GENOGRAM AND ECOMAP : BRAZILIAN NuRSING CONTRIBuTIONS

This study aimed to identify and analyze how the genogram and ecomap have been used in Brazilian nursing, summarizing this area’s contribution to family care. Integrative review, combining predetermined key words and descriptor in LILACS and SciELO, besides a non-systemized search in five qualified nursing journals, published between 2000 and 2010. Inclusion and exclusion criteria guided the paper selection, resulting in a sample of 34 articles. The genogram and ecomap have been mainly used as complementary tools in research data collection. Its use as an approximation between interviewer and interviewee, in teaching and as a therapeutic resource are hardly explored. The use and dissemination of these tools are essential to understand the family, picturing its structure and interactions with the community, enhancing the participation of individuals, and contributing to the understanding of the context of each family, which is vital to nursing care. DESCRIPTORS: Nursing assessment. Family nursing. Data collection. Nursing. GENOGRAMA E ECOMAPA: CONTRIBuIÇÕES DA ENFERMAGEM BRASILEIRA RESuMO: Este estudo objetivou identificar e analisar como o genograma e o ecomapa têm sido utilizados pela enfermagem brasileira, sintetizando a contribuição dessa área para o cuidado familial. Trata-se de revisão integrativa, combinando palavras-chave e descritor pré-determinados, no LILACS e SciELO, além de busca não sistematizada em cinco periódicos qualificados da área, no período de 2000 a 2010. Critérios de inclusão e exclusão orientaram a seleção dos artigos, culminando com amostra de 34 artigos. O genograma e ecomapa têm sido utilizados eminentemente como ferramentas complementares para a coleta de dados em pesquisas. Seu uso como aproximação entre entrevistador/entrevistado, no ensino e como recurso terapêutico são pouco explorados. A utilização e divulgação desses instrumentos são essenciais para a compreensão da família, retratando sua estrutura e interações com a comunidade, valorizando a participação dos sujeitos e contribuindo para ampliar o conhecimento do contexto de cada família, vitais para o cuidado de enfermagem. DESCRITORES: Avaliação em enfermagem. Enfermagem familiar. Coleta de dados. Enfermagem. GENOGRAMA Y ECOMAPA: CONSTRIBuCIONES DE LA ENFERMERíA BRASILEÑA RESuMEN: La finalidad fue identificar y analizar como el genograma y el ecomapa han sido utilizados por la enfermería brasileña, sintetizando su contribución en el área del cuidado de la familia. Revisión integrativa que combinó palabras-clave y descriptores predeterminados, en LILACS y SciELO, además de una búsqueda no sistematizada en cinco periódicos calificados del área, entre 2000 y 2010. Los criterios de inclusión y exclusión orientaron la selección, culminando con una muestra de 34 artículos. El genograma y ecomapa han sido utilizados principalmente como herramientas complementares a la recolección de datos de investigaciones. Su uso como aproximación entre entrevistador/entrevistado, en la enseñanza y como recurso terapéutico es poco explorado. El uso y la difusión de estas herramientas son esenciales para comprender la familia, mostrando su estructura y las interacciones con la comunidad, además de fomentar la participación de las personas y favorecer a la comprensión del contexto de cada familia, lo que es vital para el cuidado de la enfermería. DESCRIPTORES: Evaluación en enfermería. Enfermería de la familia. Recolección de datos. Enfermería. 211


INTRODuCTION
Professionals in different areas routinely use the genogram and ecomap, mainly to understand family processes.The genogram is a graphic representation of the family composition and the basic relationships in at least three generations, elaborated through symbols. 1 It permits a rapid and clear visualization of the family members, whether by blood or not, identifying the age, occupation, profession and education level of each, besides showing each person's place in the family structure. 1e ecomap is a diagram of the relations between family and community and helps to assess the available support and its use by the family. 2t can represent the presence or absence of social, cultural and economic resources.The ecomap pictures a given moment in the life of the family members and is therefore dynamic. 2 These instruments were elaborated by family therapists and have been used by different health professions, including nursing, medicine, psychology, social service and pharmacy, to represent structural, emotional and affective family processes. 3e genogram and ecomap are valuable instruments, 2 as resources to assess the family composition and interactions among family members and beyond the family.In view of the applicability of these instruments to assess the complexity and dynamics of the family structure and relations, the objective in this study is to identify and analyze how Brazilian nursing has used the genogram and ecomap, summarizing the contribution of the area to family care.

