Families in Critical Care

EFFECTS OF A
NURSING INTERVENTION
ON FAMILY-CENTERED CARE
IN ADULT CRITICAL CARE
OSITIVE

By Marion Mitchell, B Nursing (Hons), GCert Higher Education, PhD, Wendy

Chaboyer, B Science, M Nursing, PhD, Elizabeth Burmeister, BN, MS (biostatistics), and
Michelle Foster, BN, MN (Critical Care)

C E 1.0 Hour
Notice to CE enrollees:
A closed-book, multiple-choice examination
following this article tests your understanding of
the following objectives:
1. Identify a family-centered care model and the
3 key indicators that comprise such a model.
2. Describe ways in which a critical care nurse
can partner with patients families to provide
fundamental care to patients.
3. Discuss the effects of family involvement in
providing care to intensive care unit patients
on their perceptions of respect, support, and
collaboration.
To read this article and take the CE test online,
visit www.ajcconline.org and click CE Articles
in This Issue. No CE test fee for AACN members.
2009 American Association of Critical-Care Nurses
doi: 10.4037/ajcc2009226

www.ajcconline.org

Background Generally, families of critical care patients are

not actively involved in the patients care in meaningful ways.
A family-centered care model formalizes each patient and the
patients family as the unit of care. Family-centered care comprises 3 concepts: respect, collaboration, and support.
Objective To evaluate the effects on family-centered care of
having critical care nurses partner with patients families to
provide fundamental care to patients.
Methods At the control site, patients families experienced
usual care; at the intervention site, patients families were
invited to assist with some of their relatives fundamental care
with nurses support. The family-centered care survey was
used to measure families perceptions of respect, collaboration, support, and overall family care at baseline and 48 hours
later. Multivariate logistic regression was used to determine
independent predictors of scores.
Results A total of 174 family members of patients participated (75 control, 99 intervention). Total median scores on the
survey were 3.2 (control) and 3.2 (intervention) at baseline
and 3.2 (control) and 3.5 (intervention) at follow-up. After
adjustments in the multivariate model, the family-centered
care intervention was the strongest predictor of scores at 48
hours (odds ratio [OR] = 1.66; P < .001). Other independent predictors included relatives with previous critical care experience (OR = 1.27; P = .006) and those who were partners of the
patient (OR = 1.33; P = .002).
Conclusion Partnering with patients family members to provide fundamental care to the patients significantly improved
the respect, collaboration, support, and overall scores on the
family-centered care survey at 48 hours. (American Journal of
Critical Care. 2009;18:543-553)

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543

lthough patient-focused care has been part of nursing since the 1970s,1 recognition
of the important role that patients families play in providing support, assistance,
and care for adult critical care patients is much more recent. We evaluated the
effect of families participation in patient care on their perceptions of respect,
collaboration, and support, 3 key indicators of family-centered care.2,3 Familycentered care is defined as an innovative approach to the planning, delivery, and evaluation
of health care that is grounded in mutually beneficial partnerships among health care patients,
families, and providers. Patient- and family-centered care applies to patients of all ages, and it
may be practiced in any health care setting.4 Although practices to promote family-centered
care have been adopted in many areas of nursing, such as palliative care, childrens units, and
pediatric critical care units,3,5 and information on family needs in critical care is available,6 few
data are available on family-centered care interventions in adult critical care. In a landmark
study published in 1979, Molter7 found that families of critical care patients require proximity
to the patients and value communication opportunities with the nursing and medical team.
Having patients families assist in providing patient care may meet some of these family needs.

Health professionals have come to value the

role of patients family members in providing nursing care.8 Friedman et al9 assert that families are the
single greatest social institution that
influences a persons health. During a
critical illness, patients families fulfill
an additional essential role for
patients who may be unconscious or
unable to communicate or make decisions. The families not only provide
vital support to patients10 but also
become the voice of the patients.
However, critical care nurses are hesitant to add to the complexity of their
work by including patients family members in
planning and performing nursing care.11-13 Even so,
critical care nurses acknowledge that patients fam-

Patient- and
family-centered
care applies to
patients of all ages
in any health care
setting.

