Pensar Enfermagem / v.29 n.01 / July 2025

DOI: 10.71861/pensarenf.v29i1.378 / e00378

Quantitative Original Article

How to cite this article: Soares L, Guedes V, Figueiredo H. Documentation of Family Nurse Assessment

and Intervention in the Structural Dimension: A Retrospective Study. Pensar Enf [Internet]. 2025 Jul; 29(1):

e00378. Available from: https://doi.org/10.71861/pensarenf.v29i1.378

Documentation of Family Nurse Assessment and

Intervention in the Structural Dimension: A

Retrospective Study

Abstract

Introduction

Documenting the Nursing Process contributes to the quality and safety of care, both for

individuals and for families as care recipients. The structural assessment of the family is the

starting point for understanding its composition and its internal and external resources.

Therefore, documenting the structural dimension is essential to ensuring care continuity for

the family as a unit of care.

Objective

To develop documentation within the SClínico-CSP® nursing information system

encompassing assessment, intervention, and family health gains related to the structural

dimension.

Methods

This quantitative, descriptive, and retrospective study included two evaluation time points.

The study population consisted of 669 families registered with a Functional Unit. The first

sample consisted of 24 families; and the second comprised 71 families. Data were presented

using charts and tables.

Results

The highest assessment rates were observed for housing type, family type, and residential

building condition. The highest prevalence was associated with inadequate water supply.

The most significant health gains were found in family income and safety precautions.

Conclusion

The study objective was achieved, as evidenced by increased documentation rates in the

SClínico-CSP® nursing information system. Improvements in the quality of nursing care

for families within the structural dimension were reflected in higher assessment, prevalence,

and outcome indicators. However, these results must continue to improve over time. To

support this progress, the contractual inclusion of indicators that acknowledge the family

as a unit of nursing care may be essential.

Keywords

Family Health; Dynamic Family Assessment and Intervention Model; Family Nursing;

Continuous Quality Improvement; Quality; Nursing Process; Health Information Systems.

Liliana Soares1

orcid.org/0000-0002-6652-8284

Virgínia Guedes2

orcid.org/0000-0002-9654-3303

Maria Henriqueta Figueiredo3

orcid.org/0000-0001-7902-9751

1 Master. Unidade Local de Saúde do Baixo Tâmega;

CINTESIS – Centro de Investigação em Tecnologias e

Serviços de Saúde, Porto, Portugal.

2 Master. Unidade Local de Saúde do Baixo Tâmega;

CINTESIS – Centro de Investigação em Tecnologias e

Serviços de Saúde, Porto, Portugal.

3 PhD. Escola Superior de Enfermagem do Porto;

CINTESIS – Centro de Investigação em Tecnologias e

Serviços de Saúde, Porto, Portugal.

Corresponding author:

Liliana Soares

E-mail: lilianasoares1982@gmail.com

Received: 06.11.2024

Accepted: 30.06.2025

Editor:

Pedro Lucas

Soares, L.

Quantitative Original Article

Introduction

Assessing a family’s structure makes it possible to identify

its characteristics, along with potential strengths and internal

and external resources such as social class, biological

environment, extended family, and broader systems that

may support the management of health and illness, two

areas formally included in the contractual goals of

Functional Units (FUs). To this end, documenting

assessments and interventions related to these

characteristics, which make up the structural dimension of

the family as a unit of care, is essential.1

Documenting the entire Nursing Process (NP) contributes

to care quality and safety.2 It enables the transfer of relevant

information to other healthcare professionals, particularly in

identifying the client’s care needs and specifying the

interventions to be implemented, that is, demonstrating the

customization of the care plan to the client’s needs.3,4

Furthermore, documentation protects nurses against

negligence claims, preserves retrievable data for research

and quality improvement purposes, and supports the

evaluation of care outcomes.4

In addition to these functions, proper documentation

improves the quality of nursing care itself, enhances

professional satisfaction, increases the visibility of nurses’

work, reinforces the value of their actions, promotes

autonomy and efficiency, and strengthens the scientific basis

of the profession.5

To monitor improvements in care quality based on the NP,

it is necessary to use documentation indicators that can be

shared5. However, for these indicators to be meaningful, the

information about nursing care provided must be properly

recorded6. In this regard, Duclos-Miller4 states that the

quality of nursing care delivered to clients can only be

measured by the quality of nursing documentation—

namely, the documentation of the client’s care plan, the

evaluation of care effectiveness, and the communication

between the client and other healthcare professionals.