METHOD
5] To enhance the rigor of this method, two authors performed the literature search independently.
The following guiding question was used for the integrative review: how has Brazilian nursing used the genogram and the ecomap?The words genogram and ecomap are registered neither in the Health Sciences Descriptors (DeCS) nor in the MESH (Medical Subject Headings), but were nevertheless used as keywords, associated with the descriptor nursing.The combinations of the terms or the simple search were undertaken as follows: genogram; genogram and nursing; ecomap; ecomap and nursing.To search the publications, the database LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde) and the electronic library SciELO (Scientific Electronic Library Online) were used, as they include Brazilian publications.In addition, non-systematic searches were undertaken in five nursing journals: Latin American Journal of Nursing, Texto & Contexto Enfermagem, Acta Paulista de Enfermagem, Revista da Escola de Enfermagem da USP and Revista Brasileira de Enfermagem.The choice of these journals was based on the qualitative ranking of the intellectual production of graduate programs for the triennium 2007-2009 proposed by the Coordination for the Improvement of Higher Education Personnel (CAPES), called the Qualis CAPES assessment.The publications classified as A1 and A2 were chosen.The Revista Brasileira de Enfermagem was chosen due to its relevance, as a result of its broad circulation in the nursing area.
The inclusion criteria were: papers published in Brazilian journals, between 2000 and 2010; whose authors included at least one nurse; publications in Portuguese, English or Spanish; and publications with available abstracts and indexed in the abovementioned database or available in the electronic library collection.Publications in Brazilian journals but conducted outside Brazil were excluded, as well as studies exclusively produced by professionals from other areas than nursing; studies in other languages than English, Portuguese or Spanish and unpublished studies, such as theses or dissertations.The choice of the languages was based on the observed publication of papers in English, Portuguese and Spanish in the Brazilian journals selected for the review.
To select the publications, the titles and abstracts were exhaustively read to guarantee that they addressed the guiding question and complied with the inclusion criteria.In case of any doubt, the publication was included with a view to a final decision after fully reading its content and discussing the inclusion among the authors.
In the survey of studies based on the keyword genogram in the database LILACS, 57 papers were found, of which 22 were selected.The remainder (n=35) was excluded because of the publication year (n=12), because they were not related to nursing (n=18), because they were dissertations (n=3) and because they had been produced in other countries (n=2).In the electronic library SciELO, using the same keyword, 22 papers were located, none of which was selected though, as eight of them were not related to nursing and 14 had previously been selected in the database LILACS.
Using the keyword ecomap, 23 papers were found in the LILACS database.Four references were selected and 19 were excluded, due to the following reasons: one was not produced in the nursing area, one in another country and 17 had already been selected.
In the electronic library SciELO, using the keyword ecomap, 14 papers were located but none was selected, as one was not related to nursing and 13 references had already been selected.
Using the combination of keywords and the descriptor (genogram and nursing; ecomap and nursing), 12 papers were found in LILACS and six in SciELO, but none was selected as they had already been included in an earlier phase.This systemized search resulted in a sample of 26 studies.
Besides the systemized search, a complementary search was undertaken in the five Brazilian journals mentioned above, manually, year by year (2000 till 2010), volume per volume, reading the complete articles to identify any studies that answered the review question.Each papers were found in this search, which together with the 26 papers that had already been selected resulted in a final sample of 34 articles.
To analyze the selected articles, an instrument was used with the following indicators: year of publication, authors, insertion area of the authors, objectives of the paper, applicability of the genogram and ecomap, techniques used, dynamics (individual or group) and place to construct the instruments and difficulties and facilities for its use.Through these indicators, relevant data could be collected from each article, resulting in a set of elements that made it possible to answer the review question.The authors analyzed each paper independently.After consolidating the results, the knowledge synthesis procedures were applied.The critical assessment of the set of papers was based on the analysis of the usage range of the genogram and ecomap in Brazilian nursing and on the identification of gap that direct further research.

