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Advanced Practice Competencies: Family Systems Nursing

Advanced Practice Competencies: Family Systems Nursing

 Advanced nursing practice is an umbrella term describing an advanced level of clinical nursing practice that maximizes the use of graduate educational preparation, in-depth nursing knowledge and expertise in meeting the health needs of individuals, families, groups, communities and populations” (Canadian Nurses Association, 2008, p. 9). Advanced practice competencies of Family Systems Nursing related to direct clinical practice, consultation, collaboration, leadership, and research roles are identified below.  I have created this list of competencies from my own experience and scholarship and from the ideas of others who have written about competencies for practice with families in health care contexts.*  (Added information: In 2017, the International Family Nursing Association Practice Committee, of which I was a member, developed the IFNA Position Statement on Advanced Practice Competencies for Family Nursing).

The ideas offered by Scott Miller and colleagues in their quest to understand “expert performance” are particularly fitting as one considers what is advanced family nursing practice:

“What’s the best way to enhance the effectiveness of clinicians?  Studies on expertise and expert performance document a single, underlying trait shared by top performers across a variety of endeavors: deep domain-specific knowledgeIn short, the best know more, see more and, accordingly, are able to do more.  The same research identifies a universal set of processes that both account for how domain-specific knowledge is acquired and furnish step-by-step directions anyone can follow to improve their performance within a particular discipline.  Miller, Hubble, Chow, & Seidel (2013) identified and provided detailed descriptions of three essential activities giving rise to superior performance.  These include: (1) determining a baseline level of effectiveness; (2) obtaining systematic, ongoing feedback; and (3) engaging in deliberate practice.”

What then is the deep-domain specific knowledge and practice competencies needed for advanced family nursing practice? [Updated October 2015]

Central Core Competency: Direct Clinical Practice

1. Recognizes that all change occurs within the relationship between nurses and families.

2. Subsumes a belief that practicing curious compassion about a family’s health/ illness suffering invites a relationship devoid of judgment that enables family healing to occur.

3. Offers assessment and interventions that are inclusive of the family system as well as the individual system and family subsystems, and larger systems within which families are nested.

4. Adopts a stance of curiosity and tentativeness to avoid the temptation of certainty.

5. Embraces a belief that problems do not reside within individuals but between persons in language and beliefs.

6. Understands that illness suffering can be physical, emotional, relational, and/or spiritual.

7. Creatively develops systemic hypotheses that extend multiple understandings of the family and expand the direction of the clinical work with families.

8. Identifies and analyzes linkages between a variety of systems levels: individual, family, larger systems and is able to speculate how to target interventions for the greatest leverage of change.

9. Demonstrates strong engagement skills with family members and involves family choice in all aspects of planning, care, and education.

10. Demonstrates insatiable, genuine curiosity in therapeutic conversations with families and colleagues.

11. Addresses obstacles to change quickly (e.g., reluctance to participate, lack of clarity about the goals for therapeutic conversation, lack of neutrality, etc.).

12. Addresses coordination of services among care sites and multiple providers.

13. Identifies and analyzes significant conversational events between the nurse and the family.

14. Processes strong affect when it arises in the therapeutic conversations with families, i.e., sadness, anger, bolting, etc.

15. Shows confidence and competence around “speaking the unspeakable” in difficult conversations that matter (e.g., prognosis, death, suicide, abuse, domestic violence, mental illness, etc.).

16. Recognizes and acknowledges illness suffering in families, i.e., physical, emotional, relational and/or spiritual suffering.

17. Recognizes and acknowledges family strengths, competencies, and resources through the intervention of commendations.

18. Develops useful lines of inquiry using sophisticated interventive/reflexive questions that invite reflection by family members and the nurse.

19. Offers observations about families in the reflecting team intervention that are thoughtful, discerning, and extend understanding of the family.

20. Writes therapeutic letters that recognize illness suffering, offer new understanding, and are sensitive to language and tone.

21. Routinely invites goodness-of-fit conversations with families to assess the nurse/family relationship,  change/improvement in the presenting concerns of the family, as well as satisfaction with the direction and pace of the clinical work.

22. Demonstrates awareness of one’s own beliefs, values, and assumptions and shows a willingness to challenge one’s own beliefs.

23. Demonstrates a commitment to deliberate practice that involves asking for feedback from families and colleagues and reflecting on one’s own practice with families.

24. Incorporates evidence, best practices, and multiple ways of knowing in practice with families.

25. Routinely seeks consultation, learning opportunities,  and supervision for development of own practice skills and knowledge.

26. Engages in deliberate practice by reflecting on each encounter with families and and analyzing what interventions seemed useful and not useful for that particular family.


