Family Resilience in the ICU: A Concept Analysis

ABSTRACT

Background

The concept of family resilience is a promising way to improve families' ability to cope with sudden change. However, there is no consensus in the field of intensive care regarding its definition.

Aim

The aim of this concept analysis was to develop a deeper understanding of the phrase ‘family resilience in the ICU’ within the nursing discipline to facilitate its comprehension, implementation and evaluation.

Study Design

We performed a comprehensive search of Medline (PubMed), Web of Science, OVID, Embase, CINAHL (EBSCO), CNKI (Chinese), Wangfang (Chinese), VIP (Chinese) and SinoMed (Chinese) with MeSH terms and keywords, including critical care/intensive/ICU, family, resilienc* and hardiness. The inclusion criteria were the subject of family resilience in the intensive care unit (ICU), English or Chinese language, and full text. Walker and Avant's approach was used to analyse the concept.

Results

From the 22 studies selected for this analysis, four main attributes of ‘family resilience in the ICU’ were identified: the characteristics system, belief system, organisation system and support system. We developed four model cases to illustrate how the concept is operationalised. The concept analysis of ‘family resilience in the ICU’ identified four antecedents: the relatively unexpected admission of a relative to the ICU, disrupted family order, acute stress and positive response. The analysis also identified four consequences: the development of resilience, the psychology of the family, family adaptation and patient support.

Conclusions

According to the concept analysis, we suggest an operational definition to facilitate the implementation of the concept in practice. Furthermore, we propose that implementation should be guided by the following key ideas: (1) identifying family characteristics, (2) helping families establish correct expectations, (3) providing support to help families regain control, (4) promoting family participation in medical decision‐making and patient care, and (5) encouraging families to access external resources.

Relevance to Clinical Practice

This concept analysis of family resilience in the ICU will advance healthcare professionals' understanding and knowledge and encourage them to pay more attention to patients' families. It can also prepare and educate healthcare professionals to develop policies and guidance to increase family resilience in ICU settings.

Impact Statements.

• What is known about the topic

  • ○
    The concept of family resilience has been clearly defined in the field of sociology.
  • ○
    In the field of medicine, the resilience of families of patients with chronic and childhood diseases is gradually being emphasised.
  • ○
    The defining attributes and characteristics of family resilience in the ICU are not yet clear.
• What this paper adds

  • ○
    On the basis of a comprehensive literature search and analysis, we clarify the defining attributes, antecedents, consequences and measurement tools of ‘family resilience in the ICU’.
  • ○
    A model case, related case, borderline case and contrary case were constructed according to the defining attributes of ‘family resilience in the ICU’.
  • ○
    Based on a conceptual analysis, we propose key strategic recommendations for nursing staff to increase families' resilience in the ICU.

1. Introduction

Intensive care unit (ICU) patients' families play an important role in their recovery and health outcomes. In 2017, the Society of Critical Care Medicine (SCCM) released the ‘Guidelines of Family‐Centred Care for Neonatal, Paediatric, and Adult ICUs’, which emphasised the importance of family involvement [1]. However, the emergent ICU admission of a family member exposes critically ill patients' families to substantial stressors. Families may have different responses to the sudden changes. Some families make changes quickly and gather together to cope with these changes to ensure good operation of the family, whereas some families struggle with adaptation, experience family conflicts and even collapse [2]. With the rise of positive psychology and family systems theory, empirical studies have shown that positive adaptation in the face of adversity or pressure can help families overcome crises and progress [3, 4]. Family resilience is an emerging issue in the field of family research for patients with critical illness. This is a challenge for both individuals and society and deserves the attention of clinical professionals and medical scholars. However, the concept of family resilience in the ICU is currently unclear and is often confused with terms such as family elasticity and the family hardiness index (FHI). A concept is the basic unit of human thinking and an essential issue for the development of nursing because unclear concepts lead to cognitive biases and are antithetical to nursing practice and academic research [5].

2. Background

Previous studies have examined the mitigating effect of a high level of family resilience during disruptive events in family life. This mitigating effect includes a decrease in psychological symptoms among family members [6] as well as facilitating and mobilising effects on the ability to manage adversity [7, 8].

