire.
The FES can also be modified to be used as an
interview guide.38 The length of the instruments
can vary; the Family APGAR has 5 items,36 whereas
the FES has 90 true or false items.38
Unit of analysis
As noted in the Table, the unit of analysis com-
prises all family members. However, restrictions
apply related to who completes the instruments for
some of the tools reviewed. For example, each fami-
ly member is to complete the FACES III instrument
twice to obtain their present perceptions on family
functioning and their ideal perceptions.47 In addi-
tion, family members must be greater than 12 years
of age to complete the FAD37 and F-COPES.57 When
using the FES, a family profile can be generated by
averaging the family members’ scores.58 Either one
or both parents are required to complete the FFFS,35
FNAT,40 or FFI,41 whereas individual family members
can complete the Family APGAR36 and CCFNI.42 It is
essential to account for the implications of having
individual respondents complete the questionnaire
because this may have some influence on the inter-
pretation of the results.32 Consequently, caution
should be taken with analyzing and generalizing the
results to the family as a unit when only 1 or 2 family
members have completed the instrument.
206
Neabel, Fothergill-Bourbonnais, and Dunning
Ease of administration and scoring
Instruments that are easy to administer and
score will most likely be preferred and used by
clinicians and family members.31 Most of the instru-
ments critiqued were noted to be easy to adminis-
ter or were quick to complete. For example, the
FACES III, FFFS, and FAD take approximately 10 to
20 minutes to complete.35,47 The amount of time
needed to complete the FES, F-COPES, FFI, and
CCFNI was not reported.
In general, no difficulties in scoring are noted
with the instruments except for the FFFS and FFI.
The FFFS requires calculation of different scores
and subsequently may complicate the scoring
process.47 The authors of the FFI indicate ease of
scoring,41 whereas users noted that it is slightly
complicated.33
Reading level
The reading level for instruments should be
written at the sixth-grade level for those family
members who may have limited reading skills.31,33
Only 6 of the instruments meet this requirement.
The FFFS may be difficult for people who do not
have a high school education.47 In addition, the
reading level for the FFI may be confusing for some
people because the response format varies.47 The
reading level is not reported for the FNAT.
Psychometric evaluation
It is essential that an assessment tool be reli-
able and valid. A tool is reliable if it consistently
measures the attribute it is designed to mea-
sure.59 A reliable scale has 3 characteristics:
homogeneity, stability, and equivalence. “Homo-
geneity” means that all items in a tool measure
the same concept. “Stability” refers to the instru-
ment’s ability to produce similar results with
repeated testing. Finally, “equivalence” refers to
the agreement among observers using the same
instrument or an alternate form of the tool.59
Homogeneity and stability measures are reported
for most of the instruments. The FFFS, Family
APGAR, F-COPES, and CCFNI are reported to have
an internal consistency coefficient greater than
0.80,35,39,60,61 whereas the internal consistency is
0.68 for FACES III.34 Generally the coefficient value
should be at least 0.70 or higher for an instrument
to be considered reliable.62 The internal consis-
tency is not reported for the other instruments.
The test-retest is not reported for the FAD; how-
ever, the remaining instruments have coefficients
greater than 0.68, with 5 having coefficients
greater than 0.80.34,35,39,60,63
MAY/JUNE 2000 HEART & LUNG
Neabel, Fothergill-Bourbonnais, and Dunning
An instrument is valid if it obtains the data that
it is supposed to obtain.59 There are 3 forms of
validity: content validity (whether the items in a
tool adequately represent the content intended to
measure a concept); criterion-related validity (the
degree to which the subject’s performance on the
tool is correlated to the subject’s actual behavior);
and construct validity (the extent to which a test
measures the construct that is being examined).59
Each instrument is reported to have good validity.
