Nurses’ attitudes regarding the importance of families in pediatric nursing care

Actitudes de enfermeras sobre la importancia de las familias en los cuidados de enfermería en pediatría

Abstracts

Affective, cognitive and behavioral components affect nurses´ attitudes to include families in the care processes. The purpose of this study was to investigate the attitudes of nurses about the importance of including families in nursing care. Data collection was performed in pediatric and maternal-child unit of a Brazilian university hospital. A sample of 50 nurses completed the Portuguese version of the instrument Families’Importance in Nursing Care-Nurses’ Attitudes (FINC-NA). The results indicated that nurses have supportive attitudes regarding families participation in nursing care. Attitudes of lower support for involving families in nursing care were found among nurses with older age, more time in the profession and who had no previous contact with contents related to Family Nursing. The application of the instrument in other contexts of assistance may help to illuminate important aspects of the challenges to implementing a family-centered approach in clinical practice.





Family nursing; Attitude of health personnel; Scales; Professional competence; Professional-family relations

El propósito de este estudio fue identificar las actitudes de los enfermeros sobre la importancia de incluir a las familias en el cuidado de enfermería. La recolección de datos se llevó a cabo en las unidades de pediatría y materno-infantil de un hospital universitario brasileño. Una muestra de 50 enfermeras completó la versión en portugués del el instrumento Families’ Importance in Nursing Care-Nurses’ Attitudes (FINC-NA). Los resultados indicaron las puntuaciones más altas en dimensiones indicativas de actitudes de apoyo a la participación de las familias en el cuidado. Enfermeras con más tiempo en la profesión y que no tenían conocimiento previo de enfermería de familia tuvieron puntuaciones que indican actitudes de menor apoyo para involucrar a las familias en el cuidado de enfermería. La aplicación de este instrumento en otro tipo de asistencia contextos puede ayudar a iluminar aspectos importantes de los desafíos para la implementación de un enfoque centrado en la familia, en la práctica clínica.


Enfermería de la familia; Actitud del personal de salud; Escalas; Competencia profesional; Relaciones profesional-familia

Objetivo

Identificar as atitudes dos enfermeiros sobre a importância de incluir as famílias nos cuidados de enfermagem.

Método

Estudo de abordagem quantitativa descritiva, cuja coleta de dados foi realizada em unidades de pediatria e materno-infantil de um hospital universitário brasileiro. Uma amostra de 50 enfermeiros completou a versão em português da escala Families Importance in Nursing Care-Nurses Attitudes (FINC-NA).

Resultados

Indicaram escores mais elevados em dimensões indicativas de atitudes de apoio sobre a participação das famílias no cuidado de enfermagem. Enfermeiros com mais tempo na profissão e que não tiveram conhecimento prévio de enfermagem da família apresentaram escores indicativos de atitudes de menor apoio para envolver as famílias no cuidado de enfermagem.

Conclusão

A aplicação desse instrumento em outros contextos de assistência poderá contribuir para iluminar importantes aspectos relacionados aos desafios para a implementação de uma abordagem centrada na família na prática clínica e subsidiar o desenvolvimento de pesquisas mais amplas.


Enfermagem familiar; Atitude do pessoal de saúde; Escalas; Competência profissional; Relações profissional-família

Introduction

Participation of families in child care is considered essential for meeting children’s needs and for the well-being of the whole family.(¹) Giving family-centered care means that the care provided by professionals includes both the knowledge and the belief that: family is a permanent part of children’s lives; children affect and are affected by those with whom they have relationships; and when families are included in the process of care, children will be better cared for(²). In this context, nurses’ attitudes toward individuals and families reflect the importance given to the family system in the care process, defining the type of relationship that will be established among the parts. Having a supportive attitude is an important precondition to inviting and engaging families in nursing care, and such attitudes can foster facilitating behaviors between nurses and families(³).

Attitudes involve affective, cognitive and behavioral components, and are considered a response to a stimulus(⁴). The presence of families in the health care environment is a necessary stimulus to triggers nurses’ attitude towards them, and their attitudes are based on feelings and emotions (affective component), thoughts and beliefs (cognitive component), and reaction tendencies (behavioral component)(⁵).

Introducing nurses to the knowledge and strategies of family nursing can broaden the way they work with families and change current practice standards to an approach that is more focused on families. Nurses who are aware of these ideas are capable of considering the importance of families for nursing care and the importance of family care and family experiences of health and disease.(⁷) In Brazil, family nursing is not consolidated as a specialty yet, and not all curricular contents address the matter from this point of view(⁸). Besides, most national scientific outputs in the field are still focused on the description of family disease history, where the meaning of a disease and its impact on daily life are reported(⁹). Therefore, there is still a high demand for understanding how professionals act regarding family care in pediatrics.