RESuLTS
][8][9][10][11][12][13][14][15] In 20052, [16][17][18][19] and 2008, [20][21][22][23][24] five papers were published in each year.In 2004, 25- 28 2007 [29][30][31][32] and 2010, [33][34][35][36] four papers were published per year.Only one was published in 2002 37 and 2003. 3No papers were found in 2000, 2001 and 2006.In two papers, besides nursing, authors came from the social service, 24 psychology 19,24 and statistical areas. 24xcept one, 37 all papers included in the review used the genogram and ecomap as complementary tools for research data collection.One paper was identified in which the contribution of the genogram and the ecomap was explored in undergraduate nursing education and in childcare. 37Besides its applicability for research data collection, these instruments were used as a form of approximation between the interviewer and the interviewee.In three papers, 2,16,19 the authors had planned this use already at the start of the research and, in others, 12,24,35 the recognition of these instruments as a form of approximation was a finding present in the research results, although the authors had not expressed this objective in the research.2 In that sense, they were appointed as means to identify vulnerable points for the research participants, to indicate support strategies in the community and to reveal perspectives on the family relationships.
The techniques used in the construction of the genogram and ecomap were mentioned in 22 papers, 2-3,6,8-9,12-16,20-22,24-25,29-30,32-36 as follows: participation of the family members, use of materials, such as markers and color codes by the children, and the moments when the instruments were elaborated (first or second meeting) were described in some papers.27][28]31,37 The difficulties and facilities related to the use of the genogram and ecomap were described in 14 papers, 2,8,12,[15][16]19,[21][22]24,27,29,33,35,37 while the authors of the other 20 studies did not mention these aspects. Table 1 displays a summaryof the papers included in the review, according to the characteristics of the authors, publication year, objectives, facilities and difficulties in the use of these instruments.

Table 1 -Papers included in the review, according to the authors and their insertion area, year of publication, study objectives, facilities and difficulties in the use of the genogram and ecomap
Author/Year/Insertion area Objective Facilities Difficulties Santos, Pavarini (2009) 12 Nursing -identify the family composition of elderly people with cognitive alterations in Family Health Units.
-useful instrument to picture the family structure of elderly people; further approximation among family members of visualization of family peculiarities.
Schwartz, Muniz, Burille, Zillmer, Silva, Feijó, et al. ( 2009) 13 Nursing -get to know the support network for clients and families in coping with chronic kidney failure.
Laval, Olschowsky, Kantorski (2009) 14 Nursing -identify the social support network of users and families within the territory.
Moura, Nogueira, Bezerra, Pinheiro, Barroso (2008) 23 Nursing -assess structural aspects of families of pregnant women with human papillomavirus based on the Calgary model.
Joca, Pinheiro (2009) 11 Nursing -observe the structure, development and functioning of families of women with HPV based on the Calgary model.
Pereira, Teixeira, Bressan, Martini (2009) 8 Nursing -get to know coping forms of families of patients with SAH and DM in Florianópolis.
-revealed each family in its complexity and dynamics.
-infrequently applied instruments, limited academic use due to time spent on appropriate construction.

Genogram and ecomap: Brazilian nursing contributions
Author/Year/Insertion area Objective Facilities Difficulties Pavarini, Luchesi, Fernandes, Mendiondo, Filizola, Barham, et al (2008) 24 Nursing, social service, psychology, statistics -assess family composition of elderly people at a Family Health Unit using the genogram.
-permitted further approximation with families; effective to verify the elderly patients' family composition; pictured diseases.
Simioni, Geib (2008) 21 Nursing -get to know the perception of the mothers of premature children about social support at home.
-the density of the family bonds could be established.
Dias, Nascimento, Mendes, Rocha (2007) 29 Nursing -identify social supports, support networks and roles in families of nursing faculty based on family nursing.
-offered an opportunity to identify the strengths and vulnerabilities of health protection.
Silva, Galera, Moreno (2007) 32 Nursing -describe how the family reacts to the dependence of an elderly members, what resources it uses and what Nursing interventions are useful and applicable.
Roque, Ferriani (2007) 31 Nursing -get to know the family's trajectory and perceptions about justice-related events in cases of violence; quantify and analyze forensic processes.
Nascimento, Rocha, Hayes (2005) 2 Nursing -describe the experience of using the genogram and ecomap to survey data in the family of children with cancer in a qualitative research.
-the genogram enhanced the child's involvement, facilitating the relation between the child and the professional; reveals the child's perception of family relations.
Simpionato, Correia, Rocha (2005) 16 Nursing -present the data collection experience of families of children with chronic kidney failure undergoing peritoneal dialysis as the first phase of the family nursing history.
-after being set in motion, it is gratifying and mobilizing task for the family.
-construction process of the instruments demands the participants' time and availability.
Moura, Kantorski, Galera (2004) 28 Nursing -report on assessment and intervention in families of mental patients attended by the Family Health Team.
Radünz, Olson (2005) 17 Nursing -explore beliefs, values and health promotion practices among mothers of pre-adolescents, describing variances in the drugs phenomenon, health promotion, quality of life and pre-adolescent risk behavior.
Mello, Viera, Simpionato, Biasoli-Alves, Nascimento (2005) 19 Nursing, Psychology -describe the application of the genogram and ecomap in families at a Family Health Service, reflecting on their use in the Family Health Program.
-permitted knowledge about the families' internal and external structure.
Cecagno, Souza, Jardim (2004) 25 Nursing -get to know daily family life and interfaces with the disease process, historical aspects, family dynamics, development phases, support network, genogram and ecomap.
Diógenes, Varela (2004) 27 Nursing -assess the families of single pregnant women with HPV, prioritizing affective bonds between mother and daughter, using the Calgary model.
-enhanced the perception of the entire family, the interactions with the broader systems and the extended family.