1. Creates opportunities for bidirectional interdisciplinary consultation about family-focused care with colleagues.

2. Seeks consultation and professional support when need for family care exceeds level of professional competence.

4. Regularly seeks peer supervision and feedback to grow clinical practice excellence in family nursing.

5. Offers guidance to colleagues and clients about family-focused issues and family care dilemmas.


1. Demonstrates and promotes effective communication and collaborative skills in interdisciplinary relationships.

2. Employs effective communication and collaborative skills in the development and implementation of practice guidelines, peer review, standards of care and/or other scholarly products.

3. Ensures the coordination and continuity of care with families during transitions in care.

4. Initiates and supports ongoing learning and quality improvement projects focused on caring for families in health care environments.


1. Demonstrates a strong commitment to advance clinical excellence with families.

2. Uses systemic thinking and interprofessional collaboration to implement and evaluate changes in family care within health care environments.

3. Creates a culture of feedback in health care environments for the purpose of deliberate improvement in family-focused practice and health care delivery systems.

4. Advocates for families and family nursing within policy and health care communities.

5. Builds a network of relationships to receive mentorship and promote and advance family nursing in local, national and international organizations.

6. Uses social media and other marketing skills to advance family-focused care.


1. Employs evidence-based and evidence-informed models of assessment and intervention models to create and sustain practice change with families in health care contexts.

2. Engages in and/or supports diffusion of practice innovations for family care to assess efficacy on family health outcomes and care environments.

3. Initiates, participates in, and/or supports family-focused quality improvement initiatives and/or knowledge translation of family nursing theory to health care environments.

4. Uses data and health information technology to improve practice with families and practice environments for families.

Ethical Decision Making

1. Demonstrates ethical behavior with particular attention to dual relationship matters, confidentiality, informed consent, boundary issues, and clinical team functioning.

* I am grateful to Dr. Lorraine Wright and Dr. Fabie Duhamel for their refinements to this list of competencies.

References which have informed my thinking about Advanced Practice competencies in Family Systems Nursing

American Association for Marriage and Family Therapy (AAMFT).  (2004). Marriage and Family Therapy Core CompetenciesAlexandria, VA: Author. Retrieved from

Bell, J. M. Selected bibliography on Family Systems Nursing. Retrieved from:

Bell, J. M. Selected bibliography on the Scholarship of Practice with Families. Retrieved from:

Bell, J.M. (1996). Advanced practice in family nursing: One view [Editorial]. Journal of Family Nursing, 2(3), 244-247. doi: 10.1177/107484079600200302

Bell, J.M. (1998).  Rx for certainty in clinical work with families: Insatiable curiosity [Editorial]. Journal of Family Nursing, 4(2), 123-126. doi:10.1177/107484079800400201

Bell, J.M. (2003).  Clinical scholarship in family nursing [Editorial].  Journal of Family Nursing, 9(2), 127-129. doi: 10.1177/1074840703009002001

Bell. J. M. (2008). The Family Nursing Unit, University of Calgary: Reflections on 25 years of clinical scholarship (1982-2007) and closure announcement [Editorial].  Journal of Family Nursing, 14(3), 275-288. doi: 10.1177/1074840708323598

Bell, J.M. (2009).  Family Systems Nursing re-examined [Editorial].  Journal of Family Nursing, 15(2), 123-129. doi:10.1177/1074840709335533

Bell, J. M. (2011).  Relationships: The heart of the matter in family nursing [Editorial].  Journal of Family Nursing, 17(1), 3-10. doi: 10.1177/1074840711398464

Bell, J. M. (2013). Family nursing is more than family centered care [Editorial]. Journal of Family Nursing, 19(4), 411-417. doi:10.1177/1074840713512750

Bell, J. M. (2014).  Family centered care and family nursing: Three beliefs that matter most [Guest Editorial for a Special Issue on Family Centered Care]. Pfelge, 27(4), 213-217. doi:10.1024/1012-5302/a000369

Bell, J. M. (2014). Knowledge translation in family nursing: Gazing into the Promised Land [Editorial]. Journal of Family Nursing, 20(1), 3-12. doi:10.1177/1074840714521731

Bell, J. M. (2014). Creating a culture of feedback in family nursing [Editorial]. Journal of Family Nursing, 20(4), 383-389. doi: 10.1177/1074840714559505

Bell, J. M. (2015). Growing the science of Family Systems Nursing: Family health intervention research focused on illness suffering and family healing [L’avancement de la recherché sur l’intervention infirmiere systémique en santé familiale: bilan]. In F. Duhamel (Ed.), La santé et la famille: Une approche systémique en soins infirmiers [Families and health: A systemic approach in nursing care] (3rd ed., 102-125.) Montreal, Quebec, Canada: Gaëtan Morin editeur, Chenelière Éducation. [In French]

Bell, J. M., Moules, N. J., & Wright, L. M. (2009).  Therapeutic letters and the Family Nursing Unit: A legacy of advanced nursing practice.  Journal of Family Nursing, 15(1), 6-30. doi: 10.1177/1074840709331865

Bell, J.M., & Wright, L.M. (2011).  The Illness Beliefs Model: Creating practice knowledge for families experiencing illness suffering.  In E.K. Svarvarsdottir & H. Jonsdottir (Eds.), Family nursing in action (pp. 15-51). Reykjavik, Iceland: University of Iceland Press.