One study showed that nurses’ experiences in care given to families in the context of pediatrics is neither unique, nor homogeneous; motivations are still personal, so the inclusion and engagement of families in nursing care depend on each professional’s personal knowledge and motivation(⁹). A supportive attitude toward the involvement of families is an important precondition to inviting and engaging families in nursing care(¹⁰). Based on these observations, a guiding question was formulated for this study: What are nurses’ attitudes regarding the importance of families in the process of child care?

The objective of this study was to identify attitudes of nurses regarding the importance of families in nursing care in the context of pediatrics.

Method

A quantitative and descriptive study, carried out in the first half of 2011 in a university hospital in São Paulo, Brazil, with all nurses (n=59) who were working in pediatric and maternal-child units. Inclusion criteria were: being involved in performing caregiving duties with patients and families, and availability to participate in the study..

The data collection strategy was defined by the researchers, together with the head nurses from each unit. Thus, to make data collection possible, 59 envelopes containing the instrument with instructions for completing it and a Free and Informed Consent form were left in all units, so nurses from all shifts could fill them out at their convenience. Envelopes with completed instruments were eventually collected by the researchers to perform the analyses.

The data collection instrument was composed of a two-part questionnaire: the first had sociodemographic and professional characterizing questions, such as gender, age, education, years of professional practice, sector of activity, history of serious illnesses in the family and type of education in family nursing; the second part consisted of the scale Families’ Importance in Nursing Care: Nurses’ Attitudes (FINC-NA).

This scale, originally developed in Sweden(¹⁰), was translated into Portuguese and validated(⁵) and had not been used in studies in Brazil before. It is a Likert-type auto-fill scale consisting of 26 items with 4 response options (1- totally disagree, 2- disagree, 3-agree and 4- totally agree). Total scores in the FINC-NA scale range from 26 to 104(⁵). The 26-item scale is divided into 3 subscales, (Picture 1), which can be measured as 3 independent aspects: (1) Family: responsive partner and coping resources, made up of 12 items, with scores varying from 12 to 48; (2) Family: resources in nursing care, made up of 10 items, with scores varying from 10 to 40; (3) Family: burden, made up of 4 items, with scores varying from 4 to 16. The higher the score in the first two and the lower the score in the third, the more importance families have for nurses, that is, the nurses have a more supportive attitude.(⁵) Prior to the application of the scale, semantic equivalence was found for Brazilian Portuguese.(¹¹)

For data analysis, a descriptive statistical analysis and an analysis of variance were performed. All statistical analyses were carried out with the help of the Statistical Package for the Social Sciences (SPSS) for Windows, version 17.0. Analysis of variance (ANOVA) was used to compare differences between two independent groups. The total FINC-NA score and scores for the subscales were considered ordinal data. Mean values were given to missing scores. The stepwise selection model was used to investigate the most significant variables for each subscale and for the total FINC-NA scale. To identify participants with less supportive attitudes, that is, with lower scores, the first quartile (q1) of the total scale and subscales were used as the minimum score(¹¹). Participants with scores between q1 (77) and q3 (87) were considered to have a supportive attitude regarding the participation of families in nursing care; participants with scores above the third quartile were considered to have an excellent attitude (Chart 1).

Ethical aspects: The research was approved by the Research Ethics Committee of the university hospital of the University of São Paulo, under number n.979/10. All participants were duly informed about research procedure and they signed a Free and Informed Consent Form. The study was in compliance with ethical rules contained in Resolution 196/96 of the Health Council of Brazil.

Chart 1
FINC-NA scale items distributed in subscales

Results

The response rate was 84.7% (n=50). The sample of nurses who participated in the study was divided as follows: 8 from the Wards (16%); 8 from Child Emergency (16%); 10 from the Nursery (20%); 12 from the Pediatric and Neonatal Intensive Care Unit (24%); and 12 from the Pediatric Admission Unit (24%).

Participants in the study, who were mostly women (94%), and were divided into three different age groups, the oldest being made up of individuals over 41 (40%). Regarding academic qualifications, a significant portion had a lato sensu specialization degree (68%); years of professional practice varied from 2 to 5 (26%) and from 6 to 10 (26%); and there was a prevalence of individuals who had been working in the place for over 10 years (44%). Regarding history of disease within the family, 76% of the sample reported having had cases of serious illness in the family; some kind of education in Family Nursing was reported by 78% of participants (Table 1).

The mean score of the total FINC-NA scale was 82 (SD=7.7; q1=77; q3=87), which indicated that nurses who worked in the place had a supportive attitude regarding the importance of families in nursing care. Statistically significant attitudes of more or less support (p ≤ 0.05) were found in variables related to age (p =0.003), years of experience (p=0.014), sector of activity (p=0.007), and previous contact with content about Family Nursing (p=0.004).