Concepts are regarded as building blocks of theories, and concept analysis is an attempt to deconstruct a term to (1) assess the elements of a given concept, (2) elucidate vague and unclear concepts of a theory, (3) obtain a greater understanding of the concept and (4) ultimately develop a consistent definition of the concept to facilitate its measurement [9]. This is the case in the present study, which uses terms that are interchangeable with family resilience, such as tenacity and flexibility. There are many general definitions of family resilience. However, owing to the varying characteristics of different contexts, a general definition is difficult to apply. The definition of family resilience in other fields cannot reflect the specificity of the ICU setting. Moreover, most definitions and measurements of family resilience do not reflect the physiological and psychological characteristics of ICU patients' families. These factors may lead to a lack of clarity about the conceptualisation of family resilience in the ICU and may limit the precise measurement of this concept and its differentiation in other fields, such as psychopathology, sociology and medication. This lack of clarity may further hamper the assessment of and intervention in families' resilience in critical care units. We conducted the current analysis to examine the concept of family resilience in the ICU and to elucidate its definition.

3. Aim and Objective of the Study

This study aimed to analyse the concept of family resilience in the ICU and clarify its defining attributes, antecedents and consequences. Furthermore, this analysis explored the impact of family resilience on nursing practices for patients with critical illness.

4. Design and Methods

A concept analysis method was utilised to clarify the meaning and significance of ‘family resilience in the ICU’ in the nursing literature. Walker and Avant's concept analysis method (Walker & Avant, 2019) was selected because it is a rigorous and inductive method that allows for clarification of the use, nature and properties of a concept and fosters its understanding. This method consists of eight steps: (1) selecting a concept; (2) determining the aim and purpose of the analysis; (3) identifying all uses of the concept; (4) identifying the defining attributes of the concept; (5) constructing a model case; (6) constructing borderline, related and contrary cases; (7) identifying antecedents and consequences; and (8) defining empirical referents [9].

4.1. Literature Search Strategy

To support this concept analysis, bibliographical searches were performed using electronic databases, including Medline (PubMed), Web of Science, EMBASE, CINAHL (EBSCO), CNKI (Chinese), Wangfang (Chinese), VIP (Chinese) and SinoMed (Chinese). We conducted a comprehensive literature search from database inception to December 2024. The MeSH terms and keywords used for the electronic searches were “critical care/intensive/ICU”, “family”, “resilienc*” and “family resilience”. Table S1 provides a detailed search strategy for the databases. The results were filtered by the subject of family resilience in the ICU, English or Chinese language, and full text. The reference lists of the selected articles were also reviewed using the snowball technique.

4.2. Inclusion and Exclusion Criteria

Our central aim was to identify relevant sources that discuss family resilience and explore the different aspects of this concept. We included the following entries: (1) studies focused on ‘family resilience in patients with critical illness’; (2) articles that reported literature reviews or empirical studies with qualitative, quantitative or mixed‐method designs; although quantitative and mixed‐method studies provide information on empirical referents and consequences of the concept of ‘family resilience in patients with critical illness’, literature reviews and qualitative studies are especially relevant for the identification of its attributes, and (3) grey literature, such as editorials, essays, practical guides, and theses or vision statements, which provides information to determine the uses of the concept of ‘family resilience in patients with critical illness’ and the attributes and antecedents associated with it.

According to the recommendations of Walker and Avant, all studies that could help clarify the concept were included, and no studies were excluded due to methodological quality. Papers that focused on concepts that are closely related to family resilience in the ICU but did not explicitly refer to it were excluded.

4.3. Selection and Analysis Process

After the search was conducted in the electronic databases, the next step was to select the studies. The initial searches were accepted after duplicates were eliminated, and the titles of the citations were screened. We used the NoteExpress citation manager to help us find duplicates and to use filters to exclude irrelevant records. Two reviewers (SS and XL) independently completed the title and abstract screening, reviewed the full‐text articles and applied the inclusion criteria. Finally, the included studies were reviewed for the concept analysis. The review process consisted of an individual and complete analysis and synthesis of the articles. The content of each paper was analysed to identify antecedents, consequences and attributes. After the content analysis, descriptive themes were identified as attributes of the concept.

From 216 records, 40 duplicates were removed, and 176 entries were screened for relevance on the basis of their title and abstract. One hundred and forty‐eight records were excluded, and 28 records were selected for full‐text assessment. Ultimately, seven records were excluded, and 21 were selected for inclusion. One record was included from the reference lists of the selected articles using the snowball technique, and 22 were included in the concept analysis. A summary of the selection process is presented in Figure S1. A summary of the included studies and their main features is presented in Table S2.

