Family-Centered Care in the Critical Care Setting

Family-Centered Care
in the Critical Care Setting
Is It Best Practice?
Susan Cannon, MSN, RN, NE-BC

The critical illness of a family member negatively impacts the entire

family. Nurses have the opportunity to be instrumental in maintaining
the family unit. Family-centered care and open visitation are supported
by research. Research also shows that family-centered care improves
satisfaction for both the patient and family. This is an integrated
literature review and recommendations for clinical practice.
Keywords: Family-centered care, Family integrity, Information, Visitation
[DIMENS CRIT CARE NURS. 2011;30(5):241/245]

As a nurse, I often wonder about the impact of fam-
ily involvement in patient healing. My experience as a
bedside registered nurse has been in medical/surgical/
telemetry units. I also served as an interim director of
the critical care unit (CCU), where I was exposed to a
different area of nursing. Here I was able to learn about
different types of patients, as well as a different style of
providing nursing care. Nurses in CCUs have a very di-
verse view of family involvement and visitation. In my
experience, most nurses in the CCU view it as their ter-
ritory. Some argue they could provide better care to
the patient if families were not ‘‘in their way.’’ Coming
from a medical/surgical background, I saw families at
the bedside in a different, perhaps, more positive way.
They were my eyes and ears when I could not physically
be in the room with the patient, therefore a comfort to
me as the nurse. I began to ask myself: How could I
change the mindset of these nurses and encourage them
to be an advocate for our patients and their families?
Since I have little experience as a direct caregiver in a
CCU setting, could I be wrong? I began to ask myself
several questions that left me wanting to know more
about this subject. Are the patients too sick for visitors?
Do they need rest? Can nurses provide better care
without the family present? Does family-centered care
help patients and/or families? These questions troubled
me because I knew family-centered care was successful
in other patient care settings and in other CCUs in other
hospitals.
I began my search for the pros and cons of the prac-
tice model of family-centered care in the CCU setting.
For the purpose of this article, I will focus on the adult
population and exclude the neonatal intensive care unit
(ICU) setting because this type of unit offers family-
centered care as a norm. This research included the use
of several search engines to locate research already con-
ducted in this area.
According to family systems theory, the family is
viewed as ‘‘an interdependent, continually interacting
whole that is greater than the sum of its part.’’1 Family
is defined by the perception of the patient. Illness of one
family member has a great impact on the other family
members, especially if they have a close relationship. A
great deal of research has measured the impact an illness
has on the family unit. The nurse must be aware of the
needs of the family when the family has a loved one in a
CCU. Unfortunately, nurses and families are not always
on the same page with meeting those needs, such as
visitation. Nurses sometimes underestimate the impact
they can have on the family unit by meeting the needs of
the family. Asymmetry occurs when the family does not
understand the medical environment and what is going

