Development of a Family Assessment Instrument for Transcultural Use

ARTICLE

10.1177/1043659602250612 Friedemann JOURNAL OF et al. TRANSCULTURAL / DEVELOPMENTNURSING OF FAMILY / April ASSESSMENT 2003

RESEARCH DEPARTMENT

Development of a Family Assessment Instrument for Transcultural Use MARIE-LUISE FRIEDEMANN, PhD, RN Florida International University

PÄIVI ÅSTEDT-KURKI, PhD, RN EIJA PAAVILAINEN, PhD, RN University of Tampere, Finland

Purpose: The article describes challenges related to the transfer of a family assessment instrument, the Assessment of Strategies in Families-Effectiveness (ASF-E), and its theoretical basis to another culture. Design: Instrument development encompassed translation and discussion of theoretical and cultural relevance of the items. Patients from two clinics in Tampere, Finland (N = 196) completed the ASF. Psychometric tests involved factor and reliability analysis. Results: The theoretical constructs of stability, growth, control and connectedness/spirituality were represented in the factor structure, and reliability ranged from .65 to .83. Discussion: There were cultural differences in the interpretation of certain items. Characteristics of Finnish culture with impact on instrument validity were homogeneity and family emphasis on conflict resolution. Insights contributed to further instrument development and broader understanding of culture.

Keywords: family functioning; instrument; assessment; culture; Finland; translation; ethnicity; measurement; transcultural nursing

This discussion involves issues related to the development

of a culture-congruent family assessment instrument and the methodology of transferring theoretical concepts and item

Authors’ Note: The authors are grateful to Tarja Tammentie, MNSc, RN, Research Assistant and Marita Paunonen-Ilmonen, PhD, RN, Professor, department head at the University of Tampere for their contribution to the preparation of this article. Journal of Transcultural Nursing, Vol. 14 No. 2, April 2003 90-99 DOI: 10.1177/1043659602250612 © 2003 Sage Publications

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content to another culture. The example of developing a version of the Assessment of Strategies in Families– Effectiveness (ASF-E) (Friedemann, 1991) to be used in Finland is cited here to explain the process of instrument development abroad. Nurse researchers who accept the challenge of conducting research with international populations within and outside the United States will be alerted to challenges related to the transfer of theoretical constructs defined in the United States for use elsewhere and the translation of items expressing these concepts. The history of the ASF-E and its theoretical basis are followed by a description of Finnish family characteristics and core values that were developed throughout history and influenced by economics, laws, and the social welfare system. The processes of instrument translation and adjustment of some items to these Finnish cultural traits are followed by conclusions helpful for the transcultural nurse researcher. THE ASSESSMENT OF STRATEGIES IN FAMILIES–EFFECTIVENESS (ASF-E) The ASF-E is a brief screening instrument to assess family effectiveness. The Framework of Systemic Organization constitutes the theoretical basis of the ASF-E. One or more family members complete it in order to evaluate the quality of their family process. It is used for both clinical and research purposes. Clinically, it serves to determine the perceived need for therapy or determine progress as a result of family therapy. In research, it can be used to operationalize the construct or variable called family health or family functioning. The instrument is, therefore, an appropriate tool to be used in conjunction with family nursing interventions or for research guided by the Framework of Systemic Organization (Friedemann, 1995).

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Instrument development and testing for validity and reliability of the English ASF-E have been previously reported (Friedemann, 1991; Friedemann & Smith, 1997). The newest version of the 20-item English language ASF-E includes four subscores for family stability, growth, control and spirituality/ connectedness, and a total score. Each item consists of three response alternatives. These statements express outcomes of family strategies. They are rated from 1 (lowest effectiveness) to 3 (effectiveness needed to maintain the family and grow over time). The respondents select the statement that best describes their family. Methods to test content, construct, and concurrent validity as well as internal consistency and testretest reliability were described by Friedemann in 1991. Since then, seven test runs with ethnically mixed samples have consistently yielded a firm factor structure. Most recent testing showed internal consistency coefficients (Cronbach’s alpha) that ranged from .69 to .82 for the subscales (Friedemann, 1998). The version of the ASF-E used for the above cited test run in 1998 initially had 25 items that were subsequently reduced to 20 items. These initial 25 items were translated into Finnish, German, Spanish, and Portuguese and tested with various populations in Finland, Switzerland, Portugal, Mexico, Colombia and the U.S. (Chávez Aguilera, Friedemann, & Alcorte Garza, 2000, 2001; Friedemann, 1998). THE THEORETICAL BASIS The Framework of Systemic Organization (Friedemann, 1995) has been found applicable to nursing practice in Finland because, like the philosophy guiding the curriculum of the University of Tampere, it is based on ecological systems concepts and processes. The family is viewed as a pivotal system that allows individuals to play vital roles within the family and outside. Friedemann (1995) also defined the family as a system with interpersonal subsystems of dyads and larger units distinguished by mutual emotional bonds and common responsibilities (e.g. subsystems of parents and siblings). Family members do not need to be biologically related or live in the same household, but must be connected through either positive or negative emotional ties and carry functions in the family system. Culture is lived by the family and inherent in the family process as well as in the interactions of the members within the family and with their environment (Friedemann, 1995). Congruence. The core concept in the Framework of Systemic Organization is congruence that signifies a state of harmony and compatibility between members, the family, and the environment. Being a dynamic state, congruence is sought by all families but never can be fully reached. Family health. The experience of a satisfactory level of congruence, indicated by low anxiety and low family conflict,