5. Results

5.1. Emergence of the Concept

This step in Walker and Avant's analysis method helps to delimit the scope of the concept and its meaning. The word resilience comes from the present participle of the Latin verb resilire, meaning ‘to jump back’ or ‘to recoil’. According to the Merriam‐Webster dictionary, resilience is defined as ‘the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress’ [10]. Another definition is ‘an ability to recover from or adjust easily to misfortune or change’. In the 1960s, the concept of resilience gradually became incorporated into the field of family therapy. Since then, the concept of family resilience has been used consistently in different medical fields (e.g., chronic disease management, children's disease and public health emergencies) as a framework to improve care and safety by fostering continuity, comprehensiveness, patient‐centredness and interprofessional evidence‐based orientation [11, 12, 13].

In recent years, the concept of family resilience has gradually emerged in the field of critical care. In early studies, researchers usually used the general concept of family resilience to define family resilience in the ICU. In one study of the impact of critical care nurses on patients' family resilience, Lauren Ellis defined the concept of family resilience in the ICU as the ability of families to rebound from stressful events and suggested that each family in the ICU setting has innate strengths and areas for further growth [14]. Zhao Xixi referred to the concept of family resilience in the ICU as the characteristics and properties that help families recover and become stronger in hazardous situations that involve challenging and dangerous circumstances [15]. These conceptual definitions are derived mainly from Walsh's definition of family resilience. With the development of research, the concept of ICU family resilience reflects personalised characteristics. In a longitudinal qualitative study of parents' psychosocial trajectories following children's critical injury, Kim Foster defined family resilience in the ICU as temporary disruption due to injury and hospitalisation with the ability to recover mental and emotional well‐being quickly and maintain this well‐being over time [16]. Zhao Yang provided an operational definition of family resilience in the ICU that reflects families' protective effort to adapt to adversity in the ICU setting and improve their ability to overcome negative emotions [17]. An analysis of the definitions of this concept in the 22 included studies suggests that most researchers include the characteristics and attributes of families in the use of internal resources to adapt to and survive stressful situations. These defining attributes include the assumption of family responsibilities, control over life events and positive responses to challenges.

5.2. Defining Attributes

Identifying the defining attributes of a concept is the fourth stage of Walker and Avant's model. Determining which attributes are most frequently associated with family resilience in the ICU allows for more accurate and profound insight into the concept. From the 22 studies analysed, more than 20 defining attributes for the concept of family resilience in the ICU were extracted (see Table S2). A classification analysis was conducted that revealed that the concept of family resilience in the ICU has a core category, regaining control, with four main attributes: the characteristics system, belief system, organisation system and support system. Each of the defining attributes revealed in the analysis is described in the following sections.

5.2.1. Characteristics System

In the literature, family resilience in the ICU has been evaluated using certain characteristic elements of families, such as self‐empowerment and optimism. These characteristics are related to family resilience. Characteristic attributes are the natural attributes of a family. Positive and negative effects on family resilience can be defined as protective and dangerous factors. Protective factors include resilience, self‐empowerment and optimism, whereas dangerous factors include heightened emotional vulnerability.

Resilience, self‐empowerment and optimism are three items of the Connor‐Davidson Resilience Scale (CD‐RISG), which has been used to assess family resilience [17, 18, 19, 20, 21]. In addition, Brigitte Cypress refers to leadership, which can encourage families to adapt to their relative's admission to the ICU. Resilience also improves family members' ability to participate in the care process. Heightened emotional vulnerability is considered a risk factor for ICU family resilience in Pauline Wong's framework model [22]. In a crisis situation in which a relative is admitted to the ICU and the family order is disrupted, heightened emotional vulnerability can prevent families from regaining control over the situation.

5.2.2. Belief System

The belief system is another attribute of family resilience in the ICU that was identified in 6 of the 22 studies reviewed for this analysis. The belief system represents the family's feelings and attitudes towards crisis events when faced with the sudden admission of a relative to the ICU and is closely related to the family's resilience. The belief system includes two subcategories, namely positive beliefs and negative beliefs. Positive beliefs include responsibility, searching for meaning and positive expectations. Negative beliefs include disconnectedness and living with uncertainty.

