CONCEPTS OF FAMILY CENTERED NURSING

CARE AND NURSING PROCESS APPROACH IN

OBSTETRICS AND GYNAECOLOGICAL
NURSING

SUBMITTED TO

Mrs. Dhana laksmi

Assistant professor

Govt college of nursing

kurnool
 FAMILY CENTERED NURSING CARE

Family-centered care or Relationship-Centered Care is one of four approaches that

provides an expanded view of how to work with children and families. Family-centered
service is made up of a set of values, attitudes, and approaches to services for children
with special needs and their families. In some family-centered settings such as the Hasbro
Children's Partial Hospital Program, medical and psychiatric services are integrated to help
teach parents and children methods to treat illness and disease. Family-centered service
recognizes that each family is unique; that the family is the constant in the child's life; and
that they are the experts on the child's abilities and needs. The family works with service
providers to make informed decisions about the services and supports the child and family
receive. In family-centered service, the strengths and needs of all family members are
considered.
Family-centered service reflects a shift from the traditional focus on
the biomedical aspects of a child's condition to a concern with seeing the child in context of
their family and recognizing the primacy of family in the child's life. The principles argue in
favor of an approach that respects families as integral and coequal parts of the health care
team. This approach is expected to improve the quality and safety of a patient's care by
helping to foster communication between families and health care professionals.
Furthermore, by taking family/patient input and concerns into account, the family feels
comfortable working with professionals on a plan of care, and professionals are "on board"
in terms of what families expect with medical interventions and health outcomes. In some
health systems, patients and family members serve as advisers to the hospital in order to
provide input that can lead to general quality improvement efforts. Family-centered
approaches to health care intervention also generally lead to wiser allocation of health care
resources, as well as greater patient and family satisfaction.

FAMILY

“Family” means any person(s) who plays a significant role in an individual's life. This
may include a person(s) not legally related to the individual who act as advocates. Members
of “family” include spouses, domestic partners, and both different-sex and same-
sex significant others. “Family” includes a minor patient's parent or parents, regardless of
the gender of either parent. Solely for purposes of visitation policy, the concept
of parenthood is to be liberally construed without limitation as encompassing legal
parents, foster parents, same-sex parent, stepparents, those serving in loco parentis (in
place of the parent), and other persons operating in caretaker roles.

This definition of “family” places hospital personnel on notice as to the unique

nature of parenthood in the visitation context. While the definition requires that caretaker-
individuals be granted access to visit minor patients, this caretaker status does not
necessarily carry with it the rights that accompany legal parental status. For instance,
applicable state law may dictate that only a biological or custodial parent may determine
the course of medical care for a minor child.

Role of the family

While specific methods of implementing family-centered care approach differs from

facility to facility, procedures are fairly similar. On admission, the patient usually designates
one or two people who will serve as their primary "care partners". The admitting staff
discuss the reasons for admission with the patient and their "care partners" and what health
criteria are required for the patient's discharge.

"Care partners" are then intricately involved with the patient's care by their entire
attending healthcare team, including physicians, nurses, nutritionists, social workers, and
more. At every stage, "care partners" and patients discuss with healthcare professionals test
results, the state of the patient's current health, what type of things to expect throughout
the day, and discharge goals. "Care partners" are invited to take part in nursing
interventions, including bathing, feeding, helping the nursing staff with moving the patient,
and assisting the patient in exercising or moving about the unit. "Care partners" are also
invited to take an active role in "rounds," providing feedback and asking questions reflective
of theirs and the patient's wishes or concerns.