Construct validity and criterion-related validity are
readily available for the instruments except for the
FES.63 Content validity is available only for the
FFFS35 and FNAT.40
Utility to guide clinical practice and
research
A tool that is easy to administer and score rep-
resents the practicality or clinical usefulness of an
instrument.32 The ease of administering and scor-
ing for each instrument has already been dis-
cussed. Most of the instruments are easy to admin-
ister and scoring difficulties are noted with the
FFFS47 and FFI.33 Therefore the instruments can be
easily implemented in clinical and research set-
tings on the basis of the practicality of the tool.
A tool that can be used with diverse social and
cultural groups would be valuable to guide clinical
practice and research. FACES III is the only tool
reported to meet this requirement. It can be used
with a variety of families at different developmen-
tal levels and therefore has broad applicability.33,47
Restrictions have been noted regarding the clinical
and research applicability of the FFFS, FNAT, and
FFI. The FFFS was tested with middle-class families
of children with myelodysplasia. Its use in other
populations is limited until additional testing is
done.35 The FNAT is restricted to identifying needs
of families of hospitalized children who are chroni-
cally ill.40 The FFI is not useful for families without
children.33
Normative data and responsiveness of an instru-
ment are 2 important features that need to be
taken into consideration when selecting an instru-
ment for clinical or research purposes. Normative
data, or cutoff scores, are useful for screening fami-
lies.47 The responsiveness of an instrument refers
to its ability to detect clinically important differ-
ences over time.32 An awareness of normative data
and assessing change would allow nurses to deter-
mine if interventions are required and to structure
the delivery of them in a timely manner. Further-
more, normative data may help nurses to compare
results and develop models in clinical studies.57
HEART & LUNG VOL. 29, NO. 3
Family assessment tools
Some cutoff limits or normative data are available
for FACES III,43 Family APGAR,64 FAD,65 and F-
COPES39; therefore, these 4 instruments can be
used as screening tests for families having prob-
lems. However, it has been noted that the Family
APGAR may not be appropriate to assess for com-
plex family functioning because it has only 5 ques-
tions.47 The FFI can differentiate between healthy
and unhealthy families and has the potential to be
a screening tool.41 The FACES III and FES can
assess for changes in family functioning over
time.33 No information is available about the abili-
ty of the other instruments to assess for changes.
SUMMARY
Although few of the instruments reviewed have
been used with families of critically ill patients,
they do demonstrate a variety of strengths. The
theoretical frameworks from which these instru-
ments were developed are applicable to critical
care settings. However, the cognitive and affective
domains of family functioning were mainly
addressed by these theories, whereas the behav-
ioral domain was less likely to be included. There-
fore assessment data are lacking in areas such as
how the family uses existing support mechanisms;
how family members clarify what they need and
expect from each other; or how to minimize disrup-
tions in their routines. In addition, each of the
instruments examines slightly different aspects of
the family that are applicable for critical care settings.
For example, the FACES III provides a measure on
family satisfaction, and the FFFS and Family APGAR
assess satisfaction with family functioning. The FES
measures perceived family interactions and can
assess for changes in functioning with time. The F-
COPES identifies the problem-solving and behav-
ioral strategies used by families who are facing dif-
ficulties or a crisis. The FAD and FFI can be used to
identify families who may require additional assis-
tance. Last, the FNAT and CCFNI focus on family
needs. However, in keeping with the philosophy of
family systems nursing, which is concerned about
the family as a unit, few of the instruments
reviewed provide an assessment of the whole fam-
ily. The FES, F-COPES, and FNAT are the only
instruments that stem from a practice or middle-
range theory; therefore, there is limited guidance
offered that would assist nurses in providing inter-
ventions. Thus instruments that focus on the
assessment of the family unit, which includes the
affective, behavioral, and cognitive domains of
family functioning, and provide clear direction for
nursing interventions are required.
207
Family assessment tools
REFERENCES
1. Rennick J. The changing profile of acute childhood illness: a
need for the development of family nursing knowledge. J Adv
Nurs 1995;22:258-66.
2. Johnson SK, Craft M, Titler M, Halm M, Kleiber C, Montgomery
LA, et al. Perceived changes in adult family members’ roles
and responsibilities during critical illness. Image J Nurs Sch
1995;27:238-43.