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is defined as family health. The four dimensions measured by the ASF-E—stability, growth, control, and connectedness/ spirituality—are the targets that family systems pursue in their striving toward congruence and health through specific behavior patterns and strategies. Family target stability. Stability addresses processes rooted in tradition that are based on shared values and cultural beliefs. Stability is achieved by the conduct of daily family activities, mutual caring, celebration of events, communication, sharing of time and emotions, and commitment to the family. Family target growth. Growth is experienced as members gain new ideas, knowledge, and realizations and incorporate them in the family process. As members mature or change over time, the family system as a whole must realign itself, rearrange its priorities, and adjust its operation. Growth is, therefore, the product of adaptation of the family system to internal and external changes. Family target control. Control is the family’s way of minimizing destructive influences. Through control, the family maintains tradition, determines rules and roles for its members, disciplines transgressions, channels information and decides whether knowledge should be incorporated and changes should be made in the family process. Family target connectedness/spirituality. The target of connectedness/spirituality seeks the emotional togetherness of a family. It encompasses the continued renewal of relationships, mutuality, commitment within and outside the family, and the search for meaning. Connectedness/spirituality gains special importance where control fails. Instead of reacting to interfering factors, the family seeks to adjust and change within to find new congruence and harmony on a higher level. The pursuit of this target can lead to acceptance of conditions that often cannot be avoided, such as tragedies, losses, chronic illness, or deaths. The family targets represent plausible theoretical constructs that by way of interacting promote congruence. Families experience family health if they are able to balance the four targets and reach congruence or harmony the way they have defined it as being right for them. Figure 1 shows a model of the family process proposed by the Framework of Systemic Organization. The concept of culture. Culture in a broad sense is described by Friedemann (1995) as the family process itself as shown in Figure 1. Families engage in both culture maintenance and culture transformation. Maintaining culture equals the pursuit of stability as explained above, whereas transforming culture relates to growth or the continued adjustment to a changing environment that leads families to

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Environment

STABILITY

Coherence

System Maintenance

SPIRITUALITY

CONTROL Individuation

Environment

Environment

System Change

GROWTH

Environment

FIGURE 1. The Family Process. SOURCE: Friedemann (1995). Reprinted by permission of Sage Publications.

adopt new skills and strategies and incorporate them in the family process to be passed on to the children as family tradition. Culture maintenance and transformation occur concurrently as certain values and behaviors are replaced by others, whereas the majority of cultural beliefs are fiercely protected and remain part of the family. The two basic culture processes are assumed to be true for all families; the pursuit of congruence through the targets applies to all cultural groups. Differences in the way the targets are pursued and the emphasis families place on each target reflect the family’s style or cultural orientation. Great differences are evident in the behavior patterns families use and in the degree of flexibility or readiness to change learned attitudes and behaviors. Other differences are seen in the use of actions to bring about control or connectedness/spirituality that have the potential to either support culture maintenance or transformation (Friedemann, 1995). The development of the model depicted in Figure 1 started with the discovery of four dimensions of family strategies as a result of the initial factor analyses conducted for the testing of the ASF-E (Friedemann, 1991). These process dimensions used to pursue the four family targets are pictured in the inner circle of the model. They constitute behaviors that can be assessed, measured, and evaluated. Process dimension of system maintenance. System maintenance entails the family behaviors that organize and structure the family process, such as following rules, sharing space, making decisions. Process dimension of coherence. Coherence relates to behaviors that are expressive of the emotional family bond

such as sharing activities, time, and space; helping each other; and showing interest and respect for the others. Process dimension of individuation. Individuation includes the members’ ways of gaining new knowledge, being involved in activities outside the family, and finding meaning for their striving. Process dimension of system change. System change encompasses those new behaviors that result from new information gained through individuation and the subsequent change in shared values and beliefs. It includes setting new priorities and changing rules of relating to each other and rules of family operation. The innermost arrows of the model (see Figure 1) indicate that behaviors of system maintenance and coherence contribute to the target of stability, behaviors relative to individuation and system change lead to growth, system maintenance and system change encompass the family strategies leading to control, and coherence and individuation contribute to the target of connectedness/spirituality. It follows that items expressing family strategies related to these observable behaviors or process dimensions can be summed up accordingly to express scores for the four targets. The formulation of these processes in items, however, presented a formidable challenge. To render the ASF-E transculturally applicable, it was necessary to avoid the focus on behaviors known to be specific to cultural groups. Instead, the ASF-E items express family behavior outcomes relative to the four process dimensions that are generally applicable to all families. Examples are emotional closeness, satisfaction