In Walsh's family resilience model, belief systems include making meaning of adversity, a positive outlook, transcendence and spirituality. The meaning of diversity and a positive outlook were mentioned many times in the 22 included studies [14, 16, 23, 24]. Family members' ability to properly view and analyse crises, establish a correct understanding of these crises and maintain positive expectations for crisis events is beneficial for the development of family resilience. Family is the most important support for ICU patients. Family responsibility can help families overcome crisis events and inspire family members to take on the responsibility of providing support for relatives and maintaining family order [25, 26]. Due to the enclosed environment of the ICU, there is a large gap in family members' ability to obtain information on patients' conditions and disease outcomes, which can lead to uncertainty and disconnection. These feelings have a negative impact on family resilience. Walsh placed ‘connectedness’ in the organisational system to indicate poor communication among family members. However, disconnectedness here refers to the feeling of disconnection between family and patients caused by the isolated ICU environment. This concept is therefore included in the belief system.

5.2.3. Organisation System

The attributes of the organisational system were identified in three of the included studies. The family is an organisational unit. The organisational system includes internal structure and external connections, which are closely related to family resilience. The internal organisation attributes include family leadership and family adaptation. The external organisation attributes include policy and guideline contributions and health economic factors. Communication is the link between internal and external organisations.

Leadership is a core element in the operation of the family organisation. When a family is in crisis, the leadership of the family can unite the family and help them overcome the crisis. These findings were confirmed in Brigitte Cypress's research on the involvement of ICU family members in patient care [27]. Researchers have also mentioned family adaptability, which includes adjustments to family operating patterns and changes in family planning [19, 22, 27]. Practical guidelines and medical policies in the external environment have a significant impact on the treatment plans and medical burdens of ICU patients. Additionally, there are differences in the healthcare systems of different countries, which result in varying healthcare policies for patients. This can lead to different impacts on family resilience [27]. Moreover, communication elements were mentioned in several studies. Communication involves not only the exchange of ideas between family members but also dialogue between the family and the external environment [14, 16, 19, 27]. Communication is a protective factor for family resilience in the ICU that not only promotes coordination among organisational members but also helps them obtain external information.

5.2.4. Support System

The support system is an important attribute of family resilience in the ICU that was identified in 8 of the 22 studies reviewed for this analysis. The support system includes psychological and resource support, which can improve families' ability to cope with crises and overcome difficulties. The core attribute of the support system is drawing strengths, or obtaining both internal and external strength and resources. The support system includes family engagement, professional support, and social and psychological support.

Many researchers encourage families to participate in ICU patient rounds and care [20, 26]. Family engagement involves family members providing support to patients. Participation also allows family members to obtain more information about the patient's illness and contribute to the patient's recovery. Therefore, participation is also a source of strength. Medical personnel provide important support to families. During ICU treatment, family members are highly dependent on medical staff [16, 23, 27]. Medical professionals provide important information to families, assist them in establishing positive expectations and invite them to participate in the patient's care. In addition, social and psychological support is an important aspect of the support system. The support of relatives, friends, colleagues and peers can provide additional information resources for family members and allow them to obtain external information, which is an important source of psychological support for family members [21, 23, 27, 28].

5.3. Model Case

A model case is especially useful for illustrating how the concept is operationalised. Box 1 shows an example of a model case.

BOX 1. Example of a model case.

Mr. Wang's father, who is 70 years old, was diagnosed with aortic dissection and underwent emergency surgery before admission to the intensive care unit (ICU). Upon hearing this news, Mr. Wang and his family felt very nervous and worried. Mr. Wang has a younger sister, and both have completed college education and come from a well‐off family with a harmonious relationship. As the eldest son in the family, Mr. Wang has good leadership skills. He organised family meetings to discuss his father's admission to the ICU. Faced with their father's illness, all family members were grateful for timely medical treatment and the opportunity for surgery to save their father's life. In addition, all family members said that they could afford their father's hospitalisation expenses and care work, and their father's medical insurance covered most of the medical expenses. Colleagues who knew about the family situation provided positive support to Mr. Wang. With the help of colleagues, the family had sufficient time to manage hospitalisation issues and made arrangements for their mother, who stayed at home alone. Mr. Wang's uncle was a surgeon, and his family gained a comprehensive understanding of the treatment plan for aortic dissection, which helped them form a rational expectation for the disease outcome. Due to the restricted visitation, the family members experienced mild separation anxiety and were worried about the lack of companionship for their father. Mr. Wang's family had strong communication needs and abilities. Through sufficient communication with ICU medical professionals, the family understood their father's current condition and participated in a family ward round initiated by medical staff, which helped to reduce their separation anxiety and worries. Due to timely treatment and care as well as sufficient support from the family, Mr. Wang's father's condition stabilised, and he was transferred out of the ICU on the sixth day after surgery.