3. Hartrick G, Lindsey AE, Hills M. Family nursing assessment:
meeting the challenge of health promotion. J Adv Nurs
1994;20:85-91.
4. Gilliss CL, Roberts BM, Highley BL, Martinson IM. What is
family nursing? In: Gilliss CL, Highley BL, Roberts BM, Mar-
tinson IM, editors. Toward a science of family nursing. Menlo
Park (CA): Addison-Wesley; 1989. p. 64-73.
5. Friedman MM. Family nursing: research, theory and practice.
4th ed. Norwalk (CT): Appleton & Lange; 1998.
6. Grossman M. Family nursing in tertiary care: history or the
promise of things to come? Can J Nurs Res 1995;27:3-5.
7. O’Malley P, Favaloro R, Anderson B, Anderson ML, Siewe S,
Benson-Landau M, et al. Critical care nurse perceptions of
family needs. Heart Lung 1991;20:189-201.
8. Fox S, Jeffrey J. The role of the nurse with families of patients
in ICU: the nurses’ perspective. Can J Cardiovasc Nurs
1997;8:17-23.
9. Hickey M, Lewandowski L. Critical care nurses’ role with fam-
ilies: a descriptive study. Heart Lung 1988;17:670-76.
10. Vosburgh D, Simpson P. Linking family theory and practice: a
family nursing program. Image J Nurs Sch 1993;25:231-35.
11. Grossman M, Gottlieb LN. Changes in acute care: questions in
need of answers. Can J Nurs Res 1995;27:5-7.
12. McShane RE. Family theoretical perspectives and implica-
tions for nursing practice. AACN Clin Issues Crit Care Nurs
1991;2:210-9.
13. Wright LM, Leahey M. The Calgary family intervention model.
In: Wright LM, Leahey M, editors. Nurses and families a guide
to family assessment and intervention. 2nd ed. Philadelphia
(PA): F.A. Davis Company; 1994. p. 99-129.
14. Daly K, Kleinpell RM, Lawinger S, Casey G. The effects of two
nursing interventions on families of ICU patients. Clin Nurs
Res 1994;3:414-22.
15. Dracup KA, Breu CS. Using nursing research findings to meet
the needs of grieving spouses. Nurs Res 1978;27:212-6.
16. Freismuth CA. Meeting the needs of families of critically ill
patients: a comparison of visiting policies in the intensive
care setting. Heart Lung 1986;15:309-10.
17. Halm M, Alpen M. The impact of technology on patients and
families. Adv Clin Nurs Res 1993;28:443-59.
18. Lopez-Fagin L. Critical care family needs inventory: a cognitive
research utilization approach. Crit Care Nurse 1995;15:21,23-26.
19. Murphy F. A staff development programme to support the
incorporation of the McGill model of nursing into an outpa-
tient clinic department. J Adv Nurs 1994;20:750-4.
20. Sabo KA, Kraay C, Rudy E, Abraham T, Bender M, Lewandow-
ski W, et al. ICU family support group sessions: family mem-
bers’ perceived benefits. Appl Nurs Res 1989;2:82-9.
21. Vosburgh D, Simpson P. Linking family theory and practice: a
family nursing program. Image J Nurs Sch 1993;25:231-5.
22. Jacob T, Tennenbaum DL. Conclusions and future directions.
In: Family assessment rationale, methods, and future direc-
tions. New York: Plenum Press; 1988. p. 159-76.
23. Kreutzer J, Zasler N, Camplair P, Leininger B, et al. Family inter-
vention following adult traumatic brain injury. In: Kreutzer J,
Wehman P, editors. Community integration following traumat-
ic brain injury. Baltimore (MD): Paul H. Brookes; 1990.
24. Kristjanson LJ, Atwood J, Degner LF. Validity and reliability of
the family inventory of needs (FIN): measuring the care needs
of families of advanced cancer patients. J Nurs Meas
1995;3:109-26.