Bell, J. M., & Wright, L. M. (2015). The Illness Beliefs Model: Advancing practice knowledge about illness beliefs, family healing, and family interventions [Editorial]. Journal of Family Nursing, 21(2), 179-185. doi:10.1177/1074840715586889 [SPECIAL ISSUE ON THE ILLNESS BELIEFS MODEL]

Benzein, E., Hagberg, M., & Saveman, B.-I. (2008). Being appropriately unusual: A challenge for nurses in health fostering conversations with families. Nursing Inquiry, 15, 106-115. doi: 10.1111/j.1440-1800.2008.00401.

Benzein, E., Hagberg, M., & Saveman, B.-I. (2012). Att möta familjer inom vård och omsorg [Meeting with families in health and community care]. Stockholm, Sweden: Studentlitteratur. [in Swedish]

Bryant-Lukosius, D., DiCenso, A., Browne, G., & Pinelli, J. (2004). Advanced practice nursing roles: Development, implementation and evaluation. Journal of Advanced Nursing, 48(5), 519-529. doi: 10.1111/j.1365-2648.2004.03234.x

Canadian Nurses Association (2008). Advanced nursing practice: A national framework.  Ottawa, Ontario, Canada: Author.  Retrieved from

Duhamel, F. (Ed.). (2007).  La santé et la famille: Une approche systémique en soins infirmiers [Families and health: A systemic approach in nursing care] (2nd ed.). Montréal, Quebec, Canada; Gaétan Morin éditeur. Chenelière Éducation.

 Duhamel F. (2007). L’analyse du système familial dans des contextes de santé et de maladie [Family analysis in the context of health and illness]. In F. Duhamel (Ed.), La santé et la famille : Une approche systémique en soins infirmiers [Families and health: A systemic approach in nursing care] (2nd ed., pp. 39-61). Montréal, Quebec, Canada: Gaëtan Morin éditeur. Chenelière Éducation.

Duhamel F. (2007). Les interventions systémiques familiales auprès de la famille [Family nursing intervention]. In F. Duhamel (Ed.), La santé et la famille : Une approche systémique en soins infirmiers [Families and health: A systemic approach in nursing care] (2nd ed., pp. 63-86). Montréal, Quebec, Canada: Gaëtan Morin éditeur. Chenelière Éducation.

International Family Nursing Association (IFNA). (2015). IFNA Position Statement on Generalist Competencies for Family Nursing Practice.  Retrieved from

International Family Nursing Association (IFNA). (2017). IFNA Position Statement on Advanced Practice Competencies for Family Nursing.  Retrieved from

Maturana, H. R. (1998). Reality: The search for objectivity or the quest for a compelling argument.  The Irish Journal of Psychology, 9(1), 25-83.

Maturana, H. R., & Varela, F. J. (1992). The tree of knowledge: The biological roots of human understanding (rev. ed.). Boston, MA: Shambhala.

McDaniel, S. H., Grus, C. L., Cubic, R. A., Hunter, C. L., Kearney, L. K. Schuman, C. C.,…Johnson, S. B. (2014). Competencies for psychology practice in primary care.  American Psychologist, 69(4), 409-429. doi: 10.1037/a0036072

Victorian Order of Nurses (VON) (2012). Evidence-informed bereavement care: A primer of interventions towards health systems change. Toronto, Ontario, Canada: Author. Retrieved from

Wright, L. M. (2015).  Brain science and illness beliefs: An unexpected explanation of the healing power of therapeutic conversations and the family interventions that matter. Journal of Family Nursing, 21(2), 186-205. doi:10.1177/1074840715575822

Wright, L.M., & Bell, J.M. (2009). Beliefs and illness: A model for healing.  Calgary, Alberta, Canada: 4th Floor Press.

Wright, L. M., & Leahey, M. (2013). Nurses and families: A guide to family assessment and intervention (6th ed.).  Philadelphia, PA: F. A. Davis.

Wright, L.M., Watson, W.L., & Bell, J.M. (1996). Beliefs: The heart of healing in families and illness. New York, NY: Basic Books.