Is family‐centred care in critical care units that difficult? 
A view from Europe

Although, family-centred care is a well-known concept within all fields of nursing (Shields and Nixon, 2004), the elements of family-centred care are not always unequivocally understood. This confusion leads to a wide variety of nursing practise in family care, particularly within critical care nursing. For example, the existing visiting restrictions typical of some adult intensive care units (AICUs) make relatives and significant others see themselves as visiting ‘guests’. This concept is at odds with the paediatric critical care practise where terms such as visiting hours have been absent from the professional vocabulary for more than two decades. However, there is a trend within adult critical care, for adopting a more focused family-driven healthcare system. An example is a recent article about open or restricted visitation in AICU (Slota et al., 2003). The article considers the positive arguments for open visiting policies such as reduction in patients’ stress and effective patient communication when family is present. Although the authors go on to promote development of creative strategies regarding family participation, they continue to mix notions of participation and visitation. Family members are not visitors. They are members of the patient's family with the right to participate in the care of their beloved one. Therefore, the view and attitude of adult critical care nurses should be more directed to the basic principles of family-centred care. When we talk about family-centred care, who are the family members? In paediatrics, it seems fairly easy to define family members. Mostly, it concerns the parents and siblings of the critically ill child. Although grandparents often play a major role in the care of their grandchildren, they are not always integrated into family-centred practise. Defining a family in adult critical care is in some way easy, in a marital context, the spouse is the first person legally accepted as the closest to the patient. This is particularly an issue when it comes to end-of-life decisions. However, there are situations when the children of a couple are often adults themselves and sometimes they have grandchildren too. They also belong to the patient's family. But in today's pluralistic and multicultural society, it becomes more complex to define the patient's loved ones. It requires knowledge and understanding of various rituals, believes and life styles. For example, what is the decision-making status of the partner in same sex couples? Do we allow the active participation of a tribal medicine man if requested by an African or Asian patient and their family? Do we allow the guide dog of a blind patient to be at the bedside? Such questions illuminate that flexibility and the capacity to respond to the diversity in family-centred care are a challenge for all. Although these issues are more commonly addressed in paediatric intensive care nursing, they may be less well rehearsed in adult critical care nursing. More emphasis is given to specific topics such as: identifying the needs of patients and families or involvement in treatment plans and decision making. These issues are intrinsic elements of family-centred care; however, they do not necessarily examine means of improving the interaction process between, and attitude of, nurses and family. Likewise, innovative family care interventions seem not to be recognised as important (Holden et al., 2002). Therefore, it is suggested, to develop, implement and evaluate interventions directed to the participation of family members in critical care, useful lessons can be learnt from the paediatric critical care literature where the subject is more widely studied and discussed. Hutchfield (1999) has identified nine major principles from a concept analysis of family-centred care, and recently, the American Academy of Pediatrics has described similar ideal standards in a policy statement of family-centred care (American Academy of Pediatrics, 2003). They are grounded in a collaborative relationship based on respect and open communication. The continuum of family-centred care practise starts with parental involvement where nurses mainly do the care and are advocates for the family (Hutchfield, 1999). On the other side of the continuum is a more advanced practise where the role of nurses can be defined as consultants and counsellors having a dialogue with the parents. Defining the advanced role of nurses is important, but whether this role is taken seriously in practise can be questioned. Evidence shows that some adult and paediatric critical care nurses find it difficult to build up a relationship with family or parents and to meet their needs (Holden et al., 2002; Petersen et al., 2004). In a replication study by Petersen et al. (2004), using the Necessary and Current Scale of the Family-Centred Care questionnaire (Bruce and Ritchie, 1997), paediatric and neonatal intensive care nurses indicated that the principles of family-centred care are important, but they do not consistently implement these elements into daily practise. The reasons for this inconsistency were the range of organisational support, professional development and autonomy of the nurses within the units included in the studies (Bruce and Ritchie, 1997; Petersen et al., 2004). As part of a study tour, Haines (2005, cited in this issue) travelled to various paediatric intensive care units (PICUs) in order to identify possible opportunities for developing and improving the care of acutely sick children. Haines (2005, cited in this issue) provides an excellent international overview of critical care outreach teams and early warning assessment tools, in particular the relationship between paediatric critical care units and high-dependency units. However, current family practise in the observed units was not investigated. Although a well-established functioning outreach team provides better healthcare outcomes in children, parents are also part of this transitional care aspect. The impact on parental stress during and after a child's PICU admission is well documented (e.g. Balluffi et al., 2004). In this respect, Hall's work (2005, cited in this issue), provides valuable evidence and gives a deeper understanding of the lived-experience of parents in a neonatal intensive care and a paediatric unit. Qualitative studies like this emphasise the importance of nurses’ attitudes and communication skills. Yet, having these attributes alone are not enough to meet the basic principles of family-centred care. Implementation strategies or methods to implement specific family interventions are needed. Tomlinson and colleagues (2002) argue that several methods of social learning, or a combination of these methods, can accommodate the development of nursing skills in the PICU towards family interventions. A combined learning model of demonstration, role modelling and reflective practise seems to improve family sensitivity. This unit-based practise education needs guidance from experts in critical care nursing in an open and supportive atmosphere. It works two ways; ‘Clinical practise and caring relationships are privileged ways of meeting the other, and in meeting the other we meet ourselves’ (Benner et al., 1996; p. 329). Based on her finding, Hall (2005, cited in this issue) recommends implementing intervention to enhance family-centred care. The parent educational-behaviour intervention on a PICU studied by Melnyk and colleagues (2004) is such an example. This three-phase project called Creating Opportunities for Parental Empowerment focus on parental knowledge of the child's behaviour during, and after, a hospital admission. It facilitates parents’ understanding of their child's psychosocial and physical care. This intervention brought about a significant reduction in parents’ and children's stress symptoms in a, respectively, 6 and 12 months period after hospital admission. In addition, this extensive program contributed to family-centred practise by underpinning the holistic child and parents approach. However, efficiency and effectiveness of such interventions needs further evaluation. Taking care of parents or family members in critical care settings requires specific knowledge and skills. These cannot be learned overnight and require vision and teamwork. Family-centred care is not simply about visiting. It concerns collaboration between family members, patients and healthcare workers with respect to all aspects of care. Basically, we need to create a safe passage of patients and family through the critical care period and beyond. Jos M Latour 1 1 Clinical Researcher Erasmus MC – Sophia PICU SK 3143 3000 CB Rotterdam The Netherlands E-mail: [email protected]