Nursing Information Systems (NIS) enable the

documentation of care using standardized language, thereby

contributing to improved care quality, greater professional

visibility, and better performance assessment.6 The NIS

used in Primary Health Care (Cuidados de Saúde Primários -

CSP) is SClínico-CSP®. This system allows for the

documentation of care provided to individuals and families

using standardized terminology such as the International

Classification for Nursing Practice (ICNP®).7 Through

individual and family assessments, SClínico-CSP® supports

the standardized recording of data related to the structural

dimension of the family, including housing characteristics,

social class, and family type.

Nurses’ decision-making in this area is guided by theoretical

models such as the Calgary Family Assessment Model

(CFAM) and the Calgary Family Intervention Model

(CFIM),8 and, more specifically, by the Dynamic Family

Assessment and Intervention Model (MDAIF),1 which

serves not only as a theoretical framework but also as a

practical tool for clinical application.9,10

The Regulation of Specific Competencies for the Family

Health Nurse Specialist (FHNS)11 states that nurses must

care for the family as a unit, as well as for each of its

members individually, and must document the care process

by integrating health, family, and environment. However,

documenting care with the family as the client is not yet a

widespread practice among nurses who provide care to

families. This fact was confirmed by Melo et al.12 in a study

that aimed to identify, through health information systems

in northern Portugal, the nursing foci resulting from

assessments and interventions involving the family as the

unit of care. The findings showed that attention areas within

the structural dimension - specifically, family income,

residential building condition, and water supply - had

documentation rates as low as 0.002%.

Several studies also identify barriers to documenting care,

such as a lack of continuing education, excessive workload,

limited time, insufficient resources, and the perception of

documentation as a bureaucratic task5,13–16.

A study involving more than 500 Portuguese – nurses

without postgraduate training in family health nursing

showed that their self-perceived competence in the stages of

the NP declined as the process advanced.17 The same study

also found that the areas of focus with the lowest average

levels of self-perceived competence were family income,

residential building condition, water supply, and pet care, all

of which are components of the family’s structural

dimension.

All the characteristics that comprise the structural

dimension can be observed, assessed, and documented,

particularly when there is continuity of care for families and

their individual members. It is therefore important to more

effectively integrate NP documentation related to family

assessment and intervention, specifically within the

structural dimension. This integration may increase

documentation rates, contributing to improved quality of

care for families and their members, as well as greater

visibility of this care.

This study aimed to develop documentation within the

SClínico-CSP® nursing information system encompassing

assessment, intervention, and family health gains related to

the structural dimension.

Methods

This descriptive, retrospective study included two distinct

evaluation periods. We conducted the first assessment on

March 22, 2023, prior to the implementation of the project

activities, allowing for comparison with the results of the

second assessment, carried out on June 1, 2023, after the

project had been implemented. The study population

consisted of families registered with the FU, totaling 669

families as of February 2023.

We defined the inclusion criterion as families whose

members had a nursing consultation (individual,

subsystem-based, or whole-family) either at the FU or at

home. Families whose members were not permanently

registered with the FU were excluded.

The sample for the first assessment comprised all families

whose family records included some form of assessment

and documentation related to the structural dimension,

totaling 24 families. This information was retrieved using

Pensar Enfermagem / v.29 n.01 / July 2025

DOI: 10.71861/pensarenf.v29i1.378 / e00378

Quantitative Original Article

the data extraction tools available in the SClínico-CSP®

nursing information system.

In the second evaluation (June 2023), using the same data

extraction process and documentation in Microsoft Excel®,

71 families were identified.

The team responsible for implementation was composed

of the UF nursing team.

During data collection, the anonymity of family members

was maintained, with all identifying information withheld.

To conduct the evaluation, we used indicators for family

assessment and intervention within the family’s structural

dimension based on the indicator mapping from the

Dynamic Family Assessment and Intervention Model

(MDAIF).18 These included assessment rates, prevalence

rates, and outcome indicators.

The Relvas classification19 was applied to evaluate the life

cycle stage of nuclear families. This classification considers

the age of the oldest child and encompasses the following

stages: Stage 1 (couple formation); Stage 2 (family with

young children); Stage 3 (family with school-age children);

Stage 4 (family with adolescent children); and Stage 5

(family with adult children).

The Adapted Graffar Scale1 was used to evaluate housing

type and social class. This tool assesses the family’s

socioeconomic conditions based on five criteria:

occupation, education level, sources of family income,

comfort and housing, and characteristics of the

neighborhood. These criteria are scored on a 5-point scale.