Advantages and disadvantages

Family-centered care emerged as an important concept in health care at the end of

the 20th century; but the implementation of Family Centered care was met with a variety of
snags. Prior to the early 1990s, the relationship between care providers and patients was
distant. The traditional model of care centered on physicians, and an expectation that
patients and their families would assume a passive role as an observer, rather than a
participant. Healing was treated largely as an abstract or business-like affair. Special
requests by the patient were seen as interfering with the provision of their care or even as
being a detriment to their health. Modern ideas like open visitation or care partners were
almost unheard of and were generally dismissed as impossible to accomplish. This was
compounded by the implementation of Health Maintenance Organizations, which
successfully reigned in the rising healthcare costs of the 1970s at the cost of the patient-
healthcare worker relationship. Much of the early work on Family Centered care emerged
from the pediatric and geriatric medicine fields; for example, as research came to light
about the effects of separating hospitalized children from their families, many healthcare
institutions began to adopt policies that welcomed family members to be with their child
around the clock. As awareness increased of the importance of meeting
the psychosocial and holistic needs of not only children, but all patients, the family-centered
care model began to make serious headway as a bonafide intervention model. In the United
States, this was further encouraged by Federal legislation in the late 1980s and early 1990s
that provided additional validation on the importance of family-centered principles.

Beginning in the mid-1990s (although elements of family-centered care began

appearing in the early 1980s), however, this situation began to change. Studies began to
show that many of the supposed detriments to family-centered care were negligible, not
supported by research, or untrue. A study conducted in 2001 showed that open visitation
had little to no effect on physiologic parameters such as heart rate, blood pressure,
respiratory rate, cardiac arrhythmias, and intercranial pressure. Indeed, evidence suggested
anxiety levels and general cardiovascular health were positively affected after the
implementation of family-centered care, leading to fewer medical interventions being
required (physical or chemical therapies in particular). Another area of concern, septic and
infection control, found that as long as a patient's visitors were educated in the
proper aseptic procedure (such as hand washing and use of handsanitizer gel), infection
control outcomes were not negatively affected by unrestricted visitation.

Patient care was also positively affected. Decubidation rates in facilities with family-
centered care dropped significantly. In one study, it was found that patients receiving
family-centered care were far more likely to have met the criteria of medical and nursing
care plans (such as drinking x amount of fluids every eight hours, moving from NP suctioning
to bulb suctioning, or the measurement of patient's intake/output), as the patient's family
took it upon themselves to encourage or assist the patient in accomplishing these goals.
[12]
 Family and close friends were more likely to identify slight variations in the patient's
mental or physical health that health care professionals largely unfamiliar with the patient
may miss. Furthermore, while health care professionals are very talented at their work, their
jobs are generally limited by the walls of the health care facility, whereas a patient's family
is not. Enlisting a patient's family as a part of their health care team helps enable their
ability to assist, manage, and assess the patient's healing after their discharge from a health
care facility

Family-centered maternity care, a concept based on the fact that having a baby
involves all members of the family, implies thinking of human beings as individuals. It calls
for caring for the significant others in a mother’s life as well as the mother herself, and it
encourages the nursing and medical professions to prepare expectant couples physically,
emotionally, and intellectually for labor, delivery, and parenthood. Family, it should be
noted, does not refer exclusively to husbands or to blood relations. Rather, it refers to any
system of relationships in which the related persons are deeply involved with each other.
When evaluating the kind of maternity care given today in most hospitals, questions can be
raised about whether nursing care is even patient centered, much less family centered. Give
thought to what is provided. In many instances, mothers bear their pain in loneliness, their
helplessness in fear. Fathers, grandparents, and other significant people spend hours alone
in waiting rooms with little word about what is happening on the other side of the labor
room door. While mothering and fathering behaviors are known to be learned, many nurses
are content with bringing babies to mothers for 30 minutes every 4 hours. Fathers are
relegated to viewing their offspring through a glass window. Responses to parents’
questions often reflect neither care nor concern for the people being served, with little
provision being made for preparing parents for the adjustments that will take place at
home. At the end of approximately 48 hours, parents are discharged as supposedly well-
functioning and skilled mothers and fathers.

What of other common objections to family-centered maternity care? They include

these: “It will raise the infection rate.” No statistics support this. “Lawsuits will increase.”
Neither do statistics support this. “Hospital administration won’t let us do it.” The doctors
are against it.” It won’t work in our hospital.” The father will get in the way.” These
comments are made over and over again. The truth is that they don’t hold water.