About the Authors

Marion Mitchell is the deputy head of the School of
Nursing and Midwifery, Logan Campus, Research Centre
Clinical and Community Practice Innovation, Griffith
University, Meadowbrook, Queensland, Australia, and
Wendy Chaboyer is the director of Research Centre Clinical and Community Practice Innovation. Elizabeth
Burmeister is in the nursing practice and development
unit at Princess Alexandra Hospital, Woolloongabba,
Queensland, Australia, and Michelle Foster is a nurse
manager in the intensive care unit at Gold Coast Hospital, Southport, Queensland, Australia.
Corresponding author: Dr Marion Mitchell, School of
Nursing and Midwifery, Logan Campus, Research Centre
Clinical and Community Practice Innovation, Griffith
University, Meadowbrook, Queensland, Australia 4131
(e-mail: [email protected]).

544

ily members provide an essential link to patients

and are an important resource for nurses.14

Family Needs in Critical Care

Much research has been done on the needs of
families of critical care patients. The families need
information, reassurance, and proximity to the
patient.7,15 Proximity helps reassure family members
of the patients state of being; physical separation is a
constant reminder of the fragility of their relatives
existence. Eldredge16 found that family members who
wanted to be physically close to their relative in critical care also desired to be helpful but could not
always help because nurses at times did everything. A
majority (80%) of family members who helped with
some patient care stated that the act of caregiving
resulted in the family members having a more positive outlook.16 For patients, family members both
provide a link with home life that helps orient the
patients17 and produce a calming effect and sense of
security.18
Although the needs of the families of critical
care patients are well known, Verhaeghe et al6 concluded that not enough was being done to meet
families needs and that nurses underestimated their
(the nurses) role in satisfying these needs. Nurses
provide 24-hour care and, with their knowledge and
understanding of patients illness situation, are well
placed to incorporate patients families more fully
into the care the nurses give. A study in Australia19
indicated that when the needs of patients families
were met, the families were better prepared to contribute to the patients care after discharge. In a

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pilot study of 49 family caregivers in the United

States, Li et al20 found that when family caregivers
of elderly patients actively participated in the care
of the patients in an acute care setting, the patients
experienced fewer episodes of confusion and depression after hospitalization. Although the results of
these 2 studies are promising, the benefits of including patients family members in the care of critical
care patients have yet to be fully determined.

Family-Centered Care
Because of the crucial role that patients families
play in the continuum of care in critical illness,
going beyond patient-centered care to a more
encompassing family-centered care seems logical.
The inclusion of patients families as valid recipients
of nursing care may help the families participate
more actively with health professionals in making
decisions about patient care and in providing that
care.21 However, the research to date provides limited direction on how patients families can participate in the care of critically ill adults, and anecdotal
evidence suggests that family-centered care is the
exception rather than the norm in many adult critical care units.
Family-centered care provides a model of care
in which a patient and the patients family, rather
than the patient alone, are recognized and formalized as the unit of care. Family-centered care is
based on the belief that patients and their families
should participate in decisions related to their own
health care.22(p625) In family-centered care, a patients
family is an essential element in the patients wellbeing3,5,22,23 and helps protect and support that wellbeing.12,14,24 Family-centered care is far more than
what may be experienced in some pediatric units,
which often have a narrowly focused philosophy of
family-centered care. In these units, rather than providing holistic family-centered care that includes
planning, delivery, and evaluation of health care by
mutually beneficial partnerships among healthcare
providers, patients and families,4 the aim seems to
be to have parents assume a greater responsibility
for the management and actual care of their chronically ill child.25 The relationship between a patients
family and the patients nurse is essential to family-centered care and is based on mutual respect, collaboration, and support for the family and the
patient.2 Respect is defined as acknowledging individuals; collaboration, as partnerships in care and
support pertaining to a familys needs.2,3
The Institute for Family-Centered Care in the
United States advocates that a family-centered care
model of care can be implemented in any nursing

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area.26 For example, in neonatal transitional care

units, parents reported feeling less anxious after the
adoption of family-centered care, lengths of hospital stay were shorter, and rehospitalizations were
fewer.27 However, few specific strategies16,20 to promote family-centered care in adult units have been
published. Thus, although family-centered care
sounds beneficial in theory, little evidence is available of ways to operationalize this model of care.
The purpose of our research was to determine the
effect of a family-centered nursing intervention on
the perceptions of family members of critical care
patients of family-centered care as measured by
respect, collaboration, and support.

