Original Manuscript

Nursing Ethics
2019, Vol. 26(7-8) 2494–2510
Relationships among Climate ª The Author(s) 2019
Article reuse guidelines:
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of Care, Nursing Family Care 10.1177/0969733019826396
journals.sagepub.com/home/nej
and Family Well-being in ICUs

Natalie S McAndrew and Rachel Schiffman

University of Wisconsin-Milwaukee, USA
Jane Leske
Froedtert & the Medical College of Wisconsin Froedtert Hospital

Abstract
Background: Frequent exposure to ethical conflict and a perceived lack of organizational support to
address ethical conflict may negatively influence nursing family care in the intensive care unit.
Research aims: The specific aims of this study were to determine: (1) if intensive care unit climate of care
variables (ethical conflict, organizational resources for ethical conflict, and nurse burnout) were predictive
of nursing family care and family wellbeing and (2) direct and indirect effects of the climate of care on the
quality of nursing family care and family wellbeing.
Research design: A cross-sectional, correlational design was used.
Participants and research context: Convenience sample of 111 nurses and 44 family members from
five intensive care units at a Midwest hospital in the United States.
Instruments: The Ethical Conflict Questionnaire-Critical Care Version, Maslach Burnout Inventory-
Human Services Survey and Hospital Ethical Climate Scale were used to measure climate of care. The
Family-Centered Care-Adult Version and Nurse Provided Family Social Support Scale were family measures
of the quality of nursing family care. The Family Wellbeing Index was used to measure family wellbeing.
Data analysis: Hierarchical regression and mediation analysis were used to answer the study aims.
Ethical considerations: The study was approved by the Institutional Review Board at the study site.
Findings: In separate regression models, organizational resources for ethical conflict (b ¼ .401, p ¼ .006)
and depersonalization (b ¼ .511, p ¼ .006), a component of burnout, were significant predictors of family-
centered care. In simple mediation analysis the relationship between organizational resources for ethical
conflict and family-centered care was mediated by depersonalization (b ¼ .341, 95% confidence interval
(.015, .707)).
Discussion: Inadequate organizational resources and depersonalization may be related to family care
delivery, and present obstacles to family-centered care in the intensive care unit.
Conclusion: Further research to explicate the relationships among organizational resources, ethical
conflict, burnout, and family-centered care is needed to guide the development of effective interventions
that enhance the quality of nursing family care in the intensive care unit.

Corresponding author: Natalie S McAndrew, College of Nursing Cunningham Hall, University of Wisconsin-Milwaukee, 1921 East
Hartford Avenue, P.O. Box 413, Milwaukee, WI 53201-0413, USA.
Email: mcandre3@uwm.edu
McAndrew et al. 2495

Keywords
Nursing family care, family-centered care, family wellbeing, ethical conflict, moral distress, burnout,
organizational ethical climate

Introduction
Patients are often unable to make choices about life-sustaining treatments during critical illness and family
members must direct their care.1 Families experience a heavy burden in these situations.2–4 Family mem-
bers may make choices to continue life-supportive therapies that healthcare professionals perceive as
futile.5 In these situations, nurses’ ethical concerns about patient suffering as a consequence of life-
sustaining interventions may contribute to a lack of family involvement and support in critical care.6–9
Family inclusion in healthcare delivery is vital for positive patient and family outcomes,10–12 and inade-
quate family support as the result of ethical conflict and burnout may negatively affect the health and
wellbeing of critically ill patients and their families. There is a paucity of literature examining this
relationship.