For the evaluation, the classification of the partner with the

highest score was considered.

The activities carried out by the UF nursing team for

families whose members had a nursing appointment

(individual, subsystem-based, or whole-family), either at the

UF or at home, included:

- Evaluation of the type of family (nuclear, blended, single-

parent, extended, one-person, cohabiting, communal,

institutional, or other) and corresponding documentation

in the SClínico-CSP® nursing information system;

- Evaluation of the life cycle stage of nuclear families (Stage

1: couple formation; Stage 2: family with young children;

Stage 3: family with school-age children; Stage 4: family

with adolescent children; Stage 5: family with adult

children) and corresponding documentation in the

SClínico-CSP® nursing information system;

- Evaluation of housing type (grades 1–5 of the Adapted

Graffar Scale) and social class (classes I–V of the Adapted

Graffar Scale) and corresponding documentation in the

SClínico-CSP® nursing information system;

- Evaluation of the structural dimension areas of attention

based on the Dynamic Family Assessment and

Intervention Model (MDAIF), including family income,

residential building condition, safety precautions, water

supply, and pet care, and corresponding documentation in

the SClínico-CSP® nursing information system;

- Formulation of nursing diagnoses related to the structural

dimension and their documentation in the SClínico-CSP®

nursing information system; Implementation of nursing

interventions within the structural dimension and their

documentation in the SClínico-CSP® nursing information

system;

- Evaluation of health outcomes/gains within the structural

dimension and their documentation in the SClínico-CSP®

nursing information system;

- Extraction of data from the SClínico-CSP® nursing

information system into Microsoft Excel® software;

- Analysis of the collected data, including the evaluation of

assessment rates, prevalence rates, and outcome indicators

within the structural dimension (ESEP/CINTESIS, 2013).

The data were documented in the SClínico-CSP® nursing

information system and quantitatively recorded in tables

using Microsoft Excel® software.

Results

The results of both evaluations are presented in the form

of charts and tables, along with explanatory notes.

In the first evaluation, 24 families (3.59%) out of a total of

669 had at least one family-related nursing assessment

documented in their records.

Regarding family type (Chart 1), 17 out of the 24 families

had their typology assessed: 10 (41.7%) were classified as

nuclear families, 3 (12.5%) as single-person families, 2

(8.3%) as blended families, 1 (4.2%) as single-parent

families, and 1 (4.2%) as extended families. Seven families

(29.2%) did not have their typology assessed.

In the second evaluation, an increase in assessments was

observed: 71 families (10.6%) out of the same total of 669

had at least one family-related nursing assessment recorded.

As for family type, an assessment of 64 out of 71 families

revealed: 39 nuclear families (55%), 14 single-person

families (24%), 5 blended families (7%), 2 single-parent

families (2.8%), and 4 extended families (5.6%). Seven

families (9.9%) did not have their typology assessed.

Soares, L.

Quantitative Original Article

Chart 1 – Family type at the first and second evaluation

time points.

According to Relvas’ (2000) family life cycle stages

(Chart 2), the first evaluation of the 10 nuclear families

revealed: 2 families (20%) at stage 2 (young children), 1

(10%) at stage 3 (school-age children), and 7 (70%) at stage

5 (adult children).

The second evaluation of 39 nuclear families revealed the

following distribution across family life cycle stages: 7.7%

(n = 3) at Stage 2, another 7.7% (n = 3) at Stage 3,

10.2% (n = 4) at Stage 4 (families with teenage children),

and 74.3% (n = 29) at Stage 5.

Chart 2 – Life cycle stages of nuclear families at the first

and second evaluation time points.

Regarding housing conditions (Chart 3), the first evaluation

showed that 14 of the 24 families (58.3%) resided in

Grade 3 homes according to the Adapted Graffar Scale1.

These homes had a bathroom, kitchen, living room, and

bedrooms. They were well maintained and had essential

appliances, running water, sanitation, electricity, good

ventilation, and natural light. Four families (16.7%) lived in

Grade 4 housing, which had limited space, was in poor

condition, lacked essential appliances, and had little

ventilation, no running water, sanitation, or electricity, and

limited natural light. Six families (25%) had no documented

housing assessment.

Regarding social class, also based on the Adapted Graffar

Scale, 1 family (4.2%) was classified as Class II

(upper-middle), 11 (45.9%) as Class III (middle), 3 (12.5%)

as Class IV (lower-middle), and 9 families (37.5%) had no

classification documented (Chart 3).