Methods
The study was approved by the appropriate
human research ethic committees.
Research Design
A pragmatic clinical trial28 with a nonequivalent
control group pretest-posttest design29 was used.
Pragmatic (also termed practical) trials are used to
measure the effectiveness of a treatment (the benefit a treatment produces in routine clinical practice) in
real-world settings.30 In pragmatic
trials, the intervention must be
clearly described, but this requirement does not mean that the same
treatment is offered to each patient;
the management protocol is the
subject of investigation, not the
individual treatment.28(p285) Although classified as a
quasi-experiment and weaker than experiments, a
nonequivalent control group pretest-posttest design
was the best and most feasible. Because the critical
care environment is relatively small and open
planned, a randomized control trial could not be
effectively carried out; contamination across groups
would be unavoidable. Two sites were used because
a limitation of this type of design is the influence
that history may have on the study findings. If significant improvements are found at the intervention
site but not at the control site, the improvements
are less likely to be due to historical effects.

Family-centered
care recognizes
and formalizes the
family and patient
as the unit of care.

Sample and Setting

Both study sites, Princess Alexandra Hospital
and the Gold Coast Hospital, in Queensland, Australia, are metropolitan teaching hospitals with comprehensive critical care services. The mean length of
stay was similar at both sites: 2.8 days. Both sites
were combined surgical and medical units that did

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545

not admit burn patients. At both sites, patients

families were not normally invited to participate in
providing care to patients. A patients family members were defined as individuals who came to visit
the patient and who had a sustained direct relationship with the patient. Families of patients predicted
to be in critical care for longer than 2 days were eligible to participate. Families could be recruited only
once. Family participation was limited to 1 selfnominated family member per patient.
Family members were not eligible if
they were less than 18 years old or
could not speak and read English.

Family-centered
care is composed
of respect,
collaboration,
and support.

Intervention
Before the study, 4 focus groups
(with 12 critical care nurses per
group) from the intervention site
were held to discuss family-centered
care and identify activities that reflected the concepts of respect, collaboration, and support of
patients families. Audio recordings were made and
field notes were taken. Verification of the accuracy
of the discussion points was sought from participants in each focus group. Responses were coded by
searching for differences and similarities between
comments made by participants. Because many
nurses could not attend a focus group, all critical
care nurses were contacted via e-mail with the same
questions as those used in the focus groups.
In total, 53 participants provided comments.
Identified themes included that family needs were
important and that fundamental care options were
appropriate and should be individualized for each
patients situation. The participants recognized the
need of patients families for proximity and considered that the inclusion of families in
providing fundamental or basic
patient care activities such as hair
combing, hand massage, and bathing
would promote respect, collaboration, and support, and thus family-centered care.
The participants stated that they
were willing to negotiate with
patients families what activities the
families would be willing to participate in, taking into consideration the
patients condition and context. Such
bundles of care options31 were thought essential
to allow for individualizing the intervention to suit
patients, family members, and cultural perspectives.32 That is, the participants thought limiting a
familys participation to only a single patient care

The 3 most
common care
activities provided
by family members
were massage, full
wash, and
eye care.

546

option would be inappropriate because the option

might not suit all families. Therefore, combinations
of these activities became the basis for the intervention. As in other pragmatic trials28 and as Conn et
al31 recommend, the intervention was tailored to the
patients families.
Data Collection
Family members at both sites were invited to
participate in the study by the bedside nurse, who
then introduced the data collectors during the first
day. The data collectors were critical care research
nurses at the intervention site and a member of the
study team at the control site, which did not have a
dedicated research nurse. The data collectors
obtained consent from patients family members
and distributed and collected the 2 surveys.
After reading an information sheet and signing
a consent form, family member participants completed the baseline (pretest) survey, which included
questions on demographics and the family-centered
care survey. When possible, consent also was
obtained from patients. At the control site, routine
nursing care was continued unchanged; at the intervention site, nurses helped patients family members
participate in fundamental care. Nurses at the intervention site were clearly instructed about the project
to ensure they understood their role in supporting
family members.
After approximately 48 hours, family members
were resurveyed by using the same family-centered
care survey that was used at baseline. This time
frame was selected because it was considered sufficient time to allow family members a number of
opportunities to perform some care and yet reduce
attrition due to discharge of patients from the unit.
The type and number of episodes of care that family members provided were recorded by the bedside
nurse at the intervention site.
Instrument
The data collection instrument, a self-reporting
survey with 4 sections and 30 questions, required
approximately 5 to 10 minutes to complete. The
first section was for demographic data: the reason
for a patients admission, degree of illness, age of
the patient and the family member, sex of the patient
and family member, ethnic background, education
of the family member, the family members previous experience of critical care, and the family members relationship to the patient. The second section
was an adapted version of the Family-Centered Care
Survey, a 20-item tool developed by Shields and
Tanner3 to measure respect (6 items, such as I feel