In the case presented in Box 1, the four defining attributes of family resilience in the ICU are evident. The case describes the characteristic system of family resilience, including self‐empowerment, optimism and leadership. It demonstrates the process of dealing with negative beliefs, such as disconnectedness and uncertainty, through the positive belief systems that families build when faced with a crisis. It also describes the rational organisational system adjustments to work and life made by the family. Mr. Wang's uncle and colleague were sources of social and psychological support, and the ICU doctors and nurses were sources of professional support. The family maintained good internal and external communication throughout the process. This case demonstrates the entire process of ICU family resilience.

5.4. Related Case

A related case is a scenario that is similar to the concept but does not share the defining attributes.

In Box 2, a case of family involvement in medical decision‐making is described. This case took place in an ICU setting, and the subject is the patient's family, which fits the background and object of ICU family resilience. However, this case primarily describes the process by which families make medical decisions and does not refer to the defining attributes of family resilience in the ICU in terms of characteristics, beliefs and the organisational system. Although assistance with medical decision‐making is an aspect of professional support, it does not involve the attributes of social and psychological support. Therefore, it cannot fully reflect family resilience in the ICU, although it is an aspect of the diagnosis and treatment process. The concept of ‘medical decision‐making by the family in the ICU’ does not share the four attributes of ‘family resilience in the ICU’.

BOX 2. Example of a related case.

Mr. Wang's father, who is 70 years old, was diagnosed with aortic dissection and underwent emergency surgery before admission to the intensive care unit (ICU). At 6 h postoperatively, the patient developed an increased heart rate and decreased blood pressure, and possible surgical site bleeding was considered. The surgeon organised a doctor–patient communication and recommended another surgical exploration to stop the bleeding in addition to discussing the high risk of surgical failure and the high cost of the procedure. The other option was conservative treatment with continuous observation, but there was a high risk of a life‐threatening situation due to untimely bleeding. Faced with the choice of treatment plans, Mr. Wang's family held an emergency meeting to discuss the pros and cons of both treatment options. The surgeon's recommendation was also considered, and the final decision was made to accept an operation to stop the bleeding. The surgery was completed successfully, and the patient's bleeding was promptly resolved. On the 6th day after surgery, the patient's condition stabilised, and he was transferred out of the ICU.

5.5. Borderline Case

A borderline case contains some, but not all, of the identified defining attributes, or one attribute may differ significantly. In Box 3, an example of a borderline case is presented.

BOX 3. Example of a borderline case.

Mr. Wang's father, who is 70 years old, was diagnosed with aortic dissection and underwent emergency surgery before admission to the intensive care unit (ICU). On the sixth day after surgery, after a comprehensive assessment, the ICU doctor believed that the patient's condition was stable and met the criteria for transfer out of the ICU. When Mr. Wang's family learned that the patient was going to be transferred out of the ICU, they were both excited and worried. The family was excited because transfer out of the ICU was a sign of recovery from the illness. The family's worry was due to the different level of monitoring in the regular ward and their fear of oversight by the ward nurses when their father's condition changed. Furthermore, due to a lack of caregiving experience, the family members were afraid of not being able to perform their father's caregiving. After communicating with the medical staff and his uncle, who was a surgeon, Mr. Wang understood the safety of disease monitoring in the general ward as well as knowledge of caring for highly dependent patients. The family quickly adjusted their thinking, gradually eliminated their worry and looked forward to their father's transfer from the ICU.

In the case presented in Box 3, the psychological adaptation process of ‘transfer stress’, which is produced by patient transfer from the ICU to a regular care unit, is introduced. This belongs to the characteristic attribute aspect of family resilience in the ICU. In this case, the family members were worried due to a lack of information about observation and care during the high‐dependence period. With support from professionals and society, they overcame negative beliefs (uncertainty) and established positive expectations. However, the attributes of the ‘characteristic system’ of family resilience in the ICU were not highlighted. Therefore, this borderline case includes all the defining attributes of the phenomenon except for the characteristic system.

5.5.1. Contrary Case

A contrary case is the opposite of the concept. Walker and Avant advocate the use of these cases as a part of the internal dialogue used to examine the defining attributes. In Box 4, an example of a contrary case is presented.