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with the division of labor, resolution of conflict, or the use of community resources. To use the items with Finnish families, Finnish cultural traits, as described below, had to be studied and discussed in relation to the intended theoretical meaning of each item. FAMILIES IN FINLAND In Europe, a sense of the past is rooted strongly in people’s minds and history plays a great role in shaping the perception of today’s conditions. Finland was a predominantly agricultural society until the 1960s. Therefore, it is only recently that the nuclear family model has replaced extended farm families. Finland has a history of being ruled by foreign powers and gained its independence only after World War I, in 1917. For a long time, Finland constituted a part of Sweden until it was annexed to Russia as a Grand Duchy in 1809 (Bradley, 1998). The themes of survival in a hostile environment and fear of external threats have lasted throughout much of Finland’s history and have contributed to such national characteristics as being suspicious or exercising silence (Saarelainen, 1999). Of particular interest is the Finnish language that is markedly different from all surrounding languages and has been fiercely maintained over the past centuries (Bradley, 1998). Such isolation has shaped a people of few words known for hard work, a strong will to overcome hardship, and an extraordinary gift to express their deep inner feelings in the form of literature, art, and music (Bradley, 1998; Saarelainen, 1999). Family values are a reflection of Finnish history as well. The agricultural system has strengthened the functional roles of families and developed core values of industriousness, self-sufficiency, and seriousness. Historically, family pride rested on working and accomplishing together whereas asking for outside help was extremely difficult and giving assistance or partaking in charity was little tolerated (Saarelainen, 1999). Female family members have acquired particular strengths throughout history. Women achieved the right to vote as early as 1906, as a result of class politics and protest against Russia rather than a true suffrage movement (KorppiTommola, 1990). Political equality was paired with a historic trend of women being part of the workforce (Bradley, 1998); 85% of Finnish mothers were employed outside the house as early as in the 1980s (Tolkki-Nikkonen, 1996). Stemming from their agricultural system, women always perceived their roles as meeting responsibilities both at work and in the family (Apple-Sweetser, 1968). Thus, as in the past, the typical Finnish family of today has two wage earners (Saarelainen, 1999). Equality of women, however, falls short in terms of valuing the differences between men and women. Female employment is often seen as a negative phenomenon, taking

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mothers away from their children, and female wages are 20% lower than equivalent male wages (Tolkki-Nikkonen, 1996). Distinct gender roles are still highly ingrained in today’s family systems, particularly in the working class, and many families have remained patriarchical (Bradley, 1998). Motherhood is considered work by many, more so than enjoyment (Tolkki-Nikkonen, 1996). Due to the country’s history of cultural isolation, a strong adherence to the traditional role of the male as breadwinner has persisted. Finnish men have been found to spend considerably less time in the household than other Scandinavian men (Haavio-Mannila, 1985) but, recently, the situation has been changing rapidly, particularly in better educated population segments (Bradley, 1998). The value of self-sufficiency still is evident in the raising of children. Children are given relatively great independence at early ages and are discouraged from unnecessarily asking for help (Saarelainen, 1999). Although strong in their independence, the Finns’ reluctance to express feelings, however, has the potential to create mutual isolation within families (Hakulinen & Paunonen, 1995) and has been blamed for contributing to the heavy use of alcohol and Finland’s suicide rate, which is one of the world’s highest (Hakulinen & Paunonen, 1995; Hyssälä, Hyttinen, Rautava, & Sillanpää, 1993; Saarelainen, 1999). In more recent history, through the formation of the welfare state, families have experienced many positive changes. Social services were developed in Finland that are used by everyone. Family subsidies through child allowances and tax deductions have become a major financial support of families (Bradley, 1998). Finland is unique even among Scandinavian countries in that its strong day-care program, accessible to everyone, includes not only community centers but also the possibility of having children attended at the family’s home (Bradley, 1998; Jaakola, Cantell, & Aromaa, 1982). Maternity leaves are extensive in that, according to Government reports, 70% of new mothers tend to stay home longer than 10 months after delivery (Jaakola, Cantell, & Aromaa, 1982). In short, history has shaped the way families in Finland operate today. The distinct homogeneity of values and behavior patterns, coupled with specific ways that families interact with each other and with their communities make the transfer of an assessment instrument that was based on the highly multicultural society in the United States a challenge. DEVELOPMENT OF THE ASF-E FOR TRANSCULTURAL USE The steps of instrument development are pictured in Figure 2. Translation and Cultural Adaptation of the ASF-E