208
Neabel, Fothergill-Bourbonnais, and Dunning
25. Daley L. The perceived immediate needs of families with rela-
tives in the intensive care setting. Heart Lung 1984;13:
231-7.
26. Norris L, Grove SK. Investigation of selected psychosocial
needs of family members of critically ill adult patients. Heart
Lung 1986;15:194-9.
27. Bailey DB Jr, Simeonsson RJ. Assessing needs of families with
handicapped infants. J Spec Ed 1988;22:117-27.
28. Dunst CJ, Trivette CM. Support functions scale. In: Dunst CJ,
Trivette CM, Deal AG, editors. Enabling and empowering fam-
ilies: principles and guidelines for practice. Cambridge (MA):
Brookline Books; 1988. p. 143-5.
29. Dunst CJ, Cooper CS, Weeldreyer JC, Snyder KD, Chase JH.
Family needs scale. In: Dunst CJ, Trivette CM, Deal AG, edi-
tors. Enabling and empowering: families principles and
guidelines for practice. Cambridge (MA): Brookline Books;
1988. p. 149-51.
30. Seligman M, Darling RB. Applying a systems approach to the
identification of family strengths and needs: the individual-
ized family service plan and beyond. In: Seligman M, editor.
Ordinary families, special children: a systems approach to
childhood disability. New York: Guilford Press; 1989.
p. 245-60.
31. Hanson SMH, Mischke KB. Family health assessment and
intervention. In: Bomar PJ, editor. Nursing and family health
promotion: concepts, assessment, and interventions. 2nd ed.
Toronto: WB Saunders; 1996. p. 165-202.
32. Harris MR, Warren JJ. Patient outcomes: assessment issues for
the CNS. Clin Nurse Spec 1995;9:82-6.
33. Speer JJ, Sachs B. Selecting the appropriate family assessment
tool. Pediatr Nurs 1985;11:349-55.
34. Olson DH. Circumplex model VII: validation studies and
FACES III. Fam Process 1986;25:337-51.
35. Roberts CS, Feetham SL. Assessing family functioning across
three areas of relationships. Nurs Res 1982;31:231-5.
36. Smilkstein G. The family APGAR: a proposal for a family func-
tion test and its use by physicians. J Fam Pract 1978;6:1231-9.
37. Epstein NB, Baldwin LM, Bishop DS. The McMaster family
assessment device. J Marital Fam Ther 1983;9:171-80.
38. Moos RH, Moos BS. A typology of family social environments.
Fam Process 1976;15:357-71.
39. McCubbin HI, Olson DH, Larsen AS. F-COPES family crisis ori-
ented personal evaluation scales. In: McCubbin HI, Thompson
AI, editors. Family assessment inventories for research and
practice. Madison (WI): University of Wisconsin-Madison;
1987. p. 195-207.
40. Rawlins PS, Rawlins TD, Horner M. Development of the
family needs assessment tool. West J Nurs Res 1990;12:
201-14.
41. Pless IB, Satterwhite B. A measure of family functioning and
its application. Soc Sci Med 1973;7:613-21.
42. Leske JS. Needs of relatives of critically ill patients: a follow-
up. Heart Lung 1986;15:189-93.
43. Artinian NT. Selecting a model to guide family assessment.
Dimens Crit Care Nurs 1994;14:4-16.
44. Casey BA. The family as a system. In: Bomar PJ, editor. Nurs-
ing and family health promotion: concepts, assessment,
and interventions. 2nd ed. Toronto: WB Saunders; 1996. p.
49-59.
45. Olson DH, Russell CS, Sprenkle DH. Circumplex model of
marital and family systems: VI. Theoretical update. Fam
Process 1983;22:69-83.
46. Olson DH, Sprenkle DH, Russell CS. Circumplex model of
marital and family systems: I. Cohesion and adaptability
dimensions, family types, and clinical applications. Fam
Process 1979;18:3-28.