Of the 71 families assessed in the second evaluation,

3 (4.2%) lived in Grade 2 homes—spacious and well

maintained, with central heating, appliances beyond the

essentials, running water, sanitation, electricity, good

ventilation, and natural light. Forty families (56.3%) resided

in Grade 3 homes, 19 (26.8%) in Grade 4 homes, and 9

(12.7%) had no housing classification.

As for social class, 5 families (7%) were categorized as Class

II (upper-middle), 34 (48%) as Class III (middle), 21 (30%)

as Class IV (lower-middle), and 11 families (15.5%) had no

social class classification.

Chart 3 – Housing type and social class of families in the

first and second evaluation.

Table 1 presents the results related to assessment rates in

the first and second evaluations. An overall increase was

observed from the first to the second evaluation. The

highest rate in both the first (3.6%) and second (10.6%)

evaluations was related to documentation in the Family

Health Program, with a 7% increase between the two time

points. The lowest assessment rate in both the first (1.6%)

and second (3.3%) evaluations corresponded to Pet Care

(PC).

The category showing the greatest increase from the first to

the second evaluation was Residential Building (RB), with

a 7.2% rise. This was followed by: Family Health Program

(7%), Housing Type (6.6%), Social Class and Family

Income (FI) (6.5%), Family Type (6%), Safety Precautions

(SP) (5.7%), Water Supply (WS) (3.3%), and finally Pet Care

(PC) (1.7%).

Pensar Enfermagem / v.29 n.01 / July 2025

DOI: 10.71861/pensarenf.v29i1.378 / e00378

Quantitative Original Article

Table 1. Indicators – Assessment rates in the first and

second evaluation

As for prevalence rates (Table 2), in the first evaluation, the

most frequent diagnoses were: Inadequate Water Supply

(IWS) (42.9%), Undemonstrated Safety Precautions (USP)

(20%), Neglected Pet Care (NPC) (18.2%), and Insufficient

Family Income (IFI) (7.7%).

In the second evaluation, the most prevalent diagnoses

were: IWS (47.2%), NPC (27.3%), and Unsafe Residential

Building (URB) (17.7%). These were followed by:

USP (9.4%), IFI (7%), and Neglected Residential Building

(NRB) (3.2%).

Table 2. Indicators – Prevalence rates of nursing diagnoses

in the first and second evaluation

As for the outcome indicators (Table 3), the first evaluation

revealed no health gains related to the structural dimension.

In the second evaluation, however, there was an increase in

both documented outcomes and recorded nursing

interventions, which resulted in health gains within this

dimension. The only exception to this trend was PC, which

remained at 0% in the second evaluation.

The areas of focus with the highest percentages of positive

outcomes in the second evaluation were RB, FI, and SP.

Half of the families (50%) with RB-related diagnoses

experienced health gains following nursing interventions

aimed at improving household hygiene and sanitary

conditions. Approximately 75% of the families diagnosed

with IFI achieved resolution of this issue through increased

knowledge of family income management. SP improved in

60% of the cases in which it had previously been

compromised. WS also improved in the second evaluation,

Assessment rates

Assessment

1st

2nd

Number of families enrolled in the Family

Health Program / Total number of families

registered at the FU × 100

3.6%

(n=24)

10.6%

(n=71)

Number of families assessed for Social Class /

Total number of families registered at the FU ×

100

2.4%

(n=16)

8.9%

(n=60)

Number of families assessed for Family Type /

Total number of families registered at the FU ×

100

2.7%

(n=18)

9.3%

(n=62)

Number of families assessed for Housing Type

/ Total number of families registered at the FU

× 100

(n=20)

9.3%

(n=62)

Number of families assessed for Residential

Building Condition / Total number of families

registered at the FU × 100

2.1%

(n=14)

9.3%

(n=62)

Number of families assessed for Family Income

/ Total number of families registered at the FU

× 100

(n=13)

8.5%

(n=57)

Number of families assessed for Safety

Precautions / Total number of families

registered at the FU × 100

2.2%

(n=15)

7.9%

(n=53)

Number of families assessed for Water Supply /

Total number of families registered at the FU ×

100

2.1%

(n=14)

5.4%

(n=36)

Number of families assessed for Pet Care /

Total number of families registered at the FU ×

100

1.6%

(n=11)

3.3%

(n=22)