The instrument was translated using the back-translation technique (White & Elander, 1992). A native, licensed translator produced the initial Finnish version that was translated

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Translation and Cultural Adaptation

Expert Evaluation

Psychometric Testing

Conceptual Evaluation

TRANSLATION AND BACKTRANSLATION ITEM EVALUATION FOR CONCEPTUAL/ CULTURAL MEANING DISCUSSION OF CULTURAL ISSUES

ITEM MODIFICATION TO EXPRESS CULTURAL MEANING

RESPONSE OPTION RATING

INSTRUMENT ADMINISTRATION N = 196 EXAMINATION OF MEANING OF SCALES ITEM ANALYSIS Score Distributions Item to Item Correlations FINAL DECISISON ABOUT ITEM INCLUSION

ITEM REFINEMENT TRIMMING OF ITEMS

FACTOR ANALYSIS

TRIMMING OF ITEMS

RELIABILITY ANALYSIS OF SCALES

FIGURE 2.

Steps of Instrument Development.

back into English by three Finns, all fluent in both languages but unfamiliar with the original English version. The translation was then given to Friedemann for approval or comments. Unclear and incorrectly translated parts were mutually discussed and the wording was changed in several response alternatives in order to come closer to the intended meaning. The back-translated version, however, also became a concrete documentation of some of the cultural issues previously discussed. It became evident that items that expressed connectedness with the community and growth through individuation were most severely affected by cultural inconsistencies. Figure 3 shows two problematic items in their original and altered format. In item 1, the response choice “We participate in activities that the community, church, or school offer, because we like to be part of what’s happening” could not be transferred to the Finnish culture without changes. The word “community” has several meanings in the Finnish language and needed to be confined to “place of residence”. The church in Finland is a government-supported institution. As such, it provides strictly religious guidance and education and does not depend on private monetary contributions. Social service and social outreach are not considered church functions but are provided by other government agencies. A great majority of Finns belong to the Protestant church but few

commit their time to church activities (Saarelainen, 1999). Many attend church services only on major holidays or not at all. The services of a minister or support staff is mainly used in times of crises, for infant baptisms, confirmation celebration, funerals, and some weddings. The word church was therefore translated with congregation in this item, as this term implies a broader meaning in the Finnish language and includes assemblies for nonreligious purposes. Involvement in schools seemed problematic as well because schools in Finland allow for little parent input beyond the support of their individual child in the learning process. It was therefore eliminated. Item 2 presented a problem both with translation and cultural meaning. One of the response options was “Some community organizations are better than others but they usually try to help people”; the other two options inferred mistrust of community service agencies. The original intent of the item was the measurement of family connectedness with agencies that provide family resources. Based on the generally accessible social welfare system and more evenly distributed wealth in Finland, there is no need for Finns to seek resources in community-based agencies to maintain health and well-being as many families in the United States do. The problem was circumvented by translating the words community organiza-

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Item 1 - Original Version

We participate in activities that the community, church or school offer because we like to be part of what's happening.

We sometimes take part in a community, church, or school activity if someone asks us to come along.

(score 3)

(score 2)

We don’t have time or energy to be involved in community, church, or school activities (score 1)

Altered Version for Finland

We participate in activities that are going on in our “place of residence” or “congregations” because we like to be part of what’s happening.

We sometimes take part in an activity in our “place or residence” or a “congregation” if someone asks us to come along.

We don’t have time or energy to be involved in activities in our “place of residence” or “congregations”.

We have learned how to handle community organizations, but sometimes they give us a hard time.

It’s best to stay away from community organizations because they don’t treat us well.

Item 2 – Original Version Some community organizations are better than others but they usually try to help people.

(score 3)

(score 2)

(score 1)

We have learned to let our voice be heard in voluntary or neighborhood organizations, but sometimes they give us a hard time.

It’s best to stay away from neighborhood or voluntary organizations because they don’t support the people.

Altered Version for Finland Some neighborhood or voluntary organizations are better than others but they usually try to speak for the people.

FIGURE 3.