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like a visitor rather than a relative when I attend the

unit), collaboration (9 items, such as The staff
give me honest information about the care that my
relative may need), and support (5 items, such as All
team members listen to my concerns). All items were
questions about how often a stated event occurred;
response options ranged from 1 (never) to 4 (always).
This 4-point scale is used for mean subscale scores;
higher scores indicate perceptions of higher levels
of family-centered care. Because the original tool
was developed for pediatric settings, the wording
was changed to reflect the adult critical care context.
Data Analysis
Data were analyzed by using SPSS software (SPSS
Inc, Chicago, Illinois). Data cleaning involved checks
for completeness and a check of all variables for outof-range values and logic of values. The intention-totreat principle was used in all analyses; the survey
scores at 48 hours were used as outcome measures.
A 3-step data analysis process was used. First,
descriptive statistics were used to summarize the
sample and survey responses. The Cronbach values, medians, and interquartile ranges (IQRs) for
the total family-centered care scale and its 3 subscales for both time periods were calculated. Second,
Mann-Whitney and 2 tests were used to detect
group differences related to demographic and clinical characteristics. The third step in the analysis
involved model building. Initially, univariate ordinal
logistic regression was used to identify predictors of
each outcome variable (scores of respect, collaboration, support, and total family-centered care at 48
hours). Potential predictors entered into the univariate model were group (intervention or control),
patients age and sex, score on the Acute Physiology
and Chronic Health Evaluation (APACHE) III, length
of stay, family members age and sex, family members previous experience in critical care, and scores
at baseline; scores obtained at 48 hours were the
outcome. Then, multivariate ordinal logistic regression was used, with significant univariate predictors
only. In order to account for baseline differences
between the 2 groups, baseline scores were entered
into the multivariate logistic regression. For all statistical tests, was set at .05.

Results
In total, 174 family members (75 control, 99
intervention) participated in the study (Table 1).
The sex of the patients or family members and
patients critical care length of stay did not differ
significantly between the 2 groups. The relationship
of the family member to the patient and the family

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Table 1
Demographic characteristics of intervention and
control groups, patients, and patients family members
Groupa
Control
(n = 75)

Intervention
(n = 99)

52.1 (17.9)

45.5 (18.1)

.03b

11.1 (9.3)

12.6 (13.3)

.90

Score on Acute Physiology and Chronic

Health Evaluation III, mean (SD)

63.6 (28.3)

52.8 (26.2)

.01b

Male
Female

48
26

(65)
(35)

65
34

(66)
(34)

.90

Age, y
18-25
26-35
36-55
56-70
71+

2
7
37
24
5

(3)
(9)
(49)
(32)
(7)

4
21
45
19
1

(4)
(23)
(50)
(21)
(1)

Relationship
Partner
Son/daughter
Sister/brother
Niece/nephew
Parent
Grandparent

33
23
7
7
4
1

(44)
(31)
(9)
(9)
(5)
(1)

48
2
5
9
7
0

(53)
(23)
(6)
(10)
(8)

Female
Male

64
11

(85)
(15)

74
15

(83)
(17)

.70

Previous critical care experience

32

(43)

43

(48)

.50

Participant
Patient
Age, mean (SD), y
Length of stay in critical care unit,
mean (SD), d

Family member
.03b

.56

Values are number (%) of patients unless otherwise indicated. Values do not
always add up to total for column because of missing data.
b Significant at P < .05.

members previous experience with critical care also

did not differ between the 2 groups. Differences
between the groups were significant for patients
ages, scores on the APACHE III, and family members
ages (Table 1). Patients in the intervention group
and their family members were younger than the
patients and family members in the control group
and had lower scores on the APACHE III.
In the intervention group, care was provided to
patients by 82% of the family members. We were
unable to determine why the remainder did not
provide care. Family members provided care a median
of 3 times (IQR, 3; range, 1-14). Table 2 indicates
the types of care provided by family members to
the patients. The 3 most common care activities
provided were massage (29%), full wash (23%),
and eye care (17%).
Table 3 gives the scores for the subscales and the
total family-centered care scale obtained at baseline
and 48 hours later. Scores tended toward the positive.
The subscales and total family-centered care scale