Background
Ethical conflict is an experience in which the nurse perceives patient care is inconsistent with professional
nursing values or ethics.13 Sequelae of ethical conflict include moral distress (MD) and burnout.14 Moral
distress may occur in situations in which the nurse perceives an ethically correct action; however, a barrier
such as an institutional policy prevents the nurse from following through with a plan of care consistent with
his or her ethical appraisal.15,16 Frequent and severe moral distress may lead to nurse burnout,14 a state of
feeling emotionally drained, uninterested in work, and unable to provide support to patients and families.17
Components of burnout include: (1) overwhelming emotional exhaustion, (2) detachment from work,
cynicism, and depersonalization, and (3) low levels of personal accomplishment and feelings of ineffec-
tiveness.18 Nurse reported ethical conflict is prevalent in the intensive care unit (ICU) and increases in
frequency and severity in organizations low in resources to address ethical concerns.6,16,19–21 Institutional
barriers that hinder nurse autonomy and holistic care potentiate ethical conflict, moral distress, and burn-
out.14,16 In response, nurses may avoid and depersonalize patients and families, and take on an emotionally
distant presence during patient and family care.9,14,16,22 Consequentially, this may limit nursing support of
families in the ICU and prolong nurse perceived patient suffering.8,9,23–26
The ICU experience affects the family’s social, emotional, and physical health and wellbeing.27–30 Patient
and family-centered care is considered a standard approach to healthcare delivery that can enhance family
wellbeing through the establishment of partnerships among patients, families, and healthcare profession-
als.31,32 Family-centered care is based on mutual respect, information sharing, collaboration, and family
participation.31 Families value nurse provided family support defined as reassurance, sharing vital patient
information, and encouraging family involvement in care.27,33–35 Nursing family-centered care is critical to
the process of family adaptation during and after the ICU.11,29,36,37 Despite the importance of family involve-
ment in the ICU setting, inadequate attention to ethical conflict, moral distress, and burnout within systems of
care may negatively impact nurses’ ability to care for families and their critically ill family member.14,38

Study rationale
Although ethical conflict, moral distress, and burnout have been studied extensively in ICU nurses, under-
standing their relationship with the quality of nursing family care and family outcomes in the ICU setting
2496 Nursing Ethics 26(7-8)

Figure 1. Conceptual model describing relationships among variables.

remains largely unexplored. Therefore, the purpose of this study was to determine the relationships
among variables related to the ICU climate of care (ethical conflict, burnout, and organizational
resources for ethical conflict), the quality of nursing family care (family-centered care and nurse
provided family support), and family wellbeing in the ICU setting. The specific aims were to deter-
mine: (1) if ICU climate of care variables predicted the quality of nursing family care and family
wellbeing and (2) the direct and indirect effects of climate of care variables on the quality of nursing
family care, and family wellbeing.

Conceptual framework
An integrated conceptual figure derived from the theoretical underpinnings of the Resiliency Model
of Family Stress, Adjustment and Adaptation, moral distress theory, and the healthy work environ-
ment framework guided the design and selection of variables for this study (Figure 1). The ICU
climate of care affects the quality of nursing family care.9,39,40 Subconcepts include ethical conflict,
moral distress, burnout, organizational resources for ethical conflict, and time spent working within
the ICU environment. Ethical conflict is conceptualized as a precursor to moral distress and burn-
out.13,41 Organizational resources for ethical conflict is a reflection of unit and hospital-based support
to address ethical conflict in nursing practice.42,43 A poor climate of care occurs when nurses are
exposed to frequent and severe ethical conflict,6,13 perceive a low level of organizational resources
for ethical conflict,44,45 and experience high levels of burnout.14 The climate of care potentially exerts
negative or positive effects on the quality of family care, which is the intermediary linking the ICU
climate of care and family physical, social, and emotional wellbeing. The subconcepts of the quality
of nursing family care include the family’s perception of family-centered care delivery and nurse
provided family support. The quality of nursing family care is viewed as an important determinant of
the family’s wellbeing,35,36,46 because nurses are an instrumental family resource for emotional care
and communication about a critically ill family member.28–30,36
McAndrew et al. 2497

Methods
Design and setting
Data for this cross-sectional, correlational study were collected from April 2017 to September 2017. Data
collection occurred in five ICUs (medical, surgical, cardiovascular, transplant, and neurosciences) at a
Magnet®designated academic medical center and adult Level I Trauma Center in the Midwest region of the
United States.