Sample Items With Adjustment for Culture.

tion into neighborhood association or voluntary organization and adding other minor changes in wording (see Figure 3). In Finland, the people privately form voluntary organizations for the purpose of promoting a common interest or mission. Because the membership in such organizations is voluntary, the stakeholders in Finland are distinctly less dependent on the organization than the clients of a service agency in the United States. Clearly, the translation shifted the meaning of the item from using the community to procure family resources to using the community to advocate for the wellbeing of the family. Even though the new meaning appeared to be still congruent with the theoretical concepts of community connectedness and family growth, the exact cultural meaning of the responses was still under discussion at the time of instrument testing. The decision was made to test both items in their modified version and to examine the cultural issues once more based on the results. Method of Testing of the ASF-E

To increase content validity, the translated Finnish 25-item questionnaire was evaluated by a group of 30 graduate students in family nursing at the University of Tampere. The students rated independently the level of family functioning expressed by the response options of the items from 1 to 3; there was agreement about the rating of all 25 items. Having

studied the Framework of Systemic Organization, the group was then asked to provide input about the clarity of the statements and examine the response options for each item. Because the three response options are not always mutually exclusive, the group perceived a danger that the differences between the choices were diminished by the choice of words in the translation. Each item was therefore discussed separately and, as a result, several response options were worded more strongly in order to better distinguish them from the other choices and to facilitate a wider distribution of responses. The refined questionnaires were then given to 196 predominantly middle-aged patients in two outpatient clinics in Tampere University Hospital who completed them independently. The respondents all represented different families. The demographics are summarized in Table 1. Due to the differences in item content, The Finnish ASF-E was considered an instrument independent of the English ASF-E. Therefore, it was tested with an exploratory principal component factor analysis using Varimax orthogonal rotation rather than with confirmatory procedures. In addition, the internal consistency of the factors and relative subscales were tested by computing Cronbach’s alpha coefficients. Prior to the factor analysis, the distribution of responses within all 25 items and item-to-item correlations were exam-

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JOURNAL OF TRANSCULTURAL NURSING / April 2003 TABLE 2 ASF-E Subscales and Reliability

TABLE 1 Demographics of the Sample Variable

Category

Frequency

Percentage

Item Reliability Number (Cronbach Alpha)

Scale Gender

Marital status

Education

Number children

Number adults

Male Female Missing Single Married Living together Widowed Divorced 9 years of school 12 years of school Apprenticeship Technical college University Other No children 1 child 2 children 3 children 4 or more children 1 adult 2 adults 3 adults 4 or more adults

43 151 2 27 113 29 8 19 81 9 38 42 9 17 119 38 24 12 3 20 114 29 33

22 77 1 14 57 15 4 10 41 5 19 21 5 9 61 19 12 6 2 10 58 15 17

ined. It is recommended that items be eliminated if their p values (proportions of persons choosing the most frequent response option) are greater than .80 (Kline, 1993). In this homogeneous Finnish sample, in spite of the wording changes discussed earlier, three items were highly skewed in that 90 to 95% of the respondents selected the most effective option of family functioning and were eliminated. Item-to-item correlations within each target or intended subscale had to be at least .30 or statistically significant for items to be retained (Kline, 1993). In addition, extremely high correlations would have called for the elimination of one of the items with almost identical meaning. Based on the correlational analysis, all remaining 22 items were included in further testing. FINDINGS The result of the factor analysis was a solution with 20 items resulting in four factors that explained 50.4% of the variance. All items clearly loaded on a primary factor and cross loadings were smaller than .40. Detailed procedures and results are reported elsewhere (Astedt-Kurki, Friedemann, Paavilainen, Tammentie, & Paunonen-Ilmonen, 2001). CONGRUENCE WITH THE THEORETICAL MODEL Because the response options of the items express observable and measurable family strategies, all ASF-E items measure the

Stability (s.maintenance, coherence) Growth (s.change, individuation) Control (s.maintenance, s.change) Spirituality (coherence, individuation) Total family effectiveness

13 7 11 9 20

.83 .65 .76 .71 .85

concepts relative to the process dimensions in Friedemann’s (1995) model: System maintenance, coherence, system change, and individuation. In accordance with the model, the more abstract family targets (subscales) were inferred. The items of the two appropriate process dimensions were added to arrive at the subscale relative to each target (see Figure 1). The reliability coefficients for stability (system maintenance and coherence), growth (system change and individuation), control (system maintenance and system change), and connectedness/spirituality (coherence and individuation) ranged from .65 to .83 and the Cronbach alpha for the total scale was .85. The factor structure supported the model and suggested construct validity. Shown in Table 3, Factor 1 represented a combination of items of system maintenance (mutual activities) and coherence; Factor 2 grouped items of system change; Factor 3 was composed of three other system maintenance items (working out differences); and Factor 4 entailed individuation. The third column in Table 3 shows the dimension to which the item was assigned as a result of its factor loading. The items are listed according to the size of their loading, the item with the highest loading being listed first in each factor. The last column lists the items’ originally intended designation to a process dimension. The factor analysis placed 15 items into their originally intended dimension, whereas two items (in italics) intended to measure individuation factored on the same target of Growth but with items of the other process dimension, system change. Two items (capital letters) were switched not only to another process dimension but also to another target. The meaning of these findings will be revisited in the discussion below. DISCUSSION OF CULTURAL MEANING Factor analysis is an experimental rather than an exact procedure. Therefore, explanations of the results as they relate to cultural perceptions of the respondents have to be considered tentative, even if they are based on existing literature and previous research with Finnish families. Nevertheless, tentative conclusions presented here will serve as guidelines for further instrument development and testing.