BOX 4. Example of a contrary case.

Mr. Wang's father, who is 70 years old, was diagnosed with aortic dissection and underwent emergency surgery before admission to the intensive care unit (ICU). When they heard this news, Mr. Wang and his family felt very nervous and worried. Mr. Wang has a younger sister, both of whom were born in rural areas. Their family's economic condition is poor, and their father's medical insurance covers few medical expenses. The surgery has already consumed most of the family's savings, and the family is facing significant financial pressure. Because her child is only 1 year old, Mr. Wang's sister must stay at home to take care of the baby. To handle their father's affairs, Mr. Wang had to resign from his temporary job at a construction site. Due to his low educational level and introverted personality, Mr. Wang rarely communicated with professionals. This led to a lack of information about his father's illness and uncertainty about the outcome of the disease. He felt anxious and hopeless. At 6 h postoperatively, the patient developed an increased heart rate and decreased blood pressure, and possible surgical site bleeding was considered. The surgeon organised doctor–patient communication and recommended another surgical exploration to stop the bleeding in addition to discussing the high risk of surgical failure and the high cost of the procedure. There was disagreement among Mr. Wang's family members regarding whether to agree to the surgery, and a heated argument erupted. Finally, the family abandoned surgical treatment, and the patient was discharged.

The case presented in Box 4 displays no positive attributes of family resilience in the ICU. The family members exhibit a pessimistic and negative state in the crisis that is unrelated to aspects of the characteristic system of family resilience in the ICU, such as resilience, self‐empowerment and optimism. Moreover, a good belief system was not established within the family, and the family order was disrupted. The family failed to regain control through family adaptation.

5.6. Antecedents and Consequences

According to Walker and Avant, identifying the antecedents and consequences of a concept helps to contextualise it, thus furthering its understanding. The present concept analysis identified several antecedents and consequences of ‘family resilience in the ICU’ that have appeared recurrently in the literature (see Table S2).

The antecedents of family resilience in the ICU are relatives admitted to the ICU, the disruption of family order, acute stress and positive adaptation. Family resilience in the ICU occurs in the specific environment of the ICU, so the admission of a family member to the ICU is the basic precursor of ICU family resilience. A series of acute stress events, such as critical illness, complex treatment plans, uncertain/poor health outcomes, restricted visits, an unfamiliar ICU environment, economic pressure and long‐term care needs, emerged. The disruption of this balance and the emergence of crises stimulate families to develop resilience and make positive adaptations to overcome crises, restore family functioning and regain control. Finally, in the face of a crisis, families may have completely different reactions, that is, positive and negative reactions. Family resilience can help the family overcome the crisis, so a positive response from the family is also an antecedent of family resilience.

The literature analysis shows that the consequences of family resilience in the ICU are related to resilience itself, patients and families and include resilience development, the social psychology of family, family adaptation and patient support. A longitudinal trajectory study revealed that the development of family resilience in the ICU has three consequences, namely a resilience trajectory, recovery trajectory and pain trajectory, which represent good, moderate and poor development of family resilience, respectively. One consequence of family psychology is a reduction in the negative psychological reactions and emotional burdens of family members, such as depression, anxiety, acute stress, helplessness, emotional burden and vulnerability, and secondary stress reactions [18, 19, 23, 28, 29, 30]. ICU family resilience can also promote positive consequences for family adaptation, such as resolving difficulties, regaining control and being satisfied with patient care [19, 22]. Finally, family resilience in the ICU can provide patient support as well as family participation in the patient's medical care, which can address the patient's need for medical care as well as psychological and emotional needs [24, 29].

5.7. Empirical Referents

The final step of the concept analysis involved identification of the concept's empirical referents. These referents are ‘categories of actual phenomena that demonstrate the occurrence of the concept itself’ (Walker & Avant, 2011, 168). They are useful in practice because they provide clear, observable measurements that help to distinguish and differentiate the concept from similar concepts and are extremely useful in instrument development (Walker & Avant, 2011). The following four measurement tools were used to measure family resilience in the ICU in the included literature.