47. Grotevant HD, Carlson CI. Section VI abstracts of self-report
questionnaires: whole-family functioning. In: Family assess-
ment: a guide to methods and measures. New York: The Guil-
ford Press; 1989. p. 285-396.
MAY/JUNE 2000 HEART & LUNG
Neabel, Fothergill-Bourbonnais, and Dunning
48. Mercer RT. Theoretical perspectives on the family. In: Gilliss
CL, Highley BL, Roberts BM, Martinson IM, editors. Toward a
science of family nursing. Menlo Park (CA): Addison-Wesley;
1989. p. 9-36.
49. McCool WF, Tuttle J, Crowley A. Overview of contemporary
families. Crit Care Nurs Clin North Am 1992;4:549-58.
50. Andrews MP, Bubolz MM, Paolucci B. An ecological approach
to study of the family. Marriage Fam Rev 1980;3:29-49.
51. Flannery J. FAMLI-RESCUE: a family assessment tool for use
by neuroscience nurses in the acute care setting. J Neurosci
Nurs 1991;23:111-5.
52. Whall AL. Family system theory: relationship to nursing con-
ceptual models. In: Whall AL, Fawcett J, editors. Family theo-
ry development in nursing: state of the science and art.
Philadelphia: FA Davis Company; 1991. p. 317-41.
53. Hill R. Families under stress. New York: Harper & Row;
1949.
54. Wesley R. King’s goal attainment theory. In: Wesley R, editor.
Nursing theories and models. Philadelphia: Springhouse Cor-
poration; 1992. p. 78-85.
55. Whall AL, Fawcett J. The family as a focal phenomenon in
nursing. In: Whall AL, Fawcett J, editors. Family theory devel-
opment in nursing: state of the science and art. Philadelphia:
FA Davis Company; 1991. p. 7-29.
56. Fuhr RA, Moos RH, Dishotsky N. The use of family assessment
and feedback in ongoing family therapy. Am J Fam Ther
1981;9:24-36.
57. Birenbaum LK. Measurement of family coping. J Pediatr Oncol
Nurs 1991;8:39-42.
58. Munet-Vilaró F, Egan M. Reliability issues of the family environ-
HEART & LUNG VOL. 29, NO. 3
Family assessment tools
ment scale for cross-cultural research. Nurs Res 1990;39:
244-7.
59. LoBiondo-Wood G, Haber J. Reliability and validity. In: LoBion-
do-Wood G, Haber J, editors. Nursing research: methods, criti-
cal appraisal, and utilization. 3rd ed. St. Louis: Mosby; 1994. p.
365-84.
60. Smilkstein G, Ashworth C, Montano D. Validity and reliability
of the family APGAR as a test of family function. J Fam Pract
1982;15:303-11.
61. Leske JS. Internal psychometric properties of the critical care
family needs inventory. Heart Lung 1991;20:236-44.
62. Polit DF. Correlation and simple regression. In: Barhydt SJ,
editor. Data analysis & statistics for nursing research. Stam-
ford (CT): Appleton & Lange; 1996. p. 249.
63. Forman BD, Hogan BJ. Measures for evaluating total family
functioning. Fam Ther 1984;11:1-36.
64. Good MJD, Smilkstein G, Good BJ, Shaffer T, Arons T. The fam-
ily APGAR index: a study of construct validity. J Fam Pract
1979;8:577-82.
65. Miller IW, Epstein NB, Bishop DS, Keitner GI. The McMaster
family assessment device: reliability and validity. J Marital
Fam Ther 1985;11:345-56.
66. Olson DH. Commentary: three-dimensional (3-D) circumplex
model and revised scoring of FACES III. Fam Process
1991;30:74-9.
67. Bishop DS, Miller IW. Traumatic brain injury: empirical family
assessment techniques. J Head Trauma Rehab 1988;3:16-30.
68. Macey BA, Bouman CC. An evaluation of validity, reliability,
and readability of the critical care family needs inventory.
Heart Lung 1991;20:398-404.
209