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TABLE 3 Assigned and Originally Intended Dimensions of Instrument Items Item Content Agreement about division of labor Solving problems together Satisfaction with family decisions Allowing different interests Being helpful/not doing enough Working out disagreements Feeling about being with the family Learning from problems Putting the family first Understanding each other Family being supportive Feelings in the family Family being flexible to change Participate in congregation/neighborhood Dealing with voluntary organizations Associating with people Expressing one’s opinion Respecting differences Helping out in the neighborhood Participate in activities

Factor No. 1 1 1 3 3 3 1 1 1 1 1 1 1 2 2 2 2 2 4 4

Assigned Dimension

Intended Dimension

System maintenance System maintenance System maintenance System maintenance System maintenance System maintenance Coherence Coherence Coherence Coherence Coherence Coherence Coherence System change System change System change System change System change Individuation Individuation

System maintenance System change System maintenance Individuation System maintenance System maintenance Coherence System change Coherence Coherence Coherence Coherence Coherence System change System change System change Individuation Individuation Individuation Individuation

The most important revelation about Finnish family culture was its homogeneity. It became evident in the small variance of the responses to some ASF-E items. In addition to the three items excluded on the basis of p values above .90, there were five more items with p values around .80. Compared with response distributions of the same items in community samples in the United States the difference was considerable. Finnish families seemed to respond according to strong values true for everyone. It is interesting that these positively skewed items of the Finnish ASF-E related to problem solving, whereas, in the United States, family coherence items were most likely to be skewed. Four of the five skewed items retained in the Finnish questionnaire had the common theme of respecting differences in family members and working them out among each other. This seems to confirm the fierce individualism pursued by these families (Saarelainen, 1999). The value of individualism integrated in the functioning of the family system seemed to have shaped a family norm that tolerates openly stated arguments and ongoing interpersonal conflict and considers as healthy family work toward conflict resolution. The Finnish researcher suspected that these families experienced a fair amount of interpersonal difficulties, but, judging from their responses, they seemed to derive considerable pride from dealing with them successfully. This stands in stark contrast to other cultures, in the United States and elsewhere. Especially in cultures in which women occupy a less dominant role, rather than conflict resolution, the avoidance of conflict is valued and the family perceives its role as one of silencing conflict-provoking opinions and atti-

tudes; the successful family is the one in which members cooperate with each other without raising their voices. The predominance of conflict avoidance in U.S. families has been reflected in two previous studies with the ASF-E (DeMarco, 1996; Friedemann & Smith, 1997). In addition, the results of a third study with a sample of working class women in the Midwest seemed to support the notion that the women put high emphasis on family coherence as a function of their role. They described themselves as emotional support persons and peacemakers in the family (Friedemann & Webb, 1995). Consequently, in the United States, social desirability is most likely to affect family coherence or the target of stability, as families have difficulties acknowledging the existence of interpersonal conflict, whereas in Finland, the items most vulnerable to social desirability concern system maintenance and change or the target of control through activities of problem solving and working out solutions. This recognition had direct implications for the future revision of the items and measurement. Based on the skew of the responses, Finnish subjects were eager to report that they meet conflict head-on and feel proud of it. If they were not successful in resolving their conflict, however, the items did not always offer them a suitable choice. The negative statements of the ASF-E items reflecting decision making or openness of expression tend to lean toward conflict avoidance rather unsuccessful argumentation. For example, “If we have a strong opinion, we keep it to ourselves” seems inappropriate for the Finnish culture because such a choice does not seem to be an option. Consequently, such items will have to be modified to express the various degrees of success with conflict resolution.