Prevalence rates

Assessment

1st

2nd

Number of families with Unsafe Residential

Building (URB) / Total number of families

assessed for Residential Building (RB) × 100

(n=0)

17.7%

(n=11)

Number of families with Neglected Residential

Building (NRB) / Total number of families

assessed for Residential Building (RB) × 100

(n=0)

3.2%

(n=2)

Number of families with Insufficient Family

Income (IFI) / Total number of families assessed

for Family Income (FI) × 100

7.7%

(n=1)

7.0%

(n=4)

Number of families with Undemonstrated Safety

Precautions (USP) / Total number of families

assessed for Safety Precautions (SP) × 100

20%

(n=3)

9.4%

(n=3)

Number of families with Inadequate Water

Supply (IWS) / Total number of families assessed

for Water Supply (WS) × 100

42.9%

(n=6)

47.2%

(n=17)

Number of families with Neglected Pet Care

(NPC) / Total number of families assessed for

Pet Care (PC) × 100

18.2%

(n=2)

27.3%

(n=6)

Soares, L.

Quantitative Original Article

with a positive outcome of around 10%, as did URB, with

a 9.1% improvement.

Table 3. Indicators – Outcome/Health gains in the first

and second evaluation

Discussion

The results from the first evaluation revealed generally low

documentation rates regarding the assessment of the

family’s structural dimension. This finding is consistent

with previous studies,12,17 which also report low

documentation rates in this area and attribute this issue to

various factors, including a lack of training.5,13–16

As for the prevalence rates, we found that most diagnoses

showed an increase between the first and second

evaluations, except for two (FI and SP). However, this does

not necessarily indicate an actual increase in the prevalence

of diagnoses such as URB, NRB, IWS, and NPC. Rather,

the increase in prevalence rates is primarily related to the

substantial rise in assessment rates between the first and

second evaluations, which consequently led to more

diagnoses being recorded.

Notably, the prevalence rate of IWS accounted for nearly

half of all families whose water supply was assessed in both

evaluation periods. This result is closely associated with the

context in which these families live. Located in a

predominantly rural area, water is often supplied by private

systems, as a comprehensive public water supply network

has yet to be established in this community. According to

official data, in Portugal, approximately 96% of households

were served by public water supply systems in 2020, and

85% were connected to public wastewater systems.20

Therefore, some families may live in areas not covered by

public water services, with 4% of homes still relying on

private sources. In this particular region, the most recent

data available from 2019 indicate that only about 47% of

households were connected to public water supply systems

and 48% to public wastewater systems.20

Another important point is that IWS often reflects a lack

of knowledge about the risks of water contamination

and/or a family’s inability to properly manage the care

required for this type of water supply1, particularly in light

of the guidelines issued by the Water and Waste Services

Regulatory Authority (ERSAR) for maintaining the quality

of drinking water.21

These guidelines recommend not using unregulated water

for human consumption, including drinking, cooking, and

hygiene, and call for regular quality testing of drinking

water—annually or whenever necessary.

Regarding health gains, we found that, in the first

evaluation, there were no improvements in health

outcomes related to the structural dimension. There was a

declining trend in the documentation of nursing care for

families, which ran counter to the progression of the NP.

As such, evaluation rates were significantly higher than

outcome indicators. We believe this can be explained by the

fact that family nursing care is delivered from a co-

evolutionary and longitudinal perspective.1 It is also

important to note that the number of family nursing

consultations available to nurses to care for the family as a

unit is often lower than desired, which delays the

progression of the NP stages.

This inverse trend throughout the stages of the NP was also

identified in a previous study,17 which analyzed nurses’ self-

perception of their graduate-level competencies in the field

of family health nursing. Conducted with over 500

Portuguese nurses who had not undergone specialized

training, the study revealed that nurses’ perceived

competence decreased as the NP progressed.

In contrast, the second evaluation showed a rise in outcome

indicators, reflecting health gains in most diagnoses. These

findings reinforce the relevance of systematic assessment,

intervention, and proper documentation in securing and

measuring health improvements for families.

As Nascimento et al.6 state, quality assessment indicators

cannot be generated without comprehensive

documentation of the NP. This absence of documentation

not only limits public recognition of the nursing

profession’s contributions but also hinders transparency in

the quality improvement process.

Thus, documenting family health nursing care is

fundamental to increasing the visibility of FHNS specific

competencies and ensuring the ongoing enhancement of

care quality. As highlighted by Fernandes and Tareco,22

Outcome/Health gains indicators

Assessment

1st

2nd