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547

Table 2
Patient care provided by patients family members
No. (%) of times care provided
by patients family membersa

Care provided
Massage

61 (29)

Full wash

48 (23)

Eye care

36 (17)

Comb hair

20 (9)

Mouth care

20 (9)

Antithrombotic stockings applied

9 (4)

Hair wash

7 (3)

Shave

3 (1)

Face wash

2 (1)

Limb exercises

2 (1)

Other

3 (1)

Total

211 (100)

Because of rounding, percentages do not total 100.

Table 3
Results of survey on family-centered care
for 3 subscales and total score

Scale (score
range, 1-4)

Median score (interquartile

range), by group
Cronbach

Control

Intervention

At baseline
Respect
Collaboration
Support

0.62
0.70
0.80

3.5 (0.75)
3.0 (0.78)
3.2 (0.80)

3.7 (0.33)
3.3 (0.61)
3.6 (1.00)

Total

0.84

3.2 (0.66)

3.5 (0.49)

At 48 h
Respect
Collaboration
Support

0.67
0.72
0.78

3.5 (0.80)
3.0 (0.73)
3.2 (0.08)

3.7 (0.33)
3.4 (0.63)
3.6 (1.00)

Total

0.83

3.2 (0.61)

3.5 (0.44)

were reliable, with Cronbach from 0.62 to 0.84.

Four significant predictors of the score on the
respect subscale at 48 hours were identified in the
univariate analysis: baseline respect score, group
(control or intervention), being a partner of the
patient, and higher APACHE III scores, and these
were entered into the multivariate analysis. In this
analysis (Table 4), after adjustments for other significant factors, the baseline respect score was the
strongest predictor of the respect score at 48 hours;
group (control or intervention) was the next strongest
predictor. Compared with the control group, participants in the intervention group were almost twice
as likely to perceive more respect (odds ratio [OR] =
1.93; P <.001); in the intervention group, partners

548

who provided the care were approximately 112 times

more likely than other relatives who provided care
to perceive more respect (OR = 1.41; P = .04). The
other 2 factors, a familys experience of critical care
and APACHE III scores, were not predictors of
respect scores at 48 hours after the other factors
were controlled for.
For the collaboration subscale at 48 hours, univariate analysis indicated 5 significant predictors:
baseline collaboration score, group (control or
intervention), male family member, family members
previous critical care experience, and the patients
sex. When these factors were included in the multivariate model, the strongest predictor of the collaboration score at 48 hours was baseline collaboration
score; the next strongest was group. Participants in
the intervention group were approximately 112 times
more likely than those in the control group to perceive higher collaboration (OR = 1.63, P < .001;
Table 4). Those family members with previous critical care experience were also approximately 112
times more likely than family members without
such experience to perceive greater collaboration
(OR = 1.52; P < .001). In both the control and intervention group, family members of female patients
were approximately 113 times more likely than family members of male patients to perceive higher
collaboration scores (OR 1.35; P = .03). After adjustments for the other significant factors, the family
members sex was no longer a significant predictor
of the collaboration score at 48 hours.
Univariate analysis indicated 5 significant predictors of the score on the support subscale at 48
hours: baseline score, group, relationship of the family member to the patient, sex of the family member,
and the patients age. In the multivariate analysis
(Table 4), after adjustments for other significant
factors, baseline support score and group were the
strongest predictors. The intervention group was
approximately 134 times more likely than the control
group to perceive greater support (OR = 1.79; P = .001;
Table 4). In both the control and intervention group,
family members who were the partner of the patient
were nearly 112 times more likely than those who
were not a partner to perceive increased support
(OR = 1.44; P = .03). After the other factors were
controlled for, the sex of the family member was
not a predictor of the support score at 48 hours.
Univariate analysis indicated 7 significant predictors of total scores on the family-centered care
survey at 48 hours: baseline score, group, sex of the
family member, being the patients partner, family
members previous experience of critical care,
APACHE III score, and female patient. In the multi-

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Table 4
Multivariate ordinal logistic regression model
Respect
Variable

Collaboration

Support

Overall

OR (95% CI)

OR (95% CI)

OR (95% CI)

OR (95% CI)

Baseline score

7.05 (5.56-8.95)