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The second issue examined was the changeover to another dimension in five ASF-E items. The first item concerned with community organizations was the one initially under discussion. The modified item expressing the involvement of the family with voluntary associations that pursue a worthy cause or mission was viewed as system maintenance by Finnish respondents. A tentative explanation would indicate that participation in such an organization was for the sake of supporting the family and its members or the values they stand for. In contrast, the original intent of the item was to express system change, in that families in the United States tend to reach out to community support agencies in times of crisis at the point when they are ready to make changes in their family operation. The second and third items that changed dimensions address the phenomenon discussed previously. The second item, originally intended to measure individuation, factored together with items of system maintenance; in fact, it was the lead item of the group expressing the resolution of disagreements and accepting differences. This new assignment seemed to be a reflection of the understanding of Finnish families that conflict resolution is a basic task of family maintenance and supports the conclusion relative to the discussion of skewed items above. Finnish families seem to be oriented toward change. Their flexibility to change the family process if the situation demands it is a family characteristic routed in tradition and points to a high degree of culture transformation in Finnish families. The third item changed from the intended dimension of system change to coherence. The topic here is learning lessons as a result of problem solving. It seems clear that if problems are solved by resolving family conflicts, the strategies of getting members together to talk and discuss solutions are acts of coherence. System change is defined as a change in values and attitudes as a result of which the family process will be modified (Friedemann, 1995). Watzlawick, Weakland, and Fisch (1974) defined this process as second order change. Based on their readiness to meet conflict head-on, Finnish families seemed to be able to solve most of their problems with first order change, namely change that leaves their family process intact (Watzlawick, Weakland, & Fisch, 1974). According to Friedemann (1995) such change pertains to system maintenance and coherence or the target of stability. Differently stated, an orientation toward flexibility allows such families to shift some of their beliefs and opinions while leaving the core values of independent thinking and respect for differences among family members intact. According to Friedemann (1995), true change (target of growth) that leads to altered core values and family process is likely to meet resistance out of fear of loosing the stability that defines the very nature of the family. To grow, often as a result of a crisis, families need to use second-order change. They solve their problems by reexamining values, changing opin-

ions, and rearranging priorities. This type of change is particularly difficult for families with conservative attitudes and a high emphasis on stability who find themselves in a rapidly changing environment as in the United States. The last two items for which a dimension change was necessary concern a relatively minor shift from individuation to system change within the same target of growth. Again, both items were related to individual opinions and differences. Both were highly skewed as negative options of suppressing individualism and were unacceptable choices for Finnish families. To improve these items to express the family members’ individuation, they will need to include negative statements that encompass the range of failures families experience in solving interpersonal difficulties. CONCLUSIONS The cultural insights gained through this study concerned differences between Finnish and U.S. families and indicated the manner in which to improve the Finnish ASF-E. System maintenance was found to have two dimensions in Finland, one concerning the family operation, the other the process of resolving interpersonal crises. This finding seems to speak to an apparent contradiction described by Saarelainen (1999) typical in Finnish families. Although being loosely connected and highly individualized, Finnish families are at the same time bound by strong emotional ties that render separation very painful. Items of the ASF-E will need to be modified to express the positive and negative outcomes of these two dimensions. With the exception of one item, coherence was understood in a similar way as in the United States as being and feeling together as one unit and sharing and solving problems together. Individuation as expressed by ASF-E items was understood as family support in the expression of the members’ individuality and as being involved outside the family with the assumption that such activity will expose family members to new ideas and knowledge that they will then use for personal and family growth. Whereas the sharing of emotions has been described as difficult for many Finnish individuals (Saarelainen, 1999), the discussion of opinions as a basis for dealing with each other seems to be commonplace in Finnish families. This activity fits the definition of individuation, however, there will be a need to construct additional items to strengthen this dimension in the ASF-E. The five items of system change, however, were problematic. They were positively skewed and will need to be readdressed. It seems that these items need to express the way Finns make second-order changes, the way they broaden their horizon and find meaning in difficult situations. Because religion seems to play a relatively minor role in Finnish life and asking for advice from someone outside the family is difficult (Saarelainen, 1999), is it through literature and the arts (Apple-Sweetser, 1968), through the educational system or