Individuals between 31 and 40 years-old had a more supportive attitude regarding the importance of families in nursing care, with a total mean score of 87 (SD=7.6); with 6 to 10 years of experience, a total score of 87 (SD=6.6); from Child Emergency (score of 87, SD=7.2); and with previous contact with contents about Family Nursing, a mean score of 83 (SD=6.8).

In the subscale Family: responsive partner and coping resource, which included items such as I always try to know who the family members are, and I ask family members how I can help, the mean score was 37 (SD=3.9; q1=34; q3=40). Higher and statistically significant scores were found in groups: whose age was between 31 and 40 years, with a score of 35 (SD=3.8), with previous contact with contents about Family Nursing a score of 38 (SD=3.7), and who were from Child Emergency a score of 39 (SD=4).

Table 1
Sample characterization

Variables	Frequency	Percentage
Gender
Female	47	94
Male	3	6
Age Group
26 to 30 yrs.	17	34
31 to 40 yrs.	13	26
41 or over	20	40
Education
Bachelor’s degree	5	10
Lato sensu Specialization	34	68
Master’s Degree	9	18
PhD	2	4
Years of professional practice
2 to 5 yrs.	13	26
6 to 10 yrs.	13	26
10 yrs. or over	24	48
Years in current service
Up to 1 year	6	12
2 to 5 yrs.	11	22
6 to 10 yrs.	11	22
10 yrs. or over	22	44
Education in Family Nursing
Yes	39	78
No	11	22
History of disease in the family
Yes	38	76
No	12	24
Sector of activity
Wards	8	16
Nursery	10	20
Pediatric and Neonatal Intensive Care Unit	12	24
Pediatric Admission	12	24
Child Emergency	8	16

The mean score for subscale Family: resources in nursing care, which included items such as It is important to devote time to families, and The presence of family members is important for me as a nurse, was 33 (SD= 3.2; q1=30; q3=35). Higher and statistically significant scores were found on this subscale in groups whose age varied between 31 and 40 years, with a score of 35 (SD=3.7); 2 to 10 years of work experience (score of 34, SD=2.5); previous contact with contents about Family Nursing (score of 33, SD=2.7); and who were from Child Emergency a score of 35 (SD=3.5).

In the subscale Family: burden , which included items such as The presence of family members makes me feel stressed, and I don’t have time to care for families, the total mean score was 12 (SD=1.8; q1=11; q3=14), showing that families are not usually considered a burden by nurses participating in nursing care Higher and statistically significant scores were found in this subscale in the group with 6 to 10 years of experience, and the score was 13 (SD=1.6) (Table 2).

As for the FINC-NA total scale, less supportive attitudes regarding the importance of including families in nursing care were found in groups aged over 41, with a mean score of 78 (SD=7.2), with more than 10 years of professional experience, a total score of 80 (SD=7.3); without previous contact with contents about Family Nursing, a total score of 76 (SD=8); nurses from Wards, a total score of 76 (SD=5.7). Analysis of variables was carried out by means of the stepwise selection method, starting with a model of 4 variables: age group, years of professional practice, sector of activity and previous contact with content about Family Nursing. After regression, it was found that an important variable that explains score values is related to the fact that nurses had previous contact with some content about Family Nursing.

Table 2
Comparison of scores of nurses’ attitudes regarding the importance of families in the total FINC-NA scale and subscales with subgroups

Subgroups	Total Scale	Subscale 1(a)	Subscale 2(b)	Subscale 3(c)
All participants
Mean (q1-q3)	82 (77-87)	37 (34-40)	33 (30-35)	12 (11-14)
Gender (p value)	0.846	0.554	0.883	0.831
Female	83	38	32	12
Male	82	37	32	12
Age group (p value)	0.003	0.013	0.004	0.139
26 to 30 yrs	82	37	33	12
31 to 40 yrs	87	39	35	13
41 or over	78	35	31	12
Education (p value)	0.843	0.504	0.835	0.961
Bachelor’s degree	79	35	33	12
Lato Sensu Specialization	82	37	32	12
Master’s Degree	83	38	33	12
PhD	80	37	31	12
Years of professional practice (p value)	0.014	0.137	0.08	0.012
2 to 5 yrs	81	37	32	11
6 to 10 yrs	87	39	35	13
10 yrs or over	80	36	32	12
Years in current service (p value)	0.066	0.227	0.054	0.108
Up to 1 year	78	36	32	11
2 to 5 yrs	84	38	34	12
6 to 10 yrs	86	38	34	13
10 yrs or over	80	36	31	12
Education in Family Nursing (p value)	0.004	0.011	0.010	0,075
Yes	83	38	33	12
No	76	34	30	11
History of disease in the family (p value)	0.321	0.215	0.624	0.544
Yes	81	36	32	12
No	84	38	33	12
Sector of activity (p value)	0.007	0.075	0.01	0.256
Wards	76	35	30	11
Nursery	84	38	34	12
Pediatric and Neonatal Intensive Care Unit	78	35	31	12
Pediatric Admission	84	38	34	13
Child Emergency	87	39	35	13