<.001a

4.28 (3.69-4.97)

<.001a

6.75 (5.30-8.60)

<.001a

5.48 (4.90-6.12)

<.001a

Intervention group

1.93 (1.37-2.71)

<.001a

1.63 (1.28-2.07)

<.001a

1.79 (1.27-2.51)

.001a

1.66 (1.40-1.97)

<.001a

Family member has

critical care experience

1.21 (0.87-1.68)

.27

1.52 (1.18-1.94)

<.001a

NA

1.27 (1.07-1.50)

.006a

Partner of patient

1.41 (1.02-1.95)

.04a

NA

NA

NA

1.19 (0.81-1.70)

0.99 (0.99-1.0)

.07

NA

Male family member

APACHE III score
Patients age
Female patient

NA
NA

1.35 (1.03-1.77)

.03a

1.33 (1.11-1.58)

.002a

1.18 (0.73-1.9)

.50

0.99 (0.76-1.29)

.96

1.0 (1.00-1.00)

.21

NA

NA

NA
NA

.37

1.44 (1.03-2.01)

.03a

1.01 (1.0-1.02)

.009a

NA

NA

NA

1.48 (1.21-1.80)

<.001a

Abbreviations: APACHE, Acute Physiology and Chronic Health Evaluation; CI, confidence interval; NA, not applicable; OR, odds ratio.
a Significant at P < .05.

variate analysis (Table 4), after adjustments for other

significant factors, the baseline total score was the
highest predictor; the next highest was group. Participants in the intervention group were approximately
112 times more likely than participants in the control
group to perceive higher overall family-centered care
(OR = 1.66; P < .001). In both the control and intervention group, when the patient was female, the
total family-centered care scores were approximately
112 times greater than the scores when the patient
was male (OR = 1.48; P < .001). Family members
who had previous critical care experience (OR = 1.27;
P = .006) or were the partner of the patient (OR = 1.33;
P = .002) were approximately 113 times more likely
than those who did not have previous critical care
experience or were not the partner of the patient to
have higher total family-centered care scores (Table 4).
After other factors were controlled for, sex of the
family member and APACHE III scores were not
predictors of total family-centered care scores at
48 hours.

Discussion
Although the importance of the role of the
patients family is recognized in most areas of
health care, integration of the family into the unit
of care has not been widely explored in adult critical care. Our results indicate that patients family
members involved in the care of the patients (intervention group), even after other group differences
were controlled for, perceived more respect, support, and collaboration than did patients family
members who were not involved in the patients care
(control group). However, the 2 groups differed
significantly in age of the patient and APACHE III
scores. These differences may reflect the catchment

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areas at each site; the intervention site receives

referrals from various smaller hospitals, and the
control site is in an area favored by retirees.
The types of care delivered by the family members in the intervention group ranged from combing
hair to more complex and demanding procedures
such as bathing patients. With help from the bedside nurse, each family member decided which
patient care activity or activities the family member
would perform, thus allowing for appropriate individualized options and targeting the intervention
to suit the participant as proposed by Conn et al.31
Family members emotional connections to the
patients provided knowledge the nursing staff did
not have about individual patients preferences for
the care the nurses provided.18 Although helping
with the physical needs of patients was not high on
the list of the needs of patients family members in
the small study by Maxwell et al,33 providing care
has been suggested as a way to promote closeness,17
patients safety and security,18 and family integrity.34-36
Conversely, all patients and their family members
interviewed by Bergbom and Askwall18 thought the
family members should have the opportunity to
participate in giving care on a voluntary basis because
caregiving by a patients family member sustains the
patient though difficult periods, promotes closeness
and sharing of experiences, and contributes to the
patients well-being.
The sex of the patient affected the perceived collaboration and overall family-centered care; family
members of female patients had higher scores on the
surveys. We do not know the reason for this finding,
but the result is worthy of further examination.
Family members who were partners of the patient
perceived significantly greater overall family-centered

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549

care, respect, and support than did nonpartners.