Author/Year/Insertion area Objective Facilities Difficulties
Souza, Kantorski (2009) 15 Nursing -identify the social network of subjects under treatment at a CAPS ad, support bonds and stressors.
-the ecomap identified vulnerable points in the subjects' bonding, social, family and individual needs for health care planning.
Vall, Braga (2005) 18 Nursing -assess functional capacity and social aspects of traumatic spinal cord injured patients, with and without associated central neuropathic pain.
Ximenes, Pinheiro, Lima, Nery (2004) 26 Nursing -identify situations of health problems among children in early childhood in the family and school contexts; survey the family structure and risk factors in the domestic sphere.
Rocha, Nascimento, Lima (2002) 37 Nursing -present instruments used in nursing's approach of the family; provide support for their use in nursing education and childcare.
-instruments remain infrequently used in Brazilian nursing for childcare purposes.
Ribeiro, Rocha (2007) 30 Nursing -understand how children with nephrotic syndrome are being cared for, identify new contextual elements and horizons to reconstruct Nursing care, within a family focus.
Montefusco, Bachion, Nakatani (2008) 20 Nursing -analyze NANDA nursing diagnoses in families accompanying hospitalized patients for treatment of non-transmissible chronic conditions, using the Calgary evaluation model.
Viera, Mello (2009) 6 Nursing -describe the care after discharge of preterm and low birthweight infants from the NICU, in monitoring at home and in health services.
Meincke, Carraro (2009) 7 Nursing -discuss feelings of adolescent fathers' families in the experience of fatherhood.
Barros, Santos, Erdmann (2008) 22 Nursing -describe the social support network for elderly patients with stoma, represented by the ecomap of multiple support relations, in the light of the Complexity framework.
-the ecomapa assessed available support and their use by patients; the use was a technological resource for the indication of broad and dynamic support strategies.
Paula, Nascimento, Rocha (2009) 9 Nursing -understand the experience of families of children with chronic kidney failure to support Nursing care, quality of life and health promotion in the family.
Silva, Bousso, Galera (2009) 10 Nursing -present the experience of assessing families of elderly people based on the Calgary model.
Horta, Ferreira, Zhao (2010) 33 Nursing -get to know the perception of elderly people about aging, coping strategies and repercussions in the family.
-identified the family structure and dynamics, support networks, communication forms and strategies to cope with problems or crises.
Santos, Pavarini, Brito (2010) 34 Nursing -characterize elderly patients with cognitive alterations at Family Health Services, from different social vulnerability contexts.

Genogram and ecomap: Brazilian nursing contributions
Author/Year/Insertion area Objective Facilities Difficulties Fernandes, Boehs (2010) 36 Nursing -present aspects of changes in the roles and tasks of rural families, in family care in situations of situational and maturational transition.
Cocco, Lopes (2010) 35 Nursing -analyze the social dynamics of young violence victims through the (re)construction of daily relations and vulnerability situations.
-complementariness of information from the genogram and ecomap permitted an approach-understanding of the young people's relationship networks.
Filizola, Ribeiro, Pavarini (2003) 3 Nursing -assess and intervene in families of users with severe mental disorders, based on the Calgary model.