DOI: 10.1097/DCC.0b013e3182276f9a September/October 2011 241

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Family-Centered Care in the Critical Care Setting
on with its loved one. When the family has incomplete
information or knowledge, it may come to conclusions
that may not be true. The families may see themselves
in a power struggle with the nurse when he/she has a
negative view of family-centered care.
In the following paragraphs, studies are reviewed
that support research for family-centered care. In 1997,
Morrison2 expressed it well by saying, ‘‘entering inten-
sive care unit (ICU), there is the initial shock of walking
into an environment that makes no distinction between
night and day. They hear the sounds of high-pitched
alarms and the regular whoosh of the ventilator breaths.
Through the vine-like array of tubing and the blockade
of high-tech equipment lies their distorted, comatose
family member. As they approach, an initial reaction of
denial is in conflict with a protective desire toward the
patient.’’2(p170) One study was completed to develop a
way for nurses to understand how to partner with the
family of an ICU patient. During a patient’s hospital-
ization, it becomes the nurse’s role to support the family,
sustain the integrity of the family unit, help family
members transition into the role of caregiver, and serve
as the patient advocate if they are going to provide care
to the patient after discharge.3
Nelson and Plost4 evaluated the benefit of having a
family care specialist (FCS) in the ICU. Sometimes nurses
perceive supporting the family as time consuming which
may take away from the care they are providing the pa-
tient. The development of the program was in response
to poor family and nursing satisfaction scores. Once the
need for this position was identified and approved, the
program was initiated. The role of the FCS was to meet
the evolving needs of the families of the critical care patient
so the patient’s nurse is not distracted from providing care.
The FCS was a recognizable face for the family that
decreased questions from the families to the CCU nurse.
They focused on end-of-life issues and served as a tie to
other resources that could benefit the family. The FCS
is involved in education for the nursing staff as well as
family members of the CCU patients. After the implemen-
tation of the FCS, the CCU staff nurses’ satisfaction im-
proved, and they viewed the role of the FCS as a vital part
of their team. Family satisfaction increased, and patients
benefited by the FCS’s role in implementing a palliative
care program.
The development of the program was
in response to poor family and
nursing satisfaction scores.
242 Dimensions of Critical Care Nursing Vol. 30 / No. 5
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Blanchard and Alavi5 conducted a study of 14 reg-
istered nurses in an effort to develop ways to work with
the families of patients in the ICU to alleviate the feeling
of being disconnected between the nurse and the family.
In the beginning of the study, participants reported they
delineated the family separate from the patient. In some
cases, the CCU nurses did not recognize someone as part
of the patient’s family. Participants devised a Family As-
sessment Form to assist the nurses to see the patients as
extension of the family and to begin to build trust. The
nurses started to view patients as a part of a family and
developed a relationship with the families.
Engdahl6 described an implementation of open vis-
itation in one facility in the northeastern United States.
This research reiterated some of the findings in other
studies that showed families want to be involved in their
family members’ care. Health care professionals must be
aware of the importance of family involvement and pres-
ence when their family member is critically ill. The staff
of the medical/surgical-transplant unit in this hospital
was presented with the research that supported family-
centered care and family involvement of care during a
health crisis. The staff members had an opportunity to
provide input. The nurses completed a survey regarding
the adoption of a policy of open visitation to support the
families and involve them in the care of their loved one.
The outcome of the survey was the adoption of open
visiting hours for the families of the ICU patients. The
nurses promoted family-centered care and realized the
psychological and physiological benefits of families re-
maining at the bedside and providing care for the patient
when feasible.
Schneider7 describes how family needs can be in-
tegrated into the design and environment of a family-
centered care unit in a new hospital in a large facility in
the southern United States. Eighteen months before the
day the new hospital was to open its doors, it began
gathering family input into the design of the neurolog-
ical ICU. Although research reveals that family involve-
ment has an impact on patient outcomes, there is limited
research regarding family input on the design of an ICU.
The family input led to enclosed suites built inside the
patient’s rooms to accommodate 2 family members to
sleep during the night. A larger waiting area was de-
signed to include a children’s center, laundry facilities,
and shower area. The waiting area was also staffed with
a dedicated family representative. Family satisfaction
surveys, after the opening of the hospital and the new neu-
rological ICU, revealed an increase in family satisfaction.
Chien and colleagues8 conducted a quasi-experimental
study to examine the effect of a family needs assessment
program provided within the first 3 days of the patient’s
hospitalization. The study involved a pretest and posttest