Ethical considerations
This study was approved by the IRB at the study site (PRO00029078). The researchers obtained written
consent from all participants.
In this study nurses were asked to consider situations of ethical conflict in their practice, a sensitive topic.
It was emphasized that responding to the survey was voluntary and nurses could withdraw from the study at
any time.

Instruments
Family members completed the Family-Centered Care-Adult Version (FCCS-A),47,48 a slightly modified
version of the Nurse Social Support Scale (NSSS) of the Family Functioning, Family Health, and Social
Support instrument,49 and the Family Wellbeing Index (FMWB).50 Nurses filled out the Ethical Conflict in
Nursing Questionnaire-Critical Care Version (ECNQ-CCV),13 the Hospital Ethical Climate Scale
(HECS)43 and the Maslach Burnout Inventory-Human Services Survey (MBI-HSS).51 Nurse and family
demographic information was also collected. A description of each family and nurse measure can be found
in Table 1.

Participants
Family sample. Family members of critically ill patients at moderate to high risk of death as determined by the
Sequential Organ Failure Assessment tool (SOFA)56 were asked to participate. Additional inclusion criteria
were: the critically ill family member must be on at least two or more life-sustaining treatments (e.g.
mechanical ventilation and vasopressor support) and in the ICU at least 48 h prior to family participation.
Members of the family had to regularly visit the critically ill patient in the ICU, be 18 years of age or older,
and report an ability to understand English.
Effect size was based on a limited number of studies that reported R2 or r values for at least one of the
variables of interest.57–60 Effect sizes were based on the formula from Cohen61,62 and f2values ranged from
.12 to .47. Based on the available literature, predictions of the population parameter (f2) for this study
suggested a medium to large effect size.61,62 A more conservative estimate of effect size was used to guide
power calculation for the study given the wide range of f2 values in prior research. An a priori regression
power analysis calculator was used determine the family sample size.63 When f2 ¼ .28, inclusion of two
predictor variables, and .80 power at the alpha .05 level, at least 38 family members were needed for
adequate sample size.

Nurse sample. For nurses to be eligible for the study they had to be employed by the organization as a
registered nurse, work fulltime within one of the ICUs, and hold their position for 3 months or longer. There
were approximately 250 employed ICU nurses at the time of the study that met these criteria.
 Table 1. Nurse and family measures.

Number of
items/minutes to Total a in

2498
Concept Theoretical definition Operationalization/measure complete prior studies

Family measures
Family wellbeing Family social, emotional, and Family Wellbeing Index (FMWB) 8 items/5 min .7252–.8453
physical health and wellbeing Items scored from 0 to 10
Score ranges from 0 to 80
Higher scores ¼ greater wellbeing
Quality of nursing The degree to which family is Family-Centered Care-Adult Version (FCCS-A) 20 items/5 to 10 min .8147–.84
family care involved and treated as a Items scored 1 (never)–4 (always)
partner in healthcare, and Score ranges from 20 to 80
nurse provided family support Higher ¼ greater FCC
Modified version of Nurse Social Support Scale (NSSS) 15 items/5 to 10 min .8254–.98
from the Family Functioning, Family Health, and Social
Support tool
Items scored 1 (definitely disagree)–6 (definitely agree)
Total score 15–90, higher scores ¼ greater nurse support
Nurse measures
ICU climate of care This describes the overall ethical Ethical Conflict in Nursing Questionnaire-Critical 19 items/15 min .8813
milieu of the nursing practice Care Version (ECNQ-CCV)
environment including nurse Measures frequency and degree of conflict and exposure to
perceived ethical conflict, ethical conflict (Index of Exposure to Ethical Conflict or
resources for ethical conflict IEEC)
and burnout and time spent IEEC score from 0 (no exposure) to 475 (highest possible
working in the ICU setting exposure)
Maslach Burnout Inventory-Human Services Survey 22 items/5 min .71 to .8555
(MBI-HSS)
Three subscales: emotional exhaustion (exhaustion related
to work) (EEMBI), depersonalization (detached and
impersonal response) (DMBI), and personal
accomplishment (achievement) (PAMBI)
Items scored from 0 (never) to 6 (every day)
Cutoff scores provided for low, moderate, and high values
No overall score – each subscale used separately in analyses
Hospital Ethical Climate Scale (HECS) 26 items/10 min .9044–.9143
Items scored from 1 (almost never true) to 5 (almost always
true)
Score of 26–130
Higher scores indicate more positive perception of
organizational support
Nurse years worked in ICU: nurses provided the number of
years worked in their specialty ICU
McAndrew et al. 2499

