Where is the Family in designing Family Focused Interventions? Implications for Family Nursing Research and Practice in Critical Care Settings

Healthcare transitions are ongoing globally. Systems are shifting away from traditional care delivery approaches to more clientcentered approaches. These changes are mainly due to population dynamics and the need for cost effective healthcare systems. Furthermore, some parts of the world are beginning to realize the burden of an aging population whilst other parts of the world realizing a better-informed population [1]. Such changes have led to notable advocacy for approaches that consider involvement of the patient and their family in healthcare delivery [2]. Concepts emphasizing family involvement in care include family nursing, Family-Centered Care (FCC) [3], Person-Centered Care [4], People- Centered Care and Individual-Centered Care (WHO, 2007). Such models are aimed at fostering involvement of families in design, coordination and delivery of care.

Engaging the family in the designing phase of healthcare interventions has been linked to more acceptance and appropriateness of such interventions. Globally various organizations have endorsed these approaches. The World Health Organizations advocates for end user involvement as an approach to coordinate care services and foster inclusive decision making (WHO, 2007). In the United States, the Institute of Medicine endorses such approaches as an arena through which quality care can be achieved (“Crossing the Global Quality Chasm: Improving Health Care Worldwide: Health and Medicine Division,” n.d.) [5]. The Australian Commission on safety and Quality in Health Care (ACSQHC) [6] sees mutually beneficial partnerships between the healthcare team, patients and families as an innovative approach to planning, delivery and essential component of health care evaluation (ACSQHC, 2010).

Whilst the former concepts have gained ground in healthcare discourse today, much remains to be done to engage the family in the designing phase of family-focused interventions in healthcare. Noteworthy, this is so pronounced in critical care settings which are faced with more demand and expansion globally. The challenge for the future is to broaden the scope and application of interventions while considering the family during the design of such interventions in critical care settings. There is little evidence on potential ways of engaging the family in designing family nursing interventions. This is partly because nurses who have the biggest encounter with families are not always leading such interventions and where interventions have been nurse-led, the focused has been more on descriptive rather than interventional research [7]. Our previous review identified various barriers to realization of patient and family centered care in critical care settings. We identified that organizational, individual, interprofessional and a lack of understanding of what needs to be done to engage the family and patients in care design, delivery and continuity of care in critical care settings [8].

Nonetheless, there is a growing body of literature highlighting family-focused interventions in adult critical care settings. These include bereavement tools [9], written orientation materials [10], nurse-led liaison services [11], nurse-led family focused meetings and conversations [12,13], nursing transition programs [14] and tailored messages [15]. These interventions have been effective in identifying family health problems and tailoring plans of care [16]. Nevertheless, there is need to engage families in designing interventions. The gist of recognizing the family in designing health interventions is to design interventions that are not only relevant to the family needs and resources but also those that are sustainable. Family involvement in designing interventions is also subtle to family involvement in public health planning, implementation and evaluation. Whilst family-focused interventions have received attention in critical care settings [17], the position of the family in designing these interventions has not been emphasized. Nurses and other healthcare professionals determine how interventions fit into the emerging family needs. Moreover, while quantitative family outcomes such anxiety score, depression, post-traumatic stress [18-20], have been widely reported as family responses to these intervention, experiences of families in these interventions are missed at the level of planning.

This seminal gap in research and practice in critical care settings prompted us to write this article that aims to highlight areas through which the family can be engaged in planning familyfocused interventions in critical care settings. We explore frontiers that can be used to frame interventions in critical care settings while involving the family. We also present systematic approaches that are beneficial in planning actions for the family with the family.

How do we involve families in intervention planning in critical care settings?

Family involvement in intervention planning has been supported [13]. However, individualized approaches to family involvement in designing interventions has not received substantial attention. Typically, family members are not given an active role in intervention planning in critical care settings. Family members need to be given the impetus to engage in intervention planning while nurses need to change their practice and further empower the family to engage in planning family focused interventions in critical care settings. The initial step in designing interventions in critical care settings as well other setting is consultation with the family. Family focused interventions in critical care settings [21,22] offer few meaningful choices for families to participate in intervention planning and allow only limited roles for the family members to be part of the designing committees for both researchbased intervention and hospital projects. Nonetheless, families offer the most reliable sources of information for the most appropriate options to fulfill their needs.

When they are consulted, they know the best about what could work best. In essence, their voices need to be heard while planning family focused interventions in critical care settings. Meeting with eligible family members during the planning phase of interventions to elicit their views on design could be the way to go. To facilitate this nature of collaboration, family pre-assessment planning, and sharing intervention planning roles with the family is needed. This can be done through various ways. Focused group discussions [23] with the family before implementing interventions form an important way of involving the family in intervention design. Focused group discussions not only form part of the antecedents of qualitative research but they are also essential for eliciting sound information from family members before interventions can be implemented. These could also reduce the power imbalance between policy makers and the family thereby facilitating interventions with them rather than on them. Apart from eliciting information from the family, the family should also be allowed to create interventions for themselves. Allowing family members to create interventions is another way to engage the family in design of interventions in critical care settings as well as other settings.

These would then be advanced with further involvement of healthcare professional as mentors/ preceptors. Preparation of interventions should consist of education with family members and identification of family member champions to assist with implementation. This could also foster engagement of family members in design and implementation of family focused interventions. The aim here is to make the intervention visible to the family before implementation, so adjustments following family inputs could be made during the design-phase.

Allowing family members to participate in designing family focused intervention in critical care settings provides an opportunity to realize family centered care. There are various ways of including the family in the design phase of interventions. We highlighted the family could be engaged through consultations with the family, allowing them to create and identification of family members champions to be part of planning teams.

None.

No Conflict of Interest

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