5.8. Connor‐Davidson Resilience Scale (CD‐RISC)

Among the 10 survey studies included, five used the Connor‐Davidson Resilience Scale (CD‐RISC). The CD‐RISC was developed by the team of scholar Kathryn M Connor in 2003 [23]. The CD‐RISC is a 25‐question survey that is scored from 0 to 100. A score greater than 82 identifies individuals who are resilient. The CD‐RISC has been previously validated in a variety of settings, including community samples, primary care outpatients, general psychiatric outpatients, clinical trials of generalised anxiety disorder and two clinical trials of PTSD. The CD‐RISC measures the factors of personal competence, tenacity, tolerance of negative effects, positive acceptance of change, secure relationships and spiritual influences, among others [18]. Although this scale was commonly used to measure family resilience in the ICU in the included studies, it also has obvious shortcomings. For example, the scale was originally designed to measure individual resilience, and the evaluation elements focus mainly on personal characteristics and psychological factors rather than the measurement of organisational systems and support systems of family resilience in the ICU. This may result in insufficient representativeness of the measurement results.

5.9. Family Hardiness Index

The FHI was identified in 4 of the 10 investigative studies reviewed for this analysis. The FHI was developed by Marilyn McCubbin et al. in 1986 to measure hardiness as a stress resistance and adaptation resource in families. Hardiness functions as a buffer or mediating factor in mitigating the effects of stressors and demands and facilitates family resiliency adjustment and adaptation over time. The original US version of the FHI was translated into Chinese by Liu Yang, and reliability and validity verification was conducted in families with critically ill children [31]. This scale consists of three dimensions and 20 items. The three dimensions are responsibility (nine items), control (six items) and challenge (five items). Responses are scored on a scale of 0–4 points. A total score can be calculated by summing the responses, which gives a possible score ranging from 0 to 80. Taking the median score of 50 points as a reference, a higher family score reflects greater family resilience. The FHI has been previously validated in a variety of settings, including children with different chronic illnesses, patients with inflammatory bowel disease and elderly patients with chronic diseases. This scale effectively assesses family resilience from the perspectives of family perceptions, belief systems and the organisational system. However, few measurement elements in the FHI are involved in the family support system, especially professional and social support. There is also a lack of measurement indicators for the characteristics of the belief system for families in the ICU, such as disconnectedness and uncertainty.

5.10. Family Resilience Assessment Scale

The Family Resilience Assessment Scale (FRAS) was identified in three of the 10 investigative studies reviewed for this analysis. The FRAS was developed by Sixbey and is based on Walsh's family resilience model (family belief systems, organisational patterns and communication processes), which provides six subscales to assess areas of family resilience. The first subscale addresses family communication and problem‐solving (FCPS). The subscales for utilising social and economic resources (USER) and family connectedness (FC) are associated with organisational patterns. Family belief systems are associated with maintaining a positive outlook (MPO), family spirituality (FS) and the ability to make meaning of adversity (AMMA). The scale has 54 items in total, which are rated on a 4‐point Likert rating system. A higher family score reflects greater family resilience. Yuli Li translated the Chinese version in 2016. This scale has been used in family research on elderly individuals, patients with cancer and children with mental disorders. However, owing to the theoretical source of Walsh's process theory of family resilience, the scale does not involve any measurement elements of family characteristics.

5.11. Family Resilience Assessment Scale of China

The FRAS of China was identified in only one study reviewed for this analysis. This scale was developed by Dai Yan's group. Two subscales, family beliefs and family strength, and 10 dimensions are included. The scale was developed in China to measure the family resilience of secondary school students who experienced the Wenchuan earthquake. The measurement involves most elements of the belief system, organisational system and support system, which can accurately reflect the level of family resilience. However, some elements of the characteristic system, such as self‐improvement, a sense of responsibility, leadership and professional support, are not included in this scale. Finally, reports on the application of the scale in the medical field are limited, and its reliability and validity have not been verified.

ICU family resilience is a multidimensional concept that is applied in special settings. The current assessment tools can measure some characteristics, but they cannot fully reflect all the defining attributes of ICU family resilience. There are no reports on the development of measurement tools for family resilience in the ICU. One of the factors hindering the development of research on family resilience in the ICU is the lack of measurement tools with good reliability and validity.

6. Discussion and Implications

In this concept analysis, the concept of ‘family resilience in the ICU’ was examined by identifying its uses, antecedents, attributes, consequences and empirical referents (see Figure S2). On the basis of the attributes and consequences, the following operational definition and framework (see Figure S3) are proposed:

‘Family resilience in the ICU’ is a concept that occurs in the ICU environment and is influenced by the family's original characteristics, which refer to the ability and process of families to respond effectively to risk and overcome adversity by establishing internal belief systems, adapting organisational systems and seeking external support when a relative is admitted to the ICU.