Data collection
Family members were provided with an overview of the study, including risks and benefits. Individual
family members provided consent for their own participation, and for access to the patient’s electronic
medical record (EMR) to collect patient information. An iPad® was used to administer the instruments
through Qualtrics,64 a data management system. Family members were given a US$10 gift card in appre-
ciation for their time.
Nurse data collection was concurrent with family data collection. Surveys were initially distributed
electronically using Qualtrics software, and later on paper to increase responses rates. An email was sent
to ICU nurses that explained the study and inclusion criteria. A link to the survey was included at the end.
Completion of the survey signified consent to participate. Nurses were offered a US$5 gift card and
voluntarily provided an email address for electronic gift card delivery.

Statistical analyses
All analyses were completed in IBM SPSS Statistics (version 23). Descriptive statistics were used to
summarize the sample and responses to measures. After completing preliminary analyses, nurses and
family data files were merged. Aggregate nurse scores for each ICU were matched to individual
family members. Relationships among nurse and family variables were determined with Pearson’s
product-moment correlation coefficients and this guided the selection of variables to answer the study
aims. Hierarchical multiple regression was used for study Aim 1. Selection of predictor variables was
based on theoretical underpinnings and zero-order correlations. Predictors with a correlation of .60 or
higher were not entered simultaneously into a regression model.65 Models were evaluated to deter-
mine how much of the variance in the outcome variable was explained by the model (adjusted R
square), and each predictor variable’s (coefficients) contributions to the model. Only predictors
significant at an alpha level of .05 or less were used in subsequent analyses. Study Aim 2 was tested
with Hayes’66 approach to simple mediation analysis using the PROCESS macro in SPSS67 with the
FCCS-A and FMWB as outcome variables in four separate mediation models. The number of boot-
strapped samples was set at 5000.

Results
Sample
Family sample. A total of 300 patients were screened for a SOFA score of 10 or higher, and of these patients
141 qualified. There were 40 family members who were unavailable for participation (out of state or did not
visit), and 39 families were not approached due to imminent patient death. A total of 44 family members
participated in the study of the 62 approached (response rate of 71%). The educational level of family
members ranged from 9 to 30 years (Mdn ¼ 14). The mean family member age was 52 years (SD ¼ 13.18).
Additional family characteristics are shown in Table 2.
For the critically ill family member, SOFA scores ranged from 10 to 21 (Mdn ¼ 13), with 68.2% of the
sample at moderate risk of death and 31.8% at high risk of death. Age ranged from 19 to 88 years (M ¼ 58,
SD ¼ 18.39). ICU length of stay was between 3 and 59 days (Mdn ¼ 9.5). More than half the sample
transferred out of the ICU, and approximately 30% died.
2500 Nursing Ethics 26(7-8)

Table 2. Family member characteristics (N ¼ 44).