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with help of the media that people make such changes? Such questions need to be studied in preparation for the next version of the ASF-E. Finally, this study has contributed to the validation of the Framework of Systemic Organization. Factor analysis showed that it was possible to categorize family strategies according to the four proposed dimensions, suggesting, as Friedemann (1995) claims, that the overall family process may be applicable to different cultures whereas cultural differences are apparent in the way families pursue the systemic targets. This leaves the researcher on an open road to further revise and test the Finnish version and continue with other language versions of the ASF-E with reasonable confidence. Based on this example of instrument development, what advice can be given to others who might attempt similar work with other instruments? Before adapting psychometric measures to another culture, it is imperative to study the culture through the literature and discussion with the people. Furthermore, the instrument should be firmly anchored in a theoretical framework with assumptions that are equally valid in the culture in which the instrument is used as in the culture of instrument origin. Even with a solid foundation, however, surprises cannot be avoided. Translations of instruments are a formidable challenge as the respondents react not to the words alone. Instead, they create a personal meaning of each response option by interweaving their own values and beliefs about the world around them. Items, therefore, need to be constructed in such a way that they elicit the responses concurrent with the anticipated theoretical and cultural meaning the respondents ascribe to the items as they complete the instrument. This suggests that meticulous translation procedures are not enough. Additional procedures such as focus groups to let respondents discuss their thought processes in selecting response options similar to the ones conducted in the United States (Friedemann & Smith, 1997) may be beneficial. Of foremost importance, however, is the researchers’ vigilance and astuteness in observing the unique cultural patterns of the people studied. REFERENCES Apple-Sweetser, D. (1968). Intergenerational ties in Finnish urban families. American Sociological Review, 33, 236-246. Astedt-Kurki, P., Friedemann, M. L., Paavilainen, E, Tammentie, T., & Paunonen-Ilmonen, M. (2001). Assessment of strategies in families tested by Finnish families. International Journal of Nursing Studies, 38, 17-24. Bradley, D. (1998). Equality and patriarchy: Family law and state feminism in Finland. International Journal of the Sociology of Law, 26, 197-216. Chávez Aguilera, M. L., Friedemann, M. L., & Alcorte Garza, A. (2000). Evaluación de la escala de efectividad en el funcionamiento familiar

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[Evaluation of the Assessment of Strategies in Families—effectiveness scale]. Desarrollo Científico de Enfermería, 8, 12-18. Chávez Aguilera, M. L., Friedemann, M. L., & Alcorte Garza, A. (2001). Sistema familiar y autopercepción de sus adolescents [The family system and self-esteem of its adolescents]. Desarrollo Científico de Enfermería, 9, 297-302. DeMarco, R. (1996). The relationship between family life and workplace behavior: Exploring the gendered perceptions of staff nurses through the Framework of Systemic Organization. Unpublished doctoral dissertation, Wayne State University, Detroit, MI. Friedemann, M. L. (1991). An instrument to evaluate effectiveness of family functioning. Western Journal of Nursing Research, 13, 220-236. Friedemann, M. L. (1995). The Framework of Systemic Organization: A conceptual approach to nursing and families. Thousand Oaks, CA: Sage. Friedemann, M. L. (1998). 1998 testing of the ASF-E. Unpublished manuscript, Florida International University, Miami. Friedemann, M. L., & Smith, A. A. (1997). A triangulation approach to testing a family instrument. Western Journal of Nursing Research, 19, 364378. Friedemann, M. L., & Webb, A. A. (1995). Family health and mental health six years after economic stress and unemployment. Issues in Mental Health Nursing, 16(1), 51-66. Haavio-Mannila, E. (1985). The state, the family and the position of women in the Nordic countries and in Poland. In R. Alopuro (Ed.), Small states in comparative perspective (pp. 69-90). Oslo, Norway: NUP. Hakulinen, T., & Paunonen, M. (1995). The family dynamics of childbearing and childrearing families in Finland. Journal of Advanced Nursing, 22, 830-834. Hyssälä, L., Hyttinen, M., Rautava, P., & Sillanpää, M. (1993). The Finnish family competence study: The transition to fatherhood. The Journal of Genetic Psychology, 154(2), 199-208. Jaakola, R., Cantell, I., & Aromaa, K. (1982). Legal consequences of emerging family forms for the child. Journal of Comparative Family Studies, 13(2), 185-198. Kline, P. (1993). The handbook of psychological testing. London: Routledge. Korppi-Tommola, A. (1990). Fighting together for freedom. Scandinavian Journal of History, 15, 181-191. Saarelainen, R. (1999). Narratives that Finnish families tell themselves about themselves. In U. P. Gielen & A. L. Comunian (Eds.), International approaches to the family and family therapy (pp. 235-247). Padua, Italy: Unipress. Tolkki-Nikkonen, M. (1996). The state of family theory and research in Finland. Marriage and Family Review, 23, 657-679. Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change. New York: Norton. White, M., & Elander, E. (1992). Translation of an instrument: The USNordic family dynamics nursing research project. Scandinavian Journal of Caring Science, 6, 161-164.

Marie-Luise Friedemann, PhD, RN, is a professor and administrator in nursing at Florida International University. She is a theorist and researcher of family functioning. Päivi Åstedt-Kurki, PhD, RN, is a nursing department head at University of Tampere. Her research focus is family health and family collaboration in health care. Eija Paavilainen, PhD, RN, is acting professor at University of Tampere Department of Nursing Science. Dr. Paavilainen’s research and teaching interests concern family nursing and violence.