DISCuSSION
The genogram and ecomap are useful instruments to survey families' internal and external structures.Their application is relatively simple, as only a pen and paper are needed. 38he genogram is a diagram of the family group and the ecomap a diagram of the family's contact with institutions, services and other individuals external to the family.As they indicate the future as well as the past and the present, these instruments facilitate alternative interpretations of the family experience. 38n view of the importance of these instruments, in the selected articles, the use of the genogram and ecomap was surveyed.The results showed the vast use of these tools to complement data collection in research, as a therapeutic resource, forms of approximation between interviewer and interviewee and in teaching.
In the selected articles, the genogram and the ecomap were largely used as tools to complement data collection in research.Complex information can be collected and systematically organized in these instruments.Their use permits helping the family to identify each of its members as part of a group of individuals who relate mutually and with the environment, and who are joined by a mutual commitment, representing the set of people they consider as their own family. 2Through these instruments, the data collection allows the participants to identify strong points of health protection and vulnerabilities. 29he use of the instruments as part of the therapeutic process is also extremely important for patients and their families.In research as well as in the therapeutic process, these instruments facilitate the relations between the professional and the interviewees as they make communication freer, permitting the use of non-verbal language resources. 2It should be kept in mind, however, that their construction process is dynamic and demands updating over time, 2 besides the close engagement and participation of the interviewer and interviewee.
The approximation between the interviewer and the interviewee as a result of the application of these instruments was evidenced in some of the papers selected. 2,12,16,19,24,35The genogram showed to be an instrument that permits further approximation with the families and is effective to verify the family composition and visualize the relations among the family members. 24hese instruments permit an approximationunderstanding of the relationship networks the people experience. 35e of the papers selected highlights the importance of the genogram and ecomap for inclusion in undergraduate education.Brazilian nursing makes little use of these instruments, but they help nurses to reach a diagnosis and to obtain and organize the data for the sake of a better visualization. 374 The approach of the children, in research as well as in care, demands different techniques than those used in research with adults. 2 The advantages of using the genogram in childcare are: greater involvement of the child, facilitating the relation between the child and the professional; revealing the child's perception about the family relations; offering valuable information to the professionals that can direct the continuity of care planning. 2ascimento LC, Dantas IRO, Andrade RD, Mello DF   In some papers, the facilities and difficulties in the application and details or contributions of the genogram and ecomap were mentioned, in which the authors reported that they did not experience any problems in the elaboration of these instruments, 12,24 besides the possibility to determine the density of the family bonds. 21In many papers, however, the difficulties, facilities and contributions deriving from the use of these instruments were not mentioned.It is important for researchers to divulge these aspects in their studies, with a view to contributing to other researchers who are not familiar with these tools.This fact may favor the use of these instruments in these researchers' work and collaborate in the dissemination of knowledge.

CONCLuSIONS
Brazilian nursing has eminently used the genogram and ecomap as tools to complement data collection in research.Their use to further approximate interviewer and interviewee, in teaching and as therapeutic resources has hardly been explored.
The synthesis of this review reveals the small number of studies in Brazilian nursing that use the genogram and ecomap.In addition, the studies that do often do not present details about the difficulties and facilities found, in order to help other researchers.
Knowledge about the family relations and bonds, as well as about the families' internal and external structure, are important aspects that can enhance the understanding of the family, in studies involving individuals as well as families.Nursing researchers need to use and disseminate these instruments, as they are essential to picture the family structure and to determine the density of the bonds and interactions of the families and individuals with the community.These instruments are relevant to collect data from the families and provide the health professionals with valuable information that can direct the clinical practice, focused on the identification of vulnerabilities, the structuring of health action planning and the promotion of care continuity and qualified communication with the families.
The results of this review were reached through a strict and detailed methodological design.Nevertheless, some limitations are acknowl-edged, such as the possibility that the search for papers published in Brazilian journals was not exhausted, which could expand its results.Some possibilities for the use of the genogram and ecomap are presented, based on the scientific production in Brazilian nursing.Given the importance of using these instruments in nursing, in this review, the need for further research is appointed, with a view to further exploring the applicability of these instruments in teaching and clinical practice, including its details, so as to enhance the knowledge about the singularities of each family context, with a view to the qualification of nursing care.