Characteristic n %

ICU of critically ill family member

Medical ICU (MICU) 16 36.6
Cardiovascular ICU (CVICU) 9 20.5
Surgical ICU (SICU) 8 18.2
Neurosciences ICU (NICU) 2 4.5
Transplant ICU (TICU) 9 20.5
Relationship with critically ill family member
Spouse/partner 18 40.9
Child 7 15.9
Parent 9 20.5
Sibling 7 15.9
Other 3 6.8
In ICU before as family member
Yes 21 47.7
No 23 52.3
Gender
Male 11 25.0
Female 33 75.0
Ethnicity
Hispanic or Latino or Spanish origin of any race 1 2.3
Black or African American 9 20.5
White 33 75.0
Two or more races 1 2.3

Nurse sample
There were 111 nurses that completed all three tools and were included in analyses (response rate of 44%).
Nurse years in their specialty ICU ranged from .25 to 36 years (Mdn ¼ 2). The median for critical care
nursing experience was 4 years (.25–42), and 7 years (.25–43) for overall nursing experience. Additional
nurse characteristics are shown in Table 3.

Descriptive statistics for family measures

Overall, family members reported high scores for the FCCS-A, and NSSS, and moderate levels of wellbeing
(FMWB; Table 4).

Descriptive statistics for nurse measures

Nurses reported moderate ECNQ-CCV scores, with higher scores for the degree of conflict than frequency
(Table 5). EEMBI and DMBI scores were high; however, PAMBI scores were also high. Nurse reported
moderate HECS scores.

Aim 1: if ICU climate of care variables were related to the quality

of nursing family care and family wellbeing
A significant correlation between the NSSS and FCCS-A (r ¼ .72, p ¼ .01) was found; therefore, only
FCCS-A was used in subsequent analyses. Based on the significant relationships between DMBI
McAndrew et al. 2501

Table 3. Nurse characteristics (N ¼ 111).

Characteristic n %

Educational attainment in nursing

Diploma 7 6.3
Associate Degree in Nursing (ADN) 15 13.5
Bachelor of Science in Nursing (BSN) 75 67.6
Master of Science in Nursing (MSN) 9 8.1
Doctorate of Nursing Practice (DNP) 1 .9
Not reported 4 3.6
Age
21–24 years 7 6.3
25–35 years 61 55.0
36–45 years 12 10.8
46–55 years 16 14.4
56–65 years 12 10.8
Not reported 3 2.7
Gender
Male 12 10.8
Female 96 86.5
Not reported 3 2.7
Ethnicity
Hispanic or Latino or Spanish of any race 4 3.6
Asian 3 2.7
White 94 84.7
Two or more races 2 1.8
Not listed 3 2.7
Not reported 5 4.5
ICU
Medical 35 31.5
Cardiovascular 22 19.8
Surgical 22 19.8
Neurosciences 14 12.6
Transplant 15 13.6
Not reported 3 2.7
ICU: intensive care unit.

Table 4. Descriptive statistics for family measures (N ¼ 44).

Measure M (SD) Range Mdn Cronbach’s a

FCCS-A 69.86(7.80) 52–80 71 .86

NSSS 82.41(8.58) 55–90 86 .94
FMWB 40.64(14.92) 13–72 39 .81
FCCS-A: Family-Centered Care-Adult Version; NSSS: Nurse Social Support Scale; FMWB: Family Wellbeing Index.

(r ¼ .461, p ¼ .01), HECS (r ¼ .371, p ¼ .05), nurse years worked in the current ICU (r ¼ .299, p ¼ .05)
and FCCS-A, as well as the relationship between nurse years worked in the current ICU and FMWB (r ¼
.364, p ¼ .05), these variables were used in analysis of study Aims 1 and 2.
2502 Nursing Ethics 26(7-8)

Table 5. Descriptive statistics for nurse measures (N ¼ 111).

Measure M (SD) Range Mdn Cronbach’s a

ECNQ-CCV (Frequency) 56.92 (13.47) 21–95 56 .86

ECNQ-CCV (Degree) 64.86 (13.68) 26–95 67 .90
ECNQ-CCV (Total exposure) 209.64 (72.59) 40–475 209 .90
EEMBI 34.34 (11.73) 15–63 34 .93
DMBI 15.45 (6.53) 5–35 15 .75
PAMBI 44.97 (6.84) 26–56 46 .77
HECS 94.99 (12.16) 57–130 96 .91
ECNQ-CCV: Ethical Conflict in Nursing Questionnaire-Critical Care Version; EEMBI: exhaustion related to work; DMBI: detached
and impersonal response; PAMBI: personal accomplishment; HECS: Hospital Ethical Climate Scale.

Table 6. Hierarchical regression analysis summary for variables predicting FCCS-A (N ¼ 44).

Model Step and predictor variable b R2 Adj R2 t p

1 Step 1: nurse years in ICU –.238 .056 .034 –1.59 .12

Step 2: nurse years in ICU –.281 –2.02 .05
HECS .401 .216 .178 2.89 .006
2 Step 1: nurse years in ICU –.238 .056 .034 –1.59 .12
Step 2: nurse years in ICU .080 .45 .652
DMBI –.511 .216 .178 –2.89 .006
FCCS-A: Family-Centered Care-Adult Version; ICU: intensive care unit; HECS: Hospital Ethical Climate Scale; DMBI: detached and
impersonal response.

Table 7. Hierarchical regression analysis summary for variables predicting family wellbeing (N ¼ 44).

Model Step and predictor variable b R2 Adj R2 t p

3 Step 1: family education –.118 .014 –.012 –.73 .469

Step 2: family education –.160 –1.06 .297
Nurse years in ICU .387 .163 .117 2.56 .015
4 Step 1: family education –.118 .014 –.012 –.73 .469
Step 2: family education –.140 –.89 .378
HECS .269 .091 .042 1.78 .084
ICU: intensive care unit; HEC: Hospital Ethical Climate Scale.

Two separate models were generated using FCCS-A as the outcome variable and nurse years worked in
the ICU as a control variable (Table 6). HECS scores were the predictor variables in model 1 and DMBI
scores in model 2. Both models significantly predicted FCCS-A (Model 1, F(2,41) ¼ 5.641, p ¼ .007,
Model 2, F(2, 41) ¼ 5.66, p ¼ .007) and explained 21.6% of the variance, with HECS scores uniquely
explaining 15.9% and DMBI scores 16% of the variance in FCCS-A.
Family member educational level was used as a control variable in models 3 and 4 (Table 7). Model 3
used nurse years worked in the ICU as the predictor, and the HECS was tested in model 4. Model 3
significantly predicted FMWB (F(2, 37) ¼ 3.576, p ¼ .038) and explained 16.2% of the variance. Nurse
years in the current ICU was the only significant predictor (b ¼ .387) and uniquely explained 14.8% of the
variance in FMWB. Model 4 did not predict family FMWB (F(2, 37) ¼ 1.86, p ¼ .17).
McAndrew et al. 2503

Figure 2. Direct and indirect effects on FCCS-A and FMWB.

FCCS-A: Family-Centered Care-Adult Version; FMWB: Family Wellbeing Index.

Aim 2: effects of climate of care on the quality of nursing family care, and family wellbeing
Figure 2 shows the four simple mediation models that were tested. In model 1, nurse years in the current ICU
had a direct effect on FCCS-A with no indirect effects through HECS. In model 2, there was a significant
relationship between the HECS and FCCS-A through the DMBI, as indicated by the bootstrap samples
above 0 (.015–.707) and effect size of PM ¼ .617 (ratio of indirect effect to the total effect). In model 3, there
was a direct effect of nurse years in the current ICU on FMWB with no indirect effects through the FCCS-A.
In model 4 there were no direct or indirect effects when examining the relationship between the HECS and
FMWB with FCCS-A in the position of the mediating variable. A summary of relationships found among
variables is presented in Figure 3.