• ^a
  Subscale 1 - Family: responsive partner and coping resources
• ^b
  Subscale 2 - Family: resources in nursing care
• ^c
  Subscale 3 - Family: burden

Discussion

The study was conducted in pediatric and maternal-child units, where the presence of parents is part of the professionals’ routines. When it comes to child hospitalization, the involvement of parents in care is an important indicator of quality of care given.(¹²-¹³)

Most participating nurses showed a supportive attitude regarding the importance of involving families in nursing care. The same results were found in studies that used the same scale, carried out in different contexts and realities, such as Sweden(¹⁴-¹⁶), Portugal(²,¹⁶) and Iceland(¹⁷).

Results obtained showed that more experienced nurses had lower scores on the FINC-NA scale, which confirms less supportive attitudes regarding the participation of families in care. This result is very different from other studies, which revealed that more experienced nurses valued family care more highly than younger and less experienced nurses.(¹⁴,¹⁶-¹⁷) As for our study, this result can be an indicator of the impact of training on family nursing, which has been gaining force recently in undergraduate courses in Brazil. This did not happen in the past, when nurses participating in this study got their degrees. Likewise, a study conducted in the United Kingdom reported that pediatric nurses considered those who were more experienced with kids to have a more supportive attitude toward families.(¹⁸)

In the subscale Family: responsive partner and coping resources, higher scores were found among nurses who worked in Child Emergency. A study on the importance of families in psychiatric care also found predominant differences among nurses from different units. Nurses who worked in child and adolescent psychiatric units had higher scores, whereas nurses from severe psychiatric disorder units had lower scores(¹⁷). The permanent presence of families in pediatrics is a facilitating factor for a more favorable attitude toward the involvement of families in care. In our study, diverging results can be related to internal matters of the unit in the preparation of staff for the implementation of a family-centered care. Among different variables related to scores, in the subscale Family: resources in nursing care, the lowest scores presented in this study were found among nurses who did not have any type of training or contact with contents related to Family Nursing. Similar results were found in studies carried out in contexts of primary health care(¹⁶) and psychiatric care(¹⁷), which also included lower academic degrees, that is, undergraduate. Higher scores were also found after online training in interacting with families.(¹⁵) It was possible to observe that the use of nurses to do family nursing, although to different extents, was an important indicator of more supportive attitudes toward families involved in nursing care. In that sense, the core of attitudes toward families is beyond professional awareness. When nurses become efficient instruments, they approach families more effectively and are more able to think and act together with families in a more focused manner.(⁷)

A study found attitudes that supported the idea that families are a burden in nursing care among nurses who had graduated more recently. The authors reported that this conception of families as a burden was related to the idea that nurses do not have time to care for families and that families are not welcome in health care environments(¹⁴). In our study, this observation was found among nurses who got their degrees for long. We consider that seeing families as a burden can be important proof that nurses define their priorities when they begin their careers, and these priorities may or may not include the involvement of families in nursing care. However, it is necessary to highlight that the idea of families as a burden represents a barrier for the development of a collaborative relationship among nurses and families, and it can be associated with personal, organizational and environmental barriers.

Conclusion

Understanding the importance that nurses give to families in nursing care is a relevant indicator for a situational assessment of how open the nursing staff, a service or an institution are to the participation of families in care. The results of the application of the FINC-NA scale to a sample of nurses from pediatric and maternal-child units in a Brazilian university hospital confirm the findings of other studies carried out in other countries and bring important evidence to a field where research is still limited. Although nearly all nurses from studied areas participated in the study, the small size of the sample was a limitation. The instrument applied in this study can be used to guide implementation processes for family-centered care, as more supportive attitudes can indicate that nurses are more aware of and favorable toward nursing practice that considers families as allies. To expand the understanding of the context studied, the scale can be used at an institutional level, in other fields of care, in future studies and in comparisons between nurses from different units.

Understanding the relationship between nurses’ length of training and the importance they give to families in care is an important object of study for future research and has the potential to unveil the factors that make nurses distance themselves from families. This could also indicate at what time in professional experience interventions are necessary to make nurses provide family-centered care.

Efforts in professional training in the field of Family Nursing, either by adding specific contents to undergraduate and graduate curricula, or by specialized and complementary training, will definitely bring good results to family-centered health care practice.

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Publication Dates

• Publication in this collection
  Aug 2014

History

• Received
  21 Mar 2014
• Accepted
  06 Aug 2014