Professional Documents
Culture Documents
A Discussion of Family
A Discussion of Family
Source:
Critical Care Nursing Quarterly
Keywords
family-centered care, parental involvement, pediatric intensive care
Authors
Frazier, Angela RN
Frazier, Heath RN
Warren, Nancy A. PhD, RN
Abstract
Every year, thousands of children are admitted to pediatric intensive care for treatment. Many of
these admissions are for acute injuries, but children with chronic illnesses requiring repeated
hospitalization are also on the rise. Hospitalization of a child is extremely stressful for both the
patient and family. Historically, intensive care units had restrictive visitation hours and did not allow
for sibling visitation or multiple family members. Parents and family members were not encouraged
to participate in care when at the bedside. As the shift toward family-centered care continues, many
hospitals are now changing visitation polices to allow for active family involvement in patient care.
Parents are now encouraged to participate in care. Intensive care units are modifying layouts of the
unit to facilitate visitors and provide sleeping spaces for parents when available. Families are
considered part of the team instead of visitors, and are included in the decision making process. The
purpose of this article is to promote discussion of family-centered care in the pediatric intensive care
unit.
Article Content
FAMILY-CENTERED CARE
Family-centered care (FCC) has only recently emerged in the healthcare field since the 1950s, but it
is one of the most important movements in pediatric care for the 21st century. The word family refers
to 2 or more persons who are related in anyway-biologically, legally, or emotionally.1 In the pediatric
population, parents or guardians determine who make up the patients' family. Family structures vary
dramatically and can include blended families, single parent households, adoptive homes, same-sex
couples, and transgendered models that include extended family members.2
Family-centered care is a care delivery model that incorporates a partnership between families and
providers when caring for the patient. Some common components of FCC include respect,
collaboration, participation, and information sharing among family members. Respect and dignity are
provided for patients and families by honoring personal and cultural beliefs and incorporating these
beliefs into healthcare choices. Healthcare providers collaborate with families and patients for the
delivery of care as well as facility wide changes and improvements. Patients and families are
encouraged to play an active role in decision making and delivery of care. Healthcare providers open
communication to families about treatments and plans of care so that active involvement is
facilitated.2,3 Parent involvement in care, respect for culture, and recognition of family importance
are all factors that are important in the delivery of FCC. Family-centered care can be applied to all
patient settings and includes patient involvement along with family involvement. The very young, very
old, and all ages can be included in the collaboration of care.
Family-centered care within the pediatric intensive care unit (PICU) is largely focused on parental
involvement and parental presence at the bedside. Parents assume the role of advocates for their
children, educators to clinicians, and support to other families. Sibling visitation is slowly evolving to
include more interaction and education that includes the entire family in the care process.
VISITATION POLICIES
Since the 1800s, visitation polices within the hospital settings have been restrictive. The first
children's hospitals were opened in the 1850s to treat children in cleaner conditions than those found
at home. Visitation was heavily restricted and key goals of the hospital were related to social reform
instead of patient care. During the early 1990s, hospitals became more sanitary environments that
were no longer considered places of death. With the emergence of neonatal and pediatric intensive
care units, further restrictions on visitation policies were enforced as concerns for communicable
disease emerged.
Risk of infection, confidentiality, and crowd control were all factors that have contributed to the slow
incorporation of FCC in the pediatric setting. As recently as 10 years ago, more than half of pediatric
hospitals surveyed still restricted visitation to short time frames several times a day.4 Although FCC
was initially more focused on the ability of family presence at bedside, the shift has now changed to
include family involvement, which can include additional roles such as patient advocate, peer
support, hospital committees, and educational opportunities.5
Many factors have contributed to the slow emergence of FCC in PICUs. Although involving a child's
family within care may seem like common practice to recent nurse graduates, more experienced
nurses often have difficulty accepting the changes associated with FCC. The traditional PICU
environment is not a warm and fuzzy place that encourages visitation or parental involvement.
Pediatric intensive care units are often busy, crowded, over stimulating, short staffed, procedure
oriented, and hectic. Until recently, parents were often asked to leave the room or unit during
procedures, report, and rounds. Visits for older siblings were limited to short periods of time, if
allowed at all. Concerns over infections caused by sibling visitation have been evaluated but require
further research. Communicable diseases often found in children could possibly be transmitted to the
sibling in the hospital. The stress of viewing a sibling who is ill maybe considered traumatic and
further cause of emotional harm. Furthermore, a child that is in demise or dying may add more
trauma to an emotionally charged situation that is already difficult for parents without adding more
stress on the young siblings. Most institutions do not provide sleeping areas in the room or on
hospital property for parents to sleep at night, although this is an emerging trend across the United
States.6
evaluating coping needs are important roles of the PICU nurse. Sibling preparations prior to visits
with hospitalized children are needed. Prescreening for signs of communicable illnesses is common
practice in many PICUs. Evaluation of psychological and emotional preparation for the visit should
be considered with young children. Encouraging hand washing and universal precautions in all
visitors is useful to prevent the spread of infection.