Discussion
Although ethical conflict, moral distress, and burnout have been studied extensively in nurses,14,16,20
findings from this study highlight new directions for research in the ICU. Important findings from this
study include: (1) organizational resources for ethical conflict (HECS scores) and depersonalization (DMBI
scores) as predictors of family-centered care (FCCS-A scores) and (2) depersonalization as a potential
mediating variable in the relationship between organizational resources for ethical conflict and family-
centered care. The data suggest that when depersonalization (DMBI) is added the positive relationship
between HECS and FCCS-A scores is eliminated, signifying that depersonalization may negatively influence
the nurse’s perception of organizational resources for ethical conflict and subsequently family-centered care
delivery.
2504 Nursing Ethics 26(7-8)

Figure 3. Revised conceptual model based on study findings.

The positive relationship between HECS and FCCS-A scores indicates systems of care may play a
pivotal role in family-centered care delivery. Importantly, the predictive value of depersonalization and
its mediating effect on the relationship between organizational resources for ethical conflict and family-
centered care points to depersonalization as the most detrimental aspect of burnout for nursing family care.
Depersonalization is theorized as a contributing factor of non-supportive nurse family care behaviors,
such as an attitude the family is an obstacle in the delivery of patient care, ignoring family members, and
abrupt and inadequate communication.28–30 These types of interactions with nurses contribute to family
members’ distress and feelings of vulnerability.30 Families have identified a need for greater nursing
support in the ICU.36,68,69 Based on our findings, the prevention of burnout may be an important target
for improving nursing family-centered care in the ICU. As burnout may also be a symptom of inadequate
health system resources and support,14,42,70 decreasing the depersonalization response in critical care nurses
requires system-based interventions.
Prior studies also have highlighted the importance of the healthcare organization in the delivery of
patient and family care. Ganz and Yoffe71 found a negative correlation between barriers to family-centered
care and attitudes toward family presence during resuscitation. Similarly, nursing workflow partially
mediated the relationship between the ICU environment (staffing and resources) and nurse attitudes toward
family engagement in care.72 Although it has been documented that organizational and unit-based culture
may influence nurses capacity to establish therapeutic relationships with patients and their families,73 this is
the first known study to examine the relationship between organizational resources for ethical conflict and
family-centered care.
The negative relationship found between FCCS-A scores and nurse years worked in the ICU was
unexpected and suggested nurses who worked fewer years within the ICU were more likely to deliver
higher quality family-centered care than those with more ICU years. Nursing experience or time spent
within a specific family care delivery culture may influence nurse strategies for family care. The approach
and delivery of family care has changed over the years, with current guidelines recommending family
involvement and engagement with ICU care.31 There is evidence that these guidelines may not be translated
well into clinical practice.74 In a study of nurses’ approaches to family interactions, the more involved the
patient care activity, the less likely nurses were to engage family members.75 Younger nurses had a more
positive attitude than nurses in the age range of 25–49 years of age in a recent study on nursing attitudes
McAndrew et al. 2505

toward active family engagement.72 The relationship between nurse years worked in a specific ICU and
family-centered care delivery requires further investigation.
In contrast to the relationship found between nurse years and family-centered care, nurse years worked in
the ICU was predictive and had a direct effect on family wellbeing in this study. This was the only variable
that significantly contributed to family wellbeing. As nurses spend more time in the ICU, they may become
better at meeting family needs. In a study addressing nurse knowledge and skill related to family care,
nursing experience was positively correlated with knowledge about family needs.75 The wellbeing measure
(FMWB) used in this study examined family members’ level of distress about the health of their family
member.50 Nurses with more ICU experience may address these family concerns to a greater extent by
providing more information about the critically ill patient. The link between nursing experience and family
wellbeing aligns with the seminal work of Benner,76 in which expert nurses are characterized by the ability
to seamlessly assess and intervene. Nursing experience is considered foundational to the individualization
of patient and family care and the development of emotional connections within nurse–family relation-
ships.36,77 Further study of ICU nurse experience and family wellbeing is warranted.

Implications for nursing practice

The results of this study suggest there are opportunities to optimize nurse and family outcomes through unit
and organizational-based nurse and family support strategies. Increasing resources to address ethical con-
flict in clinical practice may enhance family care. In a pilot study examining the feasibility of an ethics
screening tool, ICU nurses found this intervention beneficial and facilitative of a proactive approach to
resolve conflicts and moral distress.6 Further inquiry into structured resources for ethical conflict resolution
and how this may affect patient and family care is needed.
Families are not consistently engaged in patient care or integrated into healthcare processes.35,78 Many
factors influence nurses’ ability to form positive relationships with family members; however, organiza-
tional characteristics are documented in the literature as having the greatest impact.42,73 Attention to ethical
conflict support resources is vital given the documented frequency of ethical conflict in the ICU setting.14
ICU and organizational policies influence the degree to which family members believe they can be involved
in the care of their critically ill family member,33 as well as nurses’ comfort with engaging families in
patient care.72,79,80 Inadequate education and training for interactions with families has been cited in the
literature as a barrier to nursing family care.81,82 The creation of patient and family engagement must be
incorporated in the organizational vision and mission with devotion of resources to improving patient and
family experiences in the ICU setting.

Directions for future research

This study fills an important gap in the literature by addressing the relationships among the climate of ICU
care, family-centered care, and family wellbeing. The organizational resources for ethical conflict variable
provided a valuable measure of how the organization may support or challenge the resolution of ethical
conflict in clinical practice. Ethical conflict and resultant moral distress and burnout are manifestations of
healthcare culture and systems.14,16,42 Measurement of organizational support is imperative for analysis of
ethical conflict within critical care.42 Interventions may not be effective without attention to healthcare
delivery systems.35,42,81 It is vital that future research examine nursing family care culture, organizational
support mechanisms, and determine how specific environments of care affect nurses, patients, and families
in the ICU setting.
This study aimed to measure the family’s perception of nursing family care quality. Family nursing care
is amenable to intervention and may be an avenue for improving family outcomes in future research. There
2506 Nursing Ethics 26(7-8)

is a need for further development of reliable and valid instruments to measure nursing family care quality to
advance the science of ICU family care delivery.

Limitations
This was a nonexperimental, descriptive, cross-sectional study that inherently does not control threats to
internal validity. Family member one-time reports of nursing family care quality and wellbeing do not
reflect fluctuations or changes in family member’s perspectives over the course of an ICU stay. Participants
may have altered their responses because they were aware they were in the study, or in response to the
researcher. Nursing experience explained a very small percentage of the variance in family wellbeing
scores. There are other variables not captured in this study that may be relevant to both family-centered
care and family wellbeing. Participant self-selection may have led to response bias, and the small nurse and
family samples limit generalizability of these findings.

Conclusion
This exploratory study may provide the groundwork for larger studies to examine climate of care variables,
the quality of nursing family care, and various family outcomes. The family is vital to patient health and
wellbeing; however, this is often overshadowed by the patient focus in healthcare, particularly in acute and
critical care environments. Empowering nurses and families in critical care through structured organiza-
tional support is a productive path to decreasing nurse burnout, as well as achieving high-quality nursing
family care and positive patient and family outcomes. Organizational resources for ethical conflict may play
a role in family care delivery in the ICU and further study is required.

Authors’ note
Natalie S McAndrew is also affiliated with Froedtert & the Medical College of Wisconsin Froedtert
Hospital, WI, USA.

Acknowledgements
Gratitude is expressed to the family members and nurses who participated in this study as well as to Dr Jill
Guttormson for her review of this manuscript, and to Dr Michael Brondino for statistical consultation.

Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or
publication of this article: The Froedtert Foundation and the Nursing Research Internship Grant provided
funding for this research through the generous support from grateful patients and donors. Additional grants
from Building Bridges to Research Based Nursing Practice and Sigma Theta Tau International—Eta Nu
Chapter also made this research possible.

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