of the experimental and control groups. The experimental
group received an individualized family needs assessment
using the Critical Care Family Needs Inventory developed
by Molter9 in 1979. This was followed by an individu-
alized education plan. The control group received the
standard orientation and education from the ICU nurses.
The findings supported the efficacy of providing the fam-
ilies of newly admitted patients with a needs-based edu-
cational program to alleviate anxiety and to help meet
the needs of the family. To be effective, the family needs
must be assessed when the patient is admitted so the edu-
cation plan is directed toward meeting their individu-
alized needs.
Azoulay and colleagues10 conducted a study to eval-
uate the degree of family satisfaction when the families
were allowed to participate in the care of their loved one.
The researchers believed that families should be viewed
as active participants instead of simply receivers of in-
formation. The family can assume an active role by act-
ing as the proxy, to speak for the incompetent patient
(if applicable), so the health care team can uphold the
patient’s values, as well as participate in the care. The
study involved 357 patients and 544 family members. At
the time of discharge, families were asked if they would
have liked to participate in care (ie, bathing, feeding, etc)
and why. Caregivers were asked if they felt families could
be involved in the care and if they actually involved the
family in the patient’s care. The study concluded that
most caregivers (88.2%) believed families should be of-
fered the opportunity to be active participants in the
patient’s care; however, a few families (33.4%) reported
they wanted to have an active role in the care. These re-
sults may be appropriate because of the lack of infor-
mation provided to the family and the family’s fear of
harming of the patient.
Gavaghan and Carroll1 viewed the family’s needs
from the perspective of the family members, nurses, and
patients. They accomplished their purpose using a 45-item
self-reporting questionnaire that addressed 5 concepts:
(1) proximity, (2) assurance, (3) information, (4) support,
and (5) comfort. In regard to visitation, the families’ per-
ception was that offering unrestricted visitation actually
increased family satisfaction by meeting their need for
information. However, nurses were more satisfied with
liberal visitation and perceived visitation was a benefit
for the family but not for the patient. Assessment of the
patient revealed no change in heart rate, blood pressure,
or self-reported stress level. The study also assessed the
presence of family during procedures and resuscitation.
The results revealed that 79% of families wanted to be
present during resuscitation, 61% felt their presence
would have been beneficial to their family member, and
64% felt their presence would have lessened their sorrow
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Family-Centered Care in the Critical Care Setting
after the death of their loved one. Nurses have been in-
strumental in promoting strategies to put family closer to
the critically ill patient. In the domain of education and
support, both families and nurses supported educating
the family with the use of a 90-minute educational ses-
sion on the ICU environment and available resources.
Families also reported support groups were beneficial by
providing a channel for expressing their feelings and
helped them feel cared for by the health care team. The
use of volunteers to meet the needs of the families im-
proved overall family satisfaction and lessened their anxi-
ety and frustration. The families also reported a benefit
of having a hospital-provided pager. They felt comfort
in knowing they had a continuous connection with the
nursing staff caring for their loved one.
Nurses have been instrumental in
promoting strategies to put family
closer to the critically ill patient.
Sacco et al11 evaluated the effectiveness of a family-
inclusive CCU using a Likert scale. Family members
(N = 42) of ICU patients participated in the survey.
Elements of family-inclusive care included (1) recogniz-
ing that patient’s families are the constant in the patient’s
life; (2) encouraging family-to-family support; (3) shar-
ing complete information continually; (4) identifying and
appreciating the strengths and individual attributes of
each family member; (5) being flexible, culturally sen-
sitive, and reactive to the needs of the family; and (6)
integrating the developmental needs of children and
adolescents in the plan of care. A family support group
was implemented and evaluated during this study. The
family support group was facilitated by an ICU staff
member and cofacilitated by families of former ICU
patients. The family was surveyed before or immediately
after the patient’s discharge. Elements of the survey were
questions regarding the nursing care, medical care, an-
cillary services, and facilities. The findings confirmed that
support groups can increase communication about ex-
pectations during and after a patient’s ICU stay. The
support group served as an avenue for the patient’s fami-
lies to discuss concerns with others who have comparable
experiences.
One group of researchers completed an observational
study in 21 ICUs in France to evaluate health-related qual-
ity of life (HRQOL) in relatives of patients 90 days af-
ter discharge from ICU or death in the ICU.12 There were
284 family members who participated in the study.
Health-related quality of life is the constituent of life
September/October 2011 243
 Family-Centered Care in the Critical Care Setting