The conceptual analysis of ICU family resilience yields significant insights that both align with and extend the literature. Our findings corroborate Walsh's foundational work, which positions family resilience as a dynamic process rather than as a static trait, while specifically contextualising this understanding within the unique setting of ICUs. Compared with other healthcare settings, the ICU environment presents distinct challenges because of the acute and often unexpected nature of admission, the technologically intensive milieu and the high uncertainty surrounding outcomes.

In contrast to studies of family resilience in the context of chronic illness, our analysis emphasises that ICU families must mobilise resources for resilience within a compressed time frame. Unlike families managing chronic conditions, which may develop resilience capacities over months or years, ICU families face immediate demands that require rapid adaptation. This temporal distinction has important implications for how healthcare professionals approach family support interventions.

Our findings also build upon recent work by Wong et al. [23] and Foster et al. [16] that highlight ‘regaining control’ as a core aspect of family resilience in critical care settings. Our analysis extends this understanding by identifying four specific systems (attribute, belief, organisation and support) that facilitate this process to offer a more comprehensive framework for assessment and intervention.

For the attribute system, interventions may include early identification of family members' coping styles and emotional responses. With respect to the belief system, healthcare professionals can foster meaning‐making through clear, consistent communication and acknowledgement of spiritual needs. Organisation system support might involve assisting families in establishing routines for ICU visitation and household responsibilities. Finally, support system interventions should connect families with appropriate resources both within and outside the hospital.

Policy implications include the need to formally recognise family resilience assessment and support as essential components of high‐quality ICU care. This may involve updating ICU visitation policies to accommodate family needs, allocating resources for family support services and integrating family resilience measures into quality improvement initiatives.

Future research should focus on developing and testing interventions specifically designed to enhance the four resilience systems identified in this analysis. Additionally, longitudinal studies that examine how family resilience evolves from ICU admission through recovery or bereavement would provide valuable insights into the dynamic nature of this construct.

7. Limitations

This conceptual analysis has obvious limitations. There are few studies on the concept of ‘resilience’ in the included literature, and most studies adopt the general concept and measurement tools of family resilience. The unique defining attributes of family resilience in the ICU have not been fully analysed. In this sense, it is uncertain whether the operational definition of the concept can be used in the ICU setting. Hence, the application of this framework to the ICU context may require further study and development.

8. Implications and Recommendation for Practice

The implications of this conceptual analysis for clinical practice are substantial. First, ICU nurses should receive education on family resilience and its components to better identify resilience‐related strengths and vulnerabilities among the families they encounter. Second, routine assessment of family resilience using validated tools (e.g., the CD‐RISC or FHI systems) should be incorporated into standard ICU family care protocols. Third, targeted interventions that address the four systems identified in our analysis should be developed.

9. Conclusion

On the basis of the conceptual analysis, we propose an operational definition to facilitate the implementation of this construct in practice. Furthermore, we recommend that implementation adhere to the following key principles: (1) identifying family attributes; (2) assisting families in establishing appropriate expectations; (3) providing support to help families regain control; (4) facilitating family engagement in medical decision‐making and patient care; and (5) encouraging families to access additional external resources.

Ethics Statement

All experiments involved in this study were reviewed and approved by the ethics committee of Chongqing General Hospital (No.: KY S2024‐046‐01, date of approval: 4 September 2024). Model case was constructed by researchers through onsite observation and interviews, and the consent of the patient's relatives was obtained. Related case, Borderline case and Contrary case are constructed based on demonstration cases. All experimental procedures were conducted in accordance with the regulations of (PRISMA) 2020 statement.

Consent

Model case was constructed by researchers through onsite observation and interviews, and the consent of the patient or their relatives was obtained, and the Informed Consent Form was signed. Related case, Borderline case and Contrary case are constructed based on demonstration cases.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Figure S1: PRISMA flow diagram (PRISMA 2020).

Figure S2: Diagram of the results of the concept analysis of family resilience in the ICU.

Figure S3: Framework of the results of the concept analysis of family resilience in the ICU.

Table S1: Example of a search strategy.

Table S2: Main characteristics of the studies identified.

Sun S., Song C., Guan L., Xiaoling T., and Wu C., “Family Resilience in the ICU: A Concept Analysis,” Nursing in Critical Care 30, no. 5 (2025): e70147, 10.1111/nicc.70147.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.