Staff education in preparation for open visitation of a unit is helpful to improve interpersonal skills that
are needed for extensive family interactions. Reinforcing positive aspects of family involvement can
help make staff more open to changes. Review of developmental and coping mechanism of healthy
children can make visitation less difficult for nurses who are uncomfortable with possible reactions of
siblings.
Both patients and family members benefit from a FCC model while in the PICU. Multiple research
projects reinforce that parent and patient stress are decreased when parents are allowed to be
involved with care. Coping and comfort in parenting roles are enhanced when parents have an active
part in decision making and activities of care. Healthy sibling interaction was generally promoted
when adequately prepared and age appropriate.
have extra money for snacks in this time of economical recession. Although hospital food may not
seem as desirable as dining at home or at a restaurant, many may need this break for a few minutes
of time to themselves.
Family members may also address feelings such as anger or guilt because they think they should
have performed actions that would have avoided the illness, accident, or cause of their child's
admission. Pediatric nurses can be attentive to such negative feelings and offer support by listening
to or seeking outside assistance from hospital chaplains, pastors, or counselors. Literature may be
provided regarding these services to the family members so they have this knowledge. Support can
be offered by discussing the environment of the unit and methods to communicate if the child is
unable to communicate because of the illness or mechanical ventilation. When children are critically
ill, family members may wish to discuss the possibility of demise or death. Because family members'
perception of bereavement experiences around the death could affect positive bereavement
outcomes, early detection of unmet needs by nursing staff is crucial. Families facing death of a
pediatric child are at potential risk for physical and psychological health problems. Although it is
unrealistic to address every aspect of family members' need when demise occurs, stressors
associated with bereavement experiences of a child may be reduced if appropriate and timely
interventions are provided. Family members require opportunities to be present at the time of death if
that should occur.
Given the complexity of variables surrounding FCC and the child's illness, nurses may be in a place
to identify needs of the both the family and the patient.12 In FCC, family members will become
involved in an egalitarian interaction that expands giving and receiving by both family members and
pediatric nurses.
REFERENCES
1. Institute for Family Centered Care. http://www.familycenteredcare.org. Accessed April 24,
2009. [Context Link]
2. Shudy M, Lihinie de Almedia M, Ly S, et al. Impact of pediatric critical illness and injury on
families: a systematic literature review. Pediatrics. 2006;118:203-215. [Context Link]
3. Neal A, Frost M, Kuhn J, Green A, Gance-Cleveland B, Kersten R. Family centered care within an
infant-toddler unit.Pediatr Nurs. 2007;33(6):481-486. [Context Link]
4. Giganti A. Families in pediatric critical care: the best option. Pediatr Nurs. 1998;24(3):261265. [Context Link]
5. Dokken D. The many roles of family members in "family-centered care." Pediatr Nurs. 2006;32(pt
1):562-565. [Context Link]
6. Rozdilsky J. Enhancing sibling presence in pediatric ICU. CC Nurs Clin NA. 2005;17:451461. [Context Link]
7. Smith A, Hefley F, Anand K. Parent bed spaces in the PICU: effect on parental stress. Pediatr
Nurs. 2007;33:215-221.[Context Link]
8. Cullen L, Titler M, Drahozal R. Family and pet visitation in the critical care unit. Crit Care Nurs.
2003;23:62-67. [Context Link]
9. Davidson J, Powers K, Hedayat K, et al. Clinical practice guidelines for support of the family in the
patient-centered intensive care unit: American College of Critical Care Medicine Task Force. Crit
Care Med. 2007;35:605-622. [Context Link]
10. Montgomery L. A research-based sibling visitation program for neonatal ICU. Crit Care Nurs.
1997;17:29-35. [Context Link]
11. Garrouste-Orgeas M, Philippart F, Timsit J, et al. Perceptions of a 24-hour visiting policy in the
intensive care unit. Crit Care Med. 2008;36:30-35. [Context Link]
12. Sturdivant L, Warren N. Perceived met and unmet needs of family members of patients in the
pediatric intensive care unit. Crit Care Nurs Q. 2009;32;149-158. [Context Link]