that focuses on diseases and treatments. The objective pitalization. The review focused on family visitation,
of measuring the HRQOL in family members after dis- providing information to family members, allowing fam-
charge or death was to evaluate the physical and men- ilies to provide care to the patient, and addressing the
tal impact of a loved one’s critical illness on the family. family’s feelings of guilt, if any. The research supported
The surveyor asked 3 questions related to the care of the allowing families to visit, providing information to the
family during the hospitalization: (1) Was enough time families, offering them an opportunity to provide care to
allowed for information? (2) Was the information easy the patient, and assisting to resolve any harbored feeling
to understand? And (3) did the family member feel the of guilt and unresolved forgiveness if applicable.
information was complete? The interviewer also inquired There are effective interventions that support family
about conflict with the ICU staff. During the interview, integrity during a crisis of hospitalization. The acute
the family member was surveyed using a questionnaire illness of a family member places a burden on the family
to assess the physical and mental components of the and threatens the integrity of the family. One responsi-
HRQOL. Anxiety and depression symptoms were also bility of the nurse is to help promote family integrity by
assessed. The interviewer also questioned the family providing family-inclusive interventions at the patient’s
member about his/her use of psychotropic treatment, bedside.
if any, during or after the ICU experience. The results
showed normal scores for physical health but lower
APPLICATION TO CLINICAL PRACTICE
scores for mental health in family members. According to
Research has supported family-centered care for over a
the survey, 49.3% of family members reported symptoms
decade. There have been multiple interventions available
of anxiety, and 20.1% reported depression. Regarding
to provide family support. These include (1) family suites,3
medications, 35.9% reported they were taking anxiolyt-
(2) FCSs, (3) open visitation, (4) orientation to the ICU,
ics or antidepressants. Regarding the information pro-
(5) allowing families to be present during procedures/
vided to them during the hospitalization, 84.4% reported
resuscitation, (6) family support groups, and (7) encour-
the information was clear to them, 84.8% reported there
aging family involvement in care. One of the themes
was a sufficient amount of time dedicated to providing
throughout the family-centered research in CCUs has
information, and 66.5% reported that the information
been including the family in the participation of care of
was complete. Only 8.4% reported a sense of conflict
their family member. Family-centered care not only im-
with the nursing staff in the ICU. The study concluded
proves family satisfaction, but also helps nurses view the
that having a loved one experience a critical illness places
patient as part of a family system as well as of an indi-
an emotional burden on the family. Nurses can help al-
vidual. We, as critical care nurses, must treat the family
leviate this burden by providing open visitation and
as a whole when one member is critically ill. Families
holding frequent meetings with families to provide them
have a right to participate in the care of their loved one.
with information. Early detection of family members
Families not only have a need to be involved, but also
who exhibit substantial emotional distress is beneficial,
have a need for information. The more information the
so early treatment can be initiated.
health care team can provide the family, the less anxiety
Davidson13 completed a cross reference of several
the family experiences. When a loved one is critically ill,
studies to evaluate meeting the needs of patient’s fam-
the patient and family are not functioning in their normal
ilies and help them adapt to critical illnesses. The studies
role within the family. Nurses can help maintain family
revealed collectively that the nurses should question the
integrity and support the family during this stressful time.
families about their needs instead of basing their sup-
We must be aware of the fear of the unknown and loss
port on the nurse’s presumptions of their needs. Nurses
of control the patient and the family are experiencing.
should be proactive in assessing the family’s needs.
It is important for organizations to implement practices
Families experience and observe a life-threatening crisis,
that support families. They may be our patients for a
which interrupts customary life functioning and the role
short period; however, they are a loved one to a family
the patient fills in the family. The patient’s family may
for a lifetime.
experience and display anxiety, dissatisfaction, and de-
pression. They may exhibit symptoms of posttraumatic
stress disorder because of this crisis being so traumatic
for the family. Nurses can assist the families to adapt by The more information the health care
providing family support and including families in the
team can provide the family, the less
patient’s care.
Van Horn and Kautz3 completed a literature review anxiety the family may experience.
to assess family integrity during a family member’s hos-

244 Dimensions of Critical Care Nursing Vol. 30 / No. 5

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Family-Centered Care in the Critical Care Setting

References 11. Sacco T, Stapleton M, Ingersoll G. Support groups facilitated

1. Gavaghan SR, Carroll DL. Families of critically ill patients and
the effect of nursing interventions. Dimens Crit Care Nurs.
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2. Morrison M. Body-guarded: the social aesthetics of critical
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New Zealand: The Dunmore Press Ltd; 1997.
3. Van Horn E, Kautz D. Promotion of family integrity in the acute
care setting. Dimens Crit Care Nurs. 2007;26(3):101-107.
4. Nelson D, Plost G. Registered nurses as family care specialists
in the intensive care unit. Crit Care Nurs. 2009;29(30):46-52.
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Crit Care. 2008;13(5):225-231.
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Nurs. 2008;28(2):47.
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ABOUT THE AUTHOR
Susan Cannon, MSN, RN, NE-BC, is the assistant vice president of
inpatient services and has served as the interim director of critical
care at Carolinas Medical Center Lincoln. She has 16 years’ nursing
experience, with the past 10 years in leadership. She recently earned her
degree in master of science in nursing from the University of North
Carolina at Greensboro.
The author has disclosed that she has no significant relationships
with, or financial interest in, any commercial companies pertaining to
this article.
Address correspondence and reprint requests to: Susan Cannon,
MSN, RN, NE-BC, PO Box 677, Lincolnton, NC 28093
(susan.cannon@carolinashealthcare.org).

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DOI: 10.1097/01.DCC.0000403680.60089.ed

September/October 2011 245

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.