Providing adequate support to family members
can reduce their anxiety levels37 and improve their
coping strategies, changes that can enhance patients
recovery.38 Critical care staff may show a bias
toward patients partners and perceive that the partners are more
likely to be the primary caregivers
when the patients leave the hospital.
Health care personnel may consider
the partners more worthy or engage
with them in such a way that the
partners feel they are treated with
greater consideration and are offered additional
assistance. This view of who is the patients caregiver may be inaccurate, and critical care staff
could broaden their support and esteem to include
other family member groups; any assumptions of
who will provide ongoing care may be questionable.
Each family member participant decided what
care he or she should provide by consulting with
the bedside nurse and the patient. These decisions,
which required discussion, collaboration, and
support by the nurses, could not have been made
without good communication. Of the top 10 needs
of family members, 7 are related to the need for
information7; thus, good communication is essential in critical care. Patients also need effective means
of communicating their feelings and needs. Family
members can help patients communicate with
staff, either because the members know the patients
well or because the members have the time to persevere to interpret the patients needs.18
Previous experience of critical care had a positive effect on family members perceptions of collaboration and of
overall family-centered care. Equipment may have been more familiar
to these families than to first-time
visitors to critical care, a situation
that may have supported the families participation and engagement
with staff. Family members who
have previous experience with critical care might feel less overawed by the surroundings and have more confidence in communicating
with nurses and staff. Li et al20(p296) agree with this
notion and suggest that care givers confidence
and knowledge in the hospital may be key to their
effective participation in the hospital care and to
achievement of positive outcomes.
During illness, a patients family generally provides care along the continuum. The inclusion of

Families providing
care perceived
more respect than
the control group.

Providing care may

promote closeness,
patient safety
and security, and
family integrity.

550

patients families in providing care that is offered in

pediatric and palliative care units3,5 is also needed in
critical care. As critical care nurses strive to improve
the care they deliver, the needs of patients family
members are both relevant and important aspects
of the care the nurses deliver.

Limitations
Our study has several limitations. First, we used
a convenience sample from 2 sites, and baseline differences existed between the 2 groups. Consequently,
the sample may not be representative and could be
biased. However, even after baseline scores were
controlled for, the intervention group still reported
more respect, collaboration, and support than the
control group did. Second, the intervention was
conducted in a single unit, and therefore the results
cannot be generalized. Third, only the family members of longer term patients were included in the
sample, thereby limiting the results to this group.
Fourth, patients were not followed up afterward to
ask how they felt about having a family member
provide some care. Such follow-up would have provided useful information. Finally, the reliability of
the family-centered care survey was not optimal.
Unexpectedly, the Cronbach for the respect subscale was less than 0.70, although the values for the
other subscales and the total scale were greater than
0.70. Although this study was the first time this
scale was used to measure perceptions of family-centered care in adults and provides a foundation for its
use, further exploration of the scale is warranted.

Further Research
Our findings provide a foundation for trials of
additional interventions to promote family-centered
care. Data on qualitative components of the experiences of family members, patients, and nurses of
such interventions would provide broader insight.
Use of a more formalized approach such as the
development of a care plan incorporating patients
family members in care activities could assist in
improving the family members satisfaction and better meet the needs of the family. Such a care plan
must be structured cautiously, because the goal is to
improve holistic care and better meet family members needs, not impose on family members to provide care to which they do not want to contribute.

Conclusion
A group of family members of patients who
were included in the patients care perceived more
respect, collaboration, and support than did a
group of family members who were not included.

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The intervention of partnering with family members

to provide fundamental care to their sick relative
resulted in a significant difference in the levels of
family-centered care as measured by respect, collaboration, and support. To provide holistic care, critical care nurses must involve patients families in
patient care and by so doing better meet the needs
of the families and patients. Partners of patients
perceived greater respect, support, and overall family-centered care.
The scores for family members who were experiencing critical care for the first time suggest that
such members may require additional recognition
by staff of the challenges this experience brings.
When their needs are met, family members have a
greater capacity to provide the support and ongoing
care their relative needs both in the critical care unit
and after discharge. The independent nursing intervention of allowing family members to help with
patient care provides a beginning for understanding
how to operationalize the family-centered care model
in the clinical setting and will be useful in the evaluation of other family-centered care interventions.
ACKNOWLEDGMENTS
This research was performed at Princess Alexandra Hospital and the Gold Coast Hospital.
FINANCIAL DISCLOSURES
Financial support was received from an Australian College of Critical Care Nurses research grant.
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SEE ALSO
For more about family-centered care, visit the Critical
Care Nurse Web site, www.ccnonline.org, and read the
article by Davidson, Family-Centered Care: Meeting
the Needs of Patients Families and Helping Families
Adapt to Critical Illness (June 2009).

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