Why do we cling so tightly to ritual, to traditional approaches, to ceremony? Why do

we accept routine kinds of care and policies when we know that anything that is routine can
contribute to dehumanization? We can hide behind hospital policy, the medical staff, and
the status quo until we retire; but, if we do, we deny our responsibility to humanity and to
ourselves.

Family-centred care

Family-centred care is a multifaceted concept that has evolved over the past 60 years and
remains a significant concept for children’s nursing in the 21st century. The concept
embraces caring for the child in the context of the family and therefore nurses recognise the
central role of the family in the child’s life.

Today’s healthcare culture, however, continues to present many challenges in

translating family-centred care theory into practice, including inter-professional working and
involving children and young people in making decisions in the context of family-centred
care. The focus of this chapter is to clarify and enhance understanding of family-centred
care as a theoretical construct and to discuss how this can be applied in everyday clinical
practice using the practice continuum tool, which was developed for this purpose. This is
supported by a toolkit of skills that will enable nurses to practice family-centred care
effectively.
Understanding family-centred care as a concept

Different definitions and theoretical frameworks have been used to explain the evolving
concept of family-centred care. These definitions and frameworks are all still reflected to
some extent in the family-centred care approaches that are currently used by children’s
nurses in practice. This is because some children’s nurses, using their professional
judgement, will select the most appropriate family-centred care framework to meet the
needs of individual children and their families. Conversely, other children’s nurses have not
adopted contemporary theoretical family-centred care frameworks for implementation in
practice and their approach to care is based on earlier theories. This may be due to choice
or because of a lack of knowledge, skills or willingness to adopt new ways of working in
practice. Bruce & Ritchie (1997) identify a need for skill development in areas of
communication that involve negotiation and the sharing of information with children and
their families. These areas of communication are defining characteristics of contemporary
family-centred care theoretical frameworks. Bruce et al (2002) advocate the need for
continuing education for healthcare professions working with families to further develop
these communication skills.

The practice continuum tool was synthesised from available research and theoretical
material, as well as practice experience, and therefore incorporates all the elements of the
theoretical frameworks already discussed. Children’s nurses should be familiar with the
terms contained within the tool but because these terms are sometimes used
interchangeably to mean the same thing, and because using the practice continuum tool
provides practitioners with a dialogue through which to articulate family-centred care in a
meaningful and achievable way, it is important to understand what we mean by the
following terms:

• Nurse-led care, no family involvement: this may occur in situations where the family is not
able or willing to be involved for a particular reason for a period of time. This is still family-
centred care because the nurse still uses a family-centred focus in care delivery in the
family’s absence.

• Nurse-led care, family/child involvement in care: this may occur when the family is
involved in some basic care, such as feeding, hygiene and/or emotional support. The nurse
takes the lead in care management at this stage.

• Nurse-led, family/child participation in care: a good rapport is established, which is

collaborative in nature, and the family participates in chosen aspects of nursing care
following negotiation. The nurse continues to oversee care management and where
necessary teaches relevant care skills to the child and/or family.

• Equal status, family/child partnership in care: this is exemplified by the change in the
nurse’s role to becoming more of a supporter and facilitator. As families become more
empowered they resume their role as primary care givers and the relationship with the
nurse is much more equal in nature.

• Parent/child-led care, nurse-consulted care: the family is now expert in all aspects of the
child’s care. There is a mutual, respectful relationship with the nurse, who is used in a
consultative capacity from time to time. Although this is expressed explicitly as parent-led
care, the implicit notion is that children are involved in their care and can lead their care in
some instances.

No matter where the family is on the practice continuum, it is family-centred care; family-
centred care is not only achieved by reaching an ‘end stage’. Parents negotiating with the
nurse choose where they wish to be on the continuum. For some this may be a progression
along the continuum, particularly for those families with a child with an ongoing illness,
whereas others may prefer to be involved differently, providing normal